Requests for coagulation studies have dropped by over a third with a concerted effort to encourage more appropriate ordering of the tests across Austin Health.
Austin’s clinical director of emergency medicine Dr Simon Judkins told the limbic the tests had become almost routine, especially in the emergency department. They were often ordered for patients with chest pain or as a pre-op work-up when just an INR would suffice.
“Coagulation studies had become a ‘just in case’ type of test. When we actually asked doctors what they needed, it might be that an INR and platelets was all that was required.”
Dr Judkins, who also chairs the Choosing Wisely committee at Austin Health, said an initial audit of ordering practice provided some early wins.
“We were able to identify who was ordering these tests more than others and feed that back to clinicians. It was quite a positive process – providing doctors with the opportunity to reflect on what they were doing.”
He said doctors might be trying to be efficient by ordering tests in a bundle but it was more often about convenience rather than answering clinical questions.
Over-ordering tests was at least wasteful and had inherent risks such as incidental findings which might lead to further unnecessary tests.
Dr Judkins said the project required a re-design of local guidelines and ‘unbundling’ coagulation studies into individual tests within the IT system. A request for coagulation studies now triggers a prompt about the guidelines.
He said it had also been important to encourage a change in language so that physicians on ward rounds weren’t asking for ‘coag studies’ when they might only mean an INR.
“There are a lot of long-term ingrained habits and certainly the path of least resistance would be to keep doing what we have been doing.”
“However we can’t afford to exploit our health care system and instead need to focus on making it effective, efficient, sustainable and safe. Everyone has a role in this.”
He said the challenge was to maintain the gains, especially as a teaching hospital where junior doctors were rotated through other hospitals, which may not have similar practices.
An update on the project was provided recently at the inaugural Choosing Wisely Australia National Meeting held in Melbourne.