Reducing unnecessary testing in the emergency department: The case for INR and aPTT

CJEM ◽  
2020 ◽  
Vol 22 (4) ◽  
pp. 534-541
Author(s):  
Davy Tawadrous ◽  
Sarah Detombe ◽  
Drew Thompson ◽  
Melanie Columbus ◽  
Kristine Van Aarsen ◽  
...  
Keyword(s):  
Emergency Department ◽  
Emergency Departments ◽  
Cost Savings ◽  
Clinical Decision ◽  
International Normalized Ratio ◽  
Educational Module ◽  
Patients Âgés ◽  
Coagulation Testing ◽  
Aggregate Rate ◽  
Routine Coagulation

ABSTRACTObjectiveRoutine coagulation testing is rarely indicated in the emergency department. Our goal is to determine the combined effects of uncoupling routine coagulation testing (i.e., international normalized ratio [INR]; activated partial thromboplastin time [aPTT]), disseminating an educational module, and implementing a clinical decision support system (CDSS) on coagulation testing rates in two academic emergency departments.MethodsA prospective pre-post study of INR-aPTT uncoupling, educational module distribution, and CDSS implementation in two academic emergency departments. All patients ages 18 years and older undergoing evaluation and treatment during the period of August 1, 2015, to November 30, 2017, were included. Primary outcome was coagulation testing utilization during the emergency department encounter. Secondary outcomes included associated costs, frequency of downstream testing, and frequency of blood transfusions.ResultsUncoupling INR-aPTT testing combined with educational module distribution and CDSS implementation resulted in significantly decreased coupled INR-aPTT testing, with significantly increased selective INR and aPTT testing. Overall, the aggregate rate of coagulation testing declined for both INR and aPTT testing (48 tests/100 patients/day to 26 tests/100 patients/day). There was a significant decrease in associated daily costs (median cost per day: $1048.32 v. $601.68), realizing estimated annual savings of $163,023 Canadian dollars (CAD). There was no signal of increased downstream testing or patient blood product requirements.ConclusionCompared to baseline practice patterns, our multimodal initiative significantly decreased coagulation testing, with meaningful cost savings and without evidence of patient harm. Clinicians and administrators now have a growing toolkit to target the plethora of low-value tests and treatments in emergency medicine.

scholarly journals What is the effect of rivaroxaban on routine coagulation tests?

Hematology ◽  
2014 ◽  
Vol 2014 (1) ◽  
pp. 334-336 ◽  
Author(s):  
Deborah M. Siegal ◽  
Barbara A. Konkle
Keyword(s):  
Emergency Department ◽  
Filtration Rate ◽  
Estimated Glomerular Filtration Rate ◽  
International Normalized Ratio ◽  
Activated Partial Thromboplastin Time ◽  
Past Medical History ◽  
Surgical Team ◽  
Normal Range ◽  
Coagulation Tests ◽  
Routine Coagulation

Abstract A 78-year-old female presents to the emergency department with a traumatic hip fracture. Her past medical history is significant for atrial fibrillation for which she receives rivaroxaban 20 mg daily. Her dose was last taken 12 hours ago. Routine bloodwork conducted in the emergency department shows prothrombin time, international normalized ratio, and activated partial thromboplastin time within the normal range, and estimated glomerular filtration rate of 50 mL/min/1.73 m2 (normal is >90 mL/min/1.73 m2) You are asked by the surgical team to confirm that it is safe to proceed with surgery at this time using neuraxial anesthesia.

scholarly journals MP36: Reducing utilization of unnecessary coagulation tests by emergency providers

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S55-S55
Author(s):  
R. Gupta ◽  
S. Mondoux ◽  
G. Rutledge
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Length Of Stay ◽  
Cost Reduction ◽  
Control Charts ◽  
Cost Savings ◽  
International Normalized Ratio ◽  
Provider Education ◽  
Statistical Process ◽  
Process Measures

