Test Utilization Projects

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

Chemistry

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

Hematology

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

Microbiology

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

Flow Cytometry

Publish criteria for appropriate use
Replace commercial lyse solution with homebrew solution
Eliminate Flow isotype control reagents
Discontinue daily normal controls on immune panels

Reference Laboratory

Reference Laboratory send-out tests monitored by pathologists
HCV genotyping brought in house
Cystic Fibrosis Screen brought in house

Hospital transfusion service
Recipient testing

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

Donor testing policies

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

Cord blood

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

Introduce thawed plasma policy to decrease Fresh Frozen Plasma wastage
Monitor surgeon specific transfusion data annually
Discontinue shed blood collection after open heart surgery