Unnecessary lab orders have long been a target for quality improvement initiatives. In fact, the Society of Hospital Medicine's Choosing Wisely recommendation against routinely performing repetitive complete blood counts (CBCs) and other labs in stable patients turns 10 years old this month.
But even though hospitalists know better, the practice remains common, according to Christopher Moriates, MD, FACP, assistant dean for health care value and associate professor of internal medicine at Dell Medical School at the University of Texas at Austin. “It's hard to change these types of practices that are so ingrained,” he said.
The ubiquity of electronic medical records (EMRs) has not helped. “You just order daily labs once on admission at, say, 2 a.m., and then you never think about it again, whereas when I was a resident, we actually had to handwrite the order every day to order labs for the next day,” said Dr. Moriates.
To alert clinicians about the need for a change in practice, he and William Silverstein, MD, MSc, a general internal medicine fellow at the University of Toronto, wrote a “Change” article for The BMJ, published Oct. 26, 2022. They spoke with ACP Hospitalist about what inspired the article and offered their tips for hospitalists.
Q: What led you to write this paper?
A: Dr. Silverstein: Some work in Toronto looking at utilization of routine bloodwork by hospitalists has shown that, with time, use has reduced, although there still is tremendous variability. … In my own practice, where I do a lot of hospital medicine, people get admitted and they just have bloodwork going for days and days and days without any real rhyme or reason, and it leads to negative outcomes. So we thought that writing something on this, to not only highlight it as an issue but to provide recommendations to the broader medical community, would be helpful.
Dr. Moriates: Just over 10 years ago, when I started my faculty career at UCSF [the University of California, San Francisco], I launched a High-Value Care Committee, and we were looking at our practices within hospital medicine at UCSF. The Choosing Wisely campaign launched that year. … A lot of my hospitalist colleagues were all on board with all this Choosing Wisely stuff, and then when we said, “Let's cut out a.m. CBCs,” all the war stories about why people felt we need regular CBCs came out of the woodwork, so that one became a really tough one to kind of tackle. … But it does feel like maybe we've loosened the lid on the jar for so long that it's finally ready to pop off.
Q: Why do you think overuse of routine blood testing is so common in the hospital?
A: Dr. Silverstein: If somebody is admitted to the hospital, you want to feel like you're doing something for them. The antibiotics take time to work, the Lasix takes time to work. But I think saying, “Oh, your CBC is fine,” or “Oh, your creatinine hasn't changed, the Chem 7 hasn't changed,” that just objectively is very reassuring. … And then I think everybody has a story of this one patient who you were getting the daily labs on, and then they got a new AKI [acute kidney injury] out of the blue, or they had a sudden drop in their hemoglobin or whatever. So the fear of having something bad happen to your patients still drives that.
Dr. Moriates: I'm a practicing hospitalist; I still kind of love the daily lab. It's uncomfortable to take away that sort of security. … And we don't usually experience any of the downsides, right? We're not the one who's getting woken up with a needle at 4 in the morning—and we're not even there, usually. … I used to joke half tongue-in-cheek about the Choosing Wisely recommendation of “Don't check labs in the face of stability,” “Well, how do you know if they're stable, if you didn't check them?” Of course, day one or day two, fine [to check], but day three, four, or five? I've got patients who are in the hospital sometimes, unfortunately, for weeks, and you notice that they've just been getting labs every single morning, and that clearly is wasteful.
Q: What are your biggest takeaways for hospitalists on this issue?
A: Dr. Silverstein: We know that repetitive, routine testing is avoidable up to 60% of the time. From a patient-centered perspective, the sleep interruption is something that we don't really realize. But when you do 24-hour call and you're woken up at 4 in the morning, you're not a happy person. So you can imagine a sick, elderly patient getting poked at 4 in the morning for a blood test that they don't need would obviously not be helpful. And it is harmful to patients. There's the risks of pain, venipuncture, and it's associated with worse outcomes: increased transfusion requirements, mortality, readmission rates. And it's costly.
Q: What kind of feedback have you gotten on your article?
A: Dr. Moriates: One thing that's interesting is people have different ways that they think [the effort] should be framed. In other words, there's folks who certainly think that we should lead around the global environmental impact—it's biohazard waste. Others debate whether cost should be a part of the calculus or not … the actual monetary costs of doing lab testing routinely at scale. And then the physical harms, the patient experience of it. It's all those things. In some responses, people are like, “Don't talk about the costs; this is about the patient and the environment.” And then other people are like, “No, the costs are real.” Everybody agrees this is a problem, but I see some disagreement in the nuance about what's really going to be compelling to folks to get on board.
Q: How can hospitalists reduce their use of routine blood testing in practice?
A: Dr. Moriates: It's very simple. Just run down the list and say, “Who needs labs tomorrow?” And you can probably just cut the labs tomorrow for a decent portion of your list. Especially think about day of discharge: Unless you're tracking something, that is a great day to skip the lab. If you're a teaching hospitalist and attending physician, that's a great opportunity to bring this up. I know one of my colleagues generally does it on the Tuesday of his teaching week, where with his team, he'll do the practice of “Let's run the list and see where we can stop labs for patients who've been here,” which then gets them thinking about that for the rest of the week. And if you're teaching, I think celebrating restraint is really important. It's hard to really notice when people are appropriately not getting things. But that's powerful: “Hey, thank you for not getting that lab yesterday on Miss Green. She really doesn't need labs this morning, and I noticed that you paid attention to that and didn't get labs.” That sends a message to the team and helps ingrain those practices for years to come.
Q: What could be done on a broader level to reduce unnecessary routine testing?
A: Dr. Silverstein: Things like education to physicians, nurses, blood techs, that's been shown to be effective. Audit and feedback, where clinicians get standardized reports comparing your practices to your colleagues', has been helpful. And then structural changes to EMRs so you actually can't order a CBC and Chem 7 indefinitely or the EMR comes up and says, “You've had three straight days where the CBC has been normal. Do you really need another one?” And importantly, a combination of those interventions doesn't increase any adverse effects.
Q: How has the pandemic affected this issue?
A: Dr. Moriates: During COVID, we focused on decreasing some of the routine COVID labs because at the beginning of COVID, we, like everybody else in the country, were getting tons of different labs on every patient—we were trending things like D-dimers, and that was a costly practice. And bringing techs into the room was an infectious risk. When people started to see the risks of doing this, then folks said, “Wait a second, maybe we don't need to get labs every single morning on these people and have a tech go in and put on all the PPE and draw the lab.” … Certainly, the pandemic did make us in hospital medicine question, “Is this thing really necessary?,” which we've been trying to get people to do forever, and suddenly they were doing it. I don't know how much of those practices stuck, but that practice of saying, “Do we really need this echo? Do we really need to transport this patient down and get a CT?”—when you made the many nonmonetary costs of doing that visible, it definitely changed people's thinking.