Background: Curbing unnecessary laboratory testing represents a significant opportunity for cost reduction in the Canadian health care system. A Choosing Wisely report cited a 31% decline in the number of tests ordered in a Canadian emergency department (ED) after implementation of recommendations. The international normalized ratio (INR) remains frequently ordered in emergency departments without an appropriate indication. Aim Statement: We aimed to reduce the number of INR tests completed in the St. Joseph's Healthcare Hamilton Emergency Department by 50% by April 30, 2019. Measures & Design: We conducted the study in an urban, academic ED employing the Epic electronic health record (EHR). We tailored interventions according to the Hierarchy of Effectiveness to address root causes revealed by analysis of our baseline ordering behaviour. Interventions included provider education around evidence-based ordering indications and removal of the INR from our “chest pain” bloodwork panel. Our outcome measure was the weekly number of INR tests completed per ED visit. Process measures included the proportion of INR tests ordered for inappropriate indications on monthly audits of 20 charts where an INR was completed. Balancing measures included average ED length of stay for patients receiving INR testing. Evaluation/Results: We collected outcome, process, and balancing measures through the EHR and analyzed this data using statistical process control charts. Over the nine-month study period, we decreased weekly INR tests from 248.4 to 115.0, a reduction of 56% which met criteria for special cause variation. This amounts to a cost savings of $43,008 per year. ED length of stay for patients receiving INR testing did not change significantly. Discussion/Impact: Our interventions were successful in realising our 50% target reduction in INR tests without an increase in ED length of stay from repeat venipuncture. This result is in keeping with similar efforts in other Canadian EDs. Our interventions could likely be spread to other settings where an INR is included as part of a “chest pain” panel. This may represent a substantial cost reduction opportunity on a national scale. Further work is needed in order to assess long term sustainability, which can be supported by employing high effectiveness mechanisms such as automation of optimal behaviour.

scholarly journals LO37: Reducing hemolysis of coagulation blood samples in the emergency department

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S20-S20
Author(s):  
H. Weatherby ◽  
V. Woolner ◽  
L. Chartier ◽  
S. Casey ◽  
C. Ong ◽  
...  
Keyword(s):  
Emergency Department ◽  
Best Practice ◽  
Average Rate ◽  
International Normalized Ratio ◽  
Chi Square ◽  
Statistical Process ◽  
Blood Samples ◽  
Process Measure ◽  
Coagulation Testing ◽  
Ed Visits

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures & Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p < 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.

The Manchester Triage System (MTS): a score for emergency management of patients with acute gastrointestinal bleeding

2018 ◽  
Vol 56 (05) ◽  
pp. 479-487 ◽  
Author(s):  
Constantin Cornelius ◽  
Arthur Hoffman ◽  
Achim Tresch ◽  
Joerg Krey ◽  
Ralf Kiesslich ◽  
...  
Keyword(s):  
Emergency Department ◽  
Emergency Departments ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Initial Assessment ◽  
Gi Bleeding ◽  
Tertiary Referral Hospital ◽  
Triage System ◽  
Manchester Triage System ◽  
Level 3

Abstract Background Suspected gastrointestinal (GI) bleeding is a common initial diagnosis in emergency departments. Despite existing endoscopic scores to estimate the risk of GI bleeding, the primary clinical assessment of urgency can remain challenging. The 5-step Manchester Triage System (MTS) is a validated score that is often applied for the initial assessment of patients presenting in emergency departments. Methods All computer-based records of patients who were admitted between January 2014 and December 2014 to our emergency department in a tertiary referral hospital were analyzed retrospectively. The aim of our retrospective analysis was to determine if patient triage using the MTS is associated with rates of endoscopy and with presence of active GI bleeding. Results In summary, 5689 patients with a GI condition were treated at our emergency department. Two hundred eighty-four patients (4.9 %) presented with suspected GI bleeding, and 165 patients (58 %) received endoscopic diagnostic. Endoscopic intervention for hemostasis was needed in 34 patients (21 %). In patients who underwent emergency endoscopy, triage into MTS categories with higher urgency was associated with higher rates of endoscopic confirmation of suspected GI bleeding (79 % of patients with MTS priority levels 1 or 2, 53 % in level 3 patients, and 40 % in levels 4 or 5 patients; p = 0.024). Conclusions The MTS is an established tool for triage in emergency departments and could have a potential to guide early clinical decision-making with regards to urgency of endoscopic evaluation in patients with suspected GI bleeding.

scholarly journals P118: Effects of system design on laboratory utilization in the emergency department: the case for INR & aPTT

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S118
Author(s):  
D. Tawadrous ◽  
T. Skoretz ◽  
D. Thompson ◽  
S.A. Detombe ◽  
K. Van Aarsen
Keyword(s):  
Emergency Department ◽  
System Design ◽  
Practice Patterns ◽  
Cost Savings ◽  
Healthcare Budget ◽  
Coagulation Testing ◽  
Provider Practice ◽  
Targeted Testing ◽  
Laboratory Utilization ◽  
Baseline Cost

