Reduced 2: Reducing Unnecessary Coagulation Testing in the Emergency Department, Stage 2

Background: The aPTT (activated partial thromboplastin time) and PT/INR (prothrombin time/international normalized ratio) coagulation tests are validated in specific circumstances, and rarely are both indicated. Yet, they are considered "routine" in medical practice. Indiscriminate testing wastes resources while potentially misleading care. We previously carried out an intervention focused on order-set modification and clinician education to reduce indiscriminate coagulation testing in the emergency department (ED) at our institution, where test volumes were particularly high. Following our intervention, coagulation test rates decreased by over 50%, resulting in $6,490 CAD in direct cost savings per month, and an annual projected savings of $55,000 CAD. Our balance measure, red blood cell transfusion rate (a proxy for major bleeding) did not show a harm signal. In this PDSA cycle, we studied whether this lower test ordering rate indicated more appropriate test ordering practices.

Methods: We performed a retrospective chart review of patients who visited the ED during the one month period following the order-set modification who had a coagulation test ordered with their bloodwork during their ED visit (N = 1027). We randomly selected 150 charts (14.6%) to audit for appropriateness of coagulation testing based on predefined contextual criteria. Two independent raters (NG and MS) reviewed patient charts for the presenting complaint, past medical history, and medication list to determine whether the clinical circumstances warranted coagulation testing. Our primary outcome measure was the number of patients who received a coagulation test with an appropriate indication for the test.

Results: Our analyses revealed 10 (7.1%) patients had one coagulation test ordered while the majority (140 {92.9%}) had both aPTT and PT/INR ordered. Only 26 patients (17.33%) had an identifiable appropriate indication for coagulation testing. The most common inappropriate reasons for test ordering were "routine hemostatic screening" in patients planned for surgery not actively bleeding (20 {13.3%}), and stable patients on direct oral anticoagulants (5 {3.3%}).

Conclusion: Our findings suggest that while our quality improvement intervention led to a meaningful reduction in coagulation testing in the ED, coagulation tests continue to be ordered inappropriately in our ED, suggesting that the educational component of our intervention has not achieved its optimal impact. Therefore, there is need for further interventions focusing on process to enhance the appropriateness of coagulation testing in our ED.