There’s only one way to reduce inappropriate coagulation test ordering

The only way to reduce unnecessary coagulation study blood tests in emergency departments may be to confiscate coagulation pathology tubes from bedside trolleys, a Victorian study has found.

Choosing Wisely Australia guidelines recommend against routine use of coagulation studies in ED patients unless there is a clearly defined specific clinical indication, such as for monitoring of anticoagulants.

But an audit of 200 patients presenting to a Melbourne hospital ED found that one in three patients had coagulations studies ordered, and most of these (74%) were deemed to have no clinical indication as per Choosing Wisely guidelines.

A subsequent education intervention for medical and nursing staff on avoidance of inappropriate coagulation testing failed to have any impact on test ordering. IN a post-intervention sample of 200 ED patients, 32% had coagulation tests ordered and the proportion of inappropriate tests remained the same, at 78%.

A second intervention was then implemented, which involved the physical removal of coagulation pathology tubes from all venepuncture trolleys in the ED, excluding resuscitation bays to avoid any delay in emergency situations.

This meant that clinical staff had to walk 100-200m from ED cubicles to the pharmacy storage room to access coagulation tubes.

Following this intervention, the rate of coagulation study ordering fell to 25% a second audit of 200 patients showed. The proportion of inappropriate tests also fell to 53%. In absolute terms, the number of low value coagulation tests was halved from around 49 to 26 per 200 patients.

Study lead author Dr Mandeep Kalsi said the findings showed that a ‘nudge strategy’ may be needed to translate guideline recommendations into clinical practice to achieve quality improvement.

“Literature and experience show that educational strategies often have weak impact on behaviour change because of factors such as lack of awareness of guidelines by busy and rotating medical/nursing staff,” the study authors wrote in Emergency Medicine Australasia.

A small change such as a physical barrier in workplace systems proved to be more effective in influencing human behaviour than an educational intervention, they concluded.

However they acknowledged that the educational intervention was limited in scope and the study did not show whether the reduction in ordering of coagulation tests would be sustained in the long term.

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