Introduction: In the context of a shrinking healthcare budget, poor physician cost awareness, and continued over-utilization of low-value tests in the emergency department, we re-designed our computerized order entry system to reduce the use of coagulation testing. Methods: A hospital-based prospective pre-post analysis following de-bundling of INRPTT testing in two academic hospital emergency departments (annual visits 140,000). All participants aged 18 years or older undergoing evaluation and/or treatment at either of during the period of August 1, 2015 to July 24, 2016 were included. Primary outcome is coagulation testing utilization rates and associated costs. Results: Unbundling INR and aPTT testing resulted in significantly decreased bundled INRPTT testing relative to baseline (INRPTT tests per patient per day: 0.60 [95% CI: 0.57-0.62] vs. 0.98 [95% CI: 0.98-0.99], p=0.000), with significantly increased targeted testing (INR tests per patient per day: 0.39 [95% CI: 0.37-0.42] vs. 0.00 [95% CI: 0.00-0.01], p=0.000; PTT tests per patient per day: 0.33 [95% CI: 0.30-0.36] vs. 0.01 [95% CI: 0.00-0.01], p=0.000). As a result of unbundling, there was a significant decrease in costs associated with coagulation testing relative to baseline (Cost per day: $958.52 [INRPTT $592.78+INR $183.91+PTT $181.83] vs. $1,074.50 [INRPTT $1,069.76+INR $2.06+PTT $2.68], p=0.000), realizing estimated daily and yearly savings of $115.98 and $42,332.70, respectively. Conclusion: Compared to baseline practice patterns, unbundling coagulation testing resulted in the reduction of coagulation testing suggesting system design and user workflows to be an integral factor to provider practice patterns. Given the significant cost-savings, we recommend institutions carefully re-evaluate their system design and user workflows to optimize emergency department laboratory utilization.

scholarly journals Laboratory predictors of death from coronavirus disease 2019 (COVID-19) in the area of Valcamonica, Italy

2020 ◽  
Vol 58 (7) ◽  
pp. 1100-1105 ◽  
Author(s):  
Graziella Bonetti ◽  
Filippo Manelli ◽  
Andrea Patroni ◽  
Alessandra Bettinardi ◽  
Gianluca Borrelli ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Clinical Decision Making ◽  
Troponin I ◽  
Laboratory Data ◽  
High Sensitivity ◽  
Clinical Decision ◽  
International Normalized Ratio ◽  
Serum Glucose ◽  
Hospital Death ◽  
Laboratory Findings

AbstractBackgroundComprehensive information has been published on laboratory tests which may predict worse outcome in Asian populations with coronavirus disease 2019 (COVID-19). The aim of this study is to describe laboratory findings in a group of Italian COVID-19 patients in the area of Valcamonica, and correlate abnormalities with disease severity.MethodsThe final study population consisted of 144 patients diagnosed with COVID-19 (70 who died during hospital stay and 74 who survived and could be discharged) between March 1 and 30, 2020, in Valcamonica Hospital. Demographical, clinical and laboratory data were collected upon hospital admission and were then correlated with outcome (i.e. in-hospital death vs. discharge).ResultsCompared to patients who could be finally discharged, those who died during hospital stay displayed significantly higher values of serum glucose, aspartate aminotransferase (AST), creatine kinase (CK), lactate dehydrogenase (LDH), urea, creatinine, high-sensitivity cardiac troponin I (hscTnI), prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (APTT), D-dimer, C reactive protein (CRP), ferritin and leukocytes (especially neutrophils), whilst values of albumin, hemoglobin and lymphocytes were significantly decreased. In multiple regression analysis, LDH, CRP, neutrophils, lymphocytes, albumin, APTT and age remained significant predictors of in-hospital death. A regression model incorporating these variables explained 80% of overall variance of in-hospital death.ConclusionsThe most important laboratory abnormalities described here in a subset of European COVID-19 patients residing in Valcamonica are highly predictive of in-hospital death and may be useful for guiding risk assessment and clinical decision-making.

scholarly journals 140. Symptoms and Situations Predispose Patients to Use Antibiotics Without Medical Advice

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S200-S200
Author(s):  
Michael Hansen ◽  
Barbara Trautner ◽  
Roger Zoorob ◽  
George Germanos ◽  
Osvaldo Alquicira ◽  
...  
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Emergency Departments ◽  
Primary Care Clinic ◽  
Antibiotic Use ◽  
Safety Net ◽  
Care Clinic ◽  
Primary Care Clinics ◽  
Primary Care Patients ◽  
Emergency Department Patients

