Unnecessary testing and treatment is a pervasive problem in health care, and is present in virtually every hospital, department and clinic, irrespective of size or how diligent the clinicians are who work there.
Although clinicians ultimately make decisions about which tests and treatments to order, many of these decisions can often be influenced by existing hospital systems that, if outdated or poorly designed, can nudge clinicians toward ordering tests and treatments that do not reflect evidence-based guidelines and practices. This can expose patients to avoidable harm, lengthen wait times, and consume precious hospital resources.
Diving into Overuse in Hospitals is a national campaign that aims to reduce unnecessary tests and treatments in hospital settings. The goal of the campaign is to get hospitals across Canada to join the global Choosing Wisely movement by making changes, small or large, to reduce overuse.
Participating hospitals get access to a wealth of resources, including a starter kit, webinars, and other supports, and can become designated “Choosing Wisely Canada hospitals.”
Hospitals interested in being part of the campaign, but are not sure if they have an overuse problem are encouraged to ask themselves the five basic questions below.
PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time) were tests developed in the early 20th century for specific and unique indications. Despite this, they are often ordered together routinely in emergency departments (ED). PT/INR and aPTT are often unknowingly ordered together because most bloodwork in the ED is based on lab order panels that are outdated and frequently couple PT/INR and aPTT tests as a bundle despite the fact that they are rarely required together. In some hospitals, laboratory software may also automatically run both tests even if only one was ordered.
Troponin has become the cardiac biomarker of choice for detecting myocardial injury. Despite troponin being clinically superior to creatine kinase (CK) in both specificity and sensitivity, CK is still being used at a high rate in some hospitals. If troponin testing is available at your hospital, there is little reason for CK to still be on your hospital’s order sets and laboratory test profiles.
Repetitive, “routine” blood tests are associated with hospital-acquired anemia and increased hospital mortality. Indiscriminate testing may mislead patient care and results in unnecessary cost to the system. At many hospitals, “daily labs” appear as an option on admission order sets. Consider changing your hospital’s admission order sets to remove all “daily lab” options, and ensure that all lab orders have a clear indication and a reasonable terminus.
Serum folate and red blood cell (RBC) folate testing is no longer justified for the investigation of anemias for the vast majority of patients in Canada. Fortifying grain products became mandatory in the late 1990s and has rendered folate deficiencies virtually nonexistent in Canada. Despite the condition being rare at best, many hospitals still include it in their ordering systems. Consider removing folate testing from your hospital’s ordering systems and restricting its use by having physicians contact the laboratory consultant should they feel the test is warranted.
Chest X-Rays (CXR) are the most frequent radiological test performed in intensive care units (ICU), with routine daily CXR being standard practice in many ICUs. But routine CXRs are rarely beneficial to patients, exposing them to unnecessary radiation, disruption and discomfort. Moving from routine CXRs to ordering CXRs only to answer specific clinical questions ensures only the patients who need CXRs are getting them. It also frees up radiation technologists to support patient care in other areas of the hospital.
Diving into Overuse in Hospitals: A Starter Kit for Reducing Unnecessary Tests and Treatments provides practical advice and guidance on implementing Choosing Wisely recommendations into hospital settings. It was developed with the support of the Ontario Hospital Association and Health Quality Ontario as part of the Choosing Wisely Ontario campaign. However, the document is intended to be relevant to hospitals across Canada.
Upon implementation of this Starter Kit, and assuming all actions have been completed, hospitals can become designated “Choosing Wisely Canada Hospitals” (at either Levels 1, 2 or 3). These groups of hospitals will receive a certificate of completion, be recognized on the Choosing Wisely Canada website, and gain national profile for their leadership in tackling overuse. To receive the certificate of completion, please complete the checklist for each level, and send it to Choosing Wisely Canada.Download Starter Kit
The Ontario Hospital Association, in partnership with Choosing Wisely Canada and Health Quality Ontario, will be hosting a three-part webinar series to support hospitals that may be looking to start, or advance, their local Choosing Wisely efforts. These interactive webinars will give participants an opportunity to ask questions and participate in an emerging community of practice.