92  bodycopy_heading">Additional Resources:
bodycopy_heading">Lnavnorm">PowerPoint - How to Successfully Influence Test Utilization & Improve Laboratory Efficiency  Below is a summary of initiatives that laboratories can implement to reduce excessive, ineffective, unnecessary and redundant testing.   General

• Educate physicians about appropriate test utilization on a continual basis with a laboratory newsletter
• Respond promptly to physician calls regarding test ordering and interpretation
• Design test requisitions to encourage optimal test ordering
• Discontinue obsolete tests
• Discontinue low volume tests, especially if you are running more quality control samples than patients
• Have pathologists review lab tests incorporated into clinical pathways
• Have pathologists review orders for esoteric tests sent to reference laboratories
• Renegotiate pricing for send out tests on a regular basis
• Review send out test volumes annually and bring high volume tests in house
• Store specimens in lab for one week for add-on tests
• Eliminate replicate testing of normal and abnormal results
• Eliminate large volume venipuncture tubes
• Decrease laboratory error rate to reduce number of repeat test orders
• Set allowable time intervals for repeat testing in hospital information system
• Implement autoverification whenever feasible
• Merge outpatient and inpatient electronic medical records to reduce number of tests ordered on admission
• Discourage writing of daily orders and set limits for mandatory rewriting of orders
• Compare physician test utilization for a specific DRG with their peers
• Discourage routine ordering of preoperative screening tests
• Improve turnaround times to reduce tendency to reorder pending tests
• Determine which confirmatory tests should be performed during the inpatient versus the outpatient setting
• Evaluate reference ranges periodically to decrease follow-up testing for slightly abnormal results
• Establish guidelines to determine medical necessity of new test requests
• Ask clinicians to refer point of care vendors to the medical director of the laboratory

• Change stat urine medical drug screens from comprehensive to Triage drug screen
• Eliminate large chemistry panels except for Medicare approved panels
• Require separate order for arterial blood gases and co-oximetry
• Change anti-nuclear antibody cutoff from 1:40 to 1:160
• Eliminate vancomycin peak levels for therapeutic monitoring
• Eliminate total CK from Cardiac Marker Panel
• Replace Amniostat PG with FLM II as first step in fetal lung profile to reduce two dimensional L/S ratio volume by ~50%
• Do not perform immunofixation without prior serum protein electrophoresis
• Change quality control for precise automated instruments to single 3 SD rule
• Screen for thyroid disease with TSH and reflex to free T4 if abnormal
• Do not perform chemistry panels on body fluids; limit testing to protein, LD, pH, glucose, amylase, triglycerides as needed
• Set limits for maximal dilutions of elevated tests such as enzymes

• DIC Panel – quantitative D-Dimer replaced FDP & SFMC
• Standardized heparin protocol based on dosage based on body weight results in a decreased number of bleeding episodes due to heparin overdose
• Continuously review hematology analyzer rules to reduce manual diff rate below 30%
• Replace manual reticulocyte with automated counts
• Implement Protime autoverification for outpatients
• Discontinue bleeding time
• Discontinue band neutrophil counts
• Discontinue RBC folate testing
• Encourage physicians to routinely order CBC instead of CBC with diff
• Encourage physicians to order urinalysis with automatic reflex to microscopic exam if positive for blood, protein or leukocyte esterase
• Implement urinalysis autoverification
• Do not perform Protein C & S for patients receiving warfarin

• Discontinue rapid bacterial antigen tests
• Change diarrhea work-up from full O&P to Giardia antigen for outpatients & C.difficile for inpatients who develop diarrhea >3 days after admission
• Decrease incubation time for urine cultures from 48 to 24 hours
• Reflex HCV EIA positive specimens to TaqMan RT PCR instead of RIBA
• Convert Chlamydia trachomatis (CT) and Neisseria gonorrheae (NG) testing to amplified test to increase detection rate by at least 1%
• Introduce chlorhexidene skin preparation to reduce blood culture contamination rate below 1.5%
• Delete Epstein Barr virus early antigen from EBV panel
• Discontinue Sabaroud slant from initial fungal culture setup
• Convert viral cultures to real time PCR
• Convert Group B Strep to real time PCR
• Discourage rapid Strep test and throat culture if physician intends to treat the patient regardless of the result
• Discourage ordering of urine culture for nonrecurring uncomplicated urinary tract infections in nonpregnant women
• Discourage fecal leukocyte testing and gram stains
• Do not allow HIV PCR or Western Blot for screening
• Encourage Neisseria PCR on urine for males with urethritis

• Use immediate spin crossmatch or electronic crossmatch
• Use of anti-IgG instead of polyspecific AHG
• Perform elutions on DAT positive samples only if transfused within last 3 months
• Eliminate recipient anti-A,B testing
• Eliminate autocontrol
• Eliminate weak D testing
• Eliminate reading antibody screen after immediate spin
• Eliminate antigen typing for clinically insignificant antibodies

• Use anti-A,B to confirm group O units instead of separate anti-A and anti-B
• Confirm Rh type only on Rh negative units

• Perform ABO & Rh typing only if mom is group O or Rh negative
• Don’t do elution if DAT is positive