Abstract Background Use of antibiotics without a prescription (non-prescription use) contributes to antimicrobial resistance. Non-prescription use includes obtaining and taking antibiotics without a prescription, taking another person’s antibiotics, or taking one’s own stored antibiotics. We conducted a quantitative survey focusing on the factors that impact patients’ decisions to use non-prescription antibiotics. Methods We surveyed patients visiting public safety net primary care clinics and private emergency departments in a racially/ethnically diverse urban area. Surveys were read aloud to patients in Spanish and English. Survey domains included patients’ perspectives on which syndromes require antibiotic treatment, their perceptions of health care, and their access to antibiotics without a prescription. Results We interviewed 190 patients, 122 from emergency departments (64%), and 68 from primary care clinics (36%). Overall, 44% reported non-prescription antibiotic use within the past 12 months. Non-prescription use was higher among primary care clinic patients (63%) than the emergency department patients (39%, p = 0.002). The majority felt that antibiotics would be needed for bronchitis (78%) while few felt antibiotics would be needed for diarrhea (30%) (Figure 1). The most common situation identified “in which respondents would consider taking antibiotics without contacting a healthcare provider was “got better by taking this antibiotic before” (Figure 2). Primary care patients were more likely to obtain antibiotics without prescription from another country than emergency department patients (27% vs. 13%, P=0.03). Also, primary care patients were more likely to report obstacles to seeking a doctor’s care, such as the inability to take time off from work or transportation difficulties, but these comparisons were not statistically significant. Figure 1. Patients’ agreement that antibiotics would be needed varied by symptom/syndrome. Figure 2. Situations that lead to non-prescription antibiotic use impacted the two clinical populations differently Conclusion Non-prescription antibiotic use is a widespread problem in the two very different healthcare systems we included in this study, although factors underlying this practice differ by patient population. Better understanding of the factors driving non-prescription antibiotic use is essential to designing patient-focused interventions to decrease this unsafe practice. Disclosures All Authors: No reported disclosures

scholarly journals PEMCRC anaphylaxis study protocol: a multicentre cohort study to derive and validate clinical decision models for the emergency department management of children with anaphylaxis

BMJ Open ◽  
2021 ◽  
Vol 11 (1) ◽  
pp. e037341
Author(s):  
Timothy E Dribin ◽  
Kenneth A Michelson ◽  
David Vyles ◽  
Mark I Neuman ◽  
David C Brousseau ◽  
...  
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Online Education ◽  
Prediction Models ◽  
Recursive Partitioning ◽  
Clinical Decision ◽  
Pediatric Emergency ◽  
Initial Reaction ◽  
Research Committee ◽  
Reaction Severity

IntroductionThere remain significant knowledge gaps about the management and outcomes of children with anaphylaxis. These gaps have led to practice variation regarding decisions to hospitalise children and length of observation periods following treatment with epinephrine. The objectives of this multicentre study are to (1) determine the prevalence of and risk factors for severe, persistent, refractory and biphasic anaphylaxis, as well as persistent and biphasic non-anaphylactic reactions; (2) derive and validate prediction models for emergency department (ED) discharge; and (3) determine data-driven lengths of ED and inpatient observation prior to discharge to home based on initial reaction severity.Methods and analysisThe study is being conducted through the Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC). Children 6 months to less than 18 years of age presenting to 30 participating EDs for anaphylaxis from October 2015 to December 2019 will be eligible. The primary outcomes for each objective are (1) severe, persistent, refractory or biphasic anaphylaxis, as well as persistent or biphasic non-anaphylactic reactions; (2) safe ED discharge, defined as no receipt of acute anaphylaxis medications or hypotension beyond 4 hours from first administered dose of epinephrine; and (3) time from first to last administered dose of epinephrine and vasopressor cessation. Analyses for each objective include (1) descriptive statistics to estimate prevalence and generalised estimating equations that will be used to investigate risk factors for anaphylaxis outcomes, (2) least absolute shrinkage and selection operator regression and binary recursive partitioning to derive and validate prediction models of children who may be candidates for safe ED discharge, and (3) Kaplan-Meier analyses to assess timing from first to last epinephrine doses and vasopressor cessation based on initial reaction severity.Ethics and disseminationAll sites will obtain institutional review board approval; results will be published in peer-reviewed journals and disseminated via traditional and social media, blogs and online education platforms.

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