Type and SCREAM STAT! Futility of ordering routine Blood Type and Screens in the ER

In Medical Concepts by Nadim Lalani1 Comment

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Where’s that STAT karyotype?!!!

My awesome hematology colleague Dr Karen Dallas was here again – giving us a learn-on on a recent audit of routine Type and Screen testing in our ER’s

Background:

  • Our biggest ER routinely sends a STAT Type & Screen to the Transfusion Medicine Lab [TML].
  • These requests are often accompanied with a request for blood.
  • Sometimes these tests are performed appropriately for emergent cases, but the TML saw an opportunity to study this [based on anecdotal experience that some of these requests may not be necessary.

Methods:

The TML undertook a 7 week chart review of patients who had a STAT T&S and blood products ordered. They uncovered a large source of wastage of pre-transfusion testing. The results would make anyone type and scream!

  • 82% of our patients had a hemoglobin > 100.
    • 15% Hb between 70-100
    • 3% Hb < 70
  • 90% didn’t need any blood product
  • even with being very lenient – 30% of the Type and Screen requests were deemed inappropriate

Many of our diagnostic tests do not change patient management. Furthermore they add cost, may confuse the diagnosis and might even force you to perform further tests that can result in harm [e.g. false positive exercise stress test – Patient gets angiogram – patient gets coronary artery dissection]

Discussion:

There are a couple of pearls we can take away from Karen’s plea.

1. Routine testing = thoughtless testing = waste of blood and money.

Those of you who know me know that I often rant about the wastefulness of routine blood panels. Don’t get me wrong. I do think that well-thought out protocols have value for example – at 4 am when I cannot think straight and may miss something. BUT in the middle of the day, coffee-in-hand:

a good clinician should be able to be selective about what he orders –  ANY test he chooses, he does so to either support or refute the pretest probability that a patient has “disease Y”.

2. Quality Improvement projects are valuable and necessary.

I encourage my residents to participate in QI because these projects are doable, supported with funds and often result in tangible benefits. If a project allows you to collaborate with other services to do what’s right – WIN! WIN! WIN!

Recommendations:

If you’re ER is like mine  you can improve on how it orders lab tests by:

Having a Gatekeeper – TML is now screening our orders and phoning the ER doc to clarify. This type of hand-holding is annoying, but may be necessary to change behavior in the short term.

Take a look at your protocols and see if there’s room to improve/reduce. For example, we order many T&S as part of a “Bleeding in Pregnancy” workup to look for the Rh status – We’re going to remove the test from the panel and call the lab to see if it’s on file first [because it usually is].

Educate each other on stewardship [my Earlier Post on Stewardship]

Reduce! Refuse and Reflect!

  1. Reduce the amount of unnecessary testing in your ER. You can only gain from this.
  2. Refuse to bow to requests for unnecessary tests [from patients and colleagues alike]
  3. Reflect on your practice regularly and look for opportunities to change

 For your Interest:

Here’s a what the literature says about routine screening in the ER for:

  1. ER patients in general [England]
  2. ER patients in general 2 [Pakistan]
  3. Psych patients
  4. Patients with severe hypertension
  5. Patients suspected of drug abuse
  6. Patients with new onset seizure
  7. Trauma patients (serum electrolytes)
  8. Orthopedic patients
  9. Adults and blood cultures
  10. Kids and blood cultures
  11. Pediatric Trauma patients
  12. Adult Trauma patients
  13. Adult trauma patients 2

 

 

 

Nadim Lalani

Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.

@ermentor

- 5 days ago