GIVE THE TEST A REST

A toolkit for decreasing unnecessary emergency

department laboratory testing

Version 1.1

May 2019

Don’t collect urine specimens for culture from adults who lack symptoms localizing

to the urinary tract or fever unless they are pregnant or undergoing genitourinary

instrumentation where mucosal bleeding is expected.

Association of Medical Microbiology and Infectious Diseases Canada,

Choosing Wisely Canada recommendation #1

Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a

urinary tract infection (UTI).

Long Term Care Medical Directors Association of Canada,

Choosing Wisely Canada recommendation #3

Don’t order an erythrocyte sedimentation rate (ESR) to look for inammation in

patients with undiagnosed conditions. Order a C-reactive protein (CRP) to detect

acute phase inammation.

American Society for Clinical Pathology,

Choosing Wisely recommendation #6

Do not test for amylase in cases of suspected acute pancreatitis. Instead, test for

lipase.

American Society for Clinical Pathology,

Choosing Wisely recommendation #13

Don’t perform urinalysis, urine culture, blood culture or C. difcile testing unless

patients have signs or symptoms of infection. Tests can be falsely positive leading to

over diagnosis and overtreatment.

Society for Healthcare Epidemiology of America,

Choosing Wisely recommendation #3

Don’t obtain a urine culture unless there are clear signs and symptoms that localize

to the urinary tract.

The Society for Post-Acute and Long-Term Care Medicine,

Choosing Wisely recommendation #3

Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction

(AMI). Instead, use troponin I or T.

American Society for Clinical Pathology,

Choosing Wisely recommendation #9

Don’t order investigations that will not change your patient’s management plan.

Don’t order non-urgent investigations or procedures that will delay discharge of

hospital inpatients.

Don’t order invasive studies if less invasive options are available and as effective.

Resident Doctors of Canada,

Choosing Wisely Canada recommendations #1,4, 5

Don’t do a urine dip or send urine specimens for culture unless urinary tract symptoms

are present.

Canadian Nurses Association and Infection Prevention and Control Canada,

Choosing Wisely Canada recommendation #1

Inspiration for this toolkit

At North York General Hospital (NYGH), 40% of all lab tests came from the emergency

department (ED). Among those, almost 50% were ordered through medical directives. While

medical directives are utilized to support quality patient care and ow within the department,

ordering unnecessary lab tests must be avoided. NYGH found that unnecessary testing was

associated with outdated medical directives, inappropriate utilization of medical directives,

and inconsistent ordering habits. As an early adopter of the Choosing Wisely initiative,

NYGH implemented a campaign in 2014 to improve the appropriateness of tests ordered in

the ED. The process involved revising and updating ED medical directives and incorporating

the latest evidence-based practices, including Choosing Wisely Canada recommendations.

The campaign engaged ED and lab staff at all levels and was accompanied simultaneously

by educational and awareness activities. With the introduction of the newly updated medical

directives, the ED has experienced and maintained a 23% reduction of total ED lab testing

over 2 years.

This toolkit was co-authored by Marwan Asalya, Andrea Ennis, Donna McRitchie, and

Kuldeep Sidhu, the key individuals involved in the NYGH project.

Introduction

This toolkit was created to support the reduction of unnecessary testing in the ED by

implementing changes to ED medical directives through a comprehensive approach that

incorporates engagement, education and sustainability.

What are medical directives

Medical directives are indirect physician orders, used to expedite patient care by competent

health professionals. Medical directives are role-specic and apply to specic patient

population who meet specic criteria.

The need to address medical directives in the ED

Studies show that the most commonly used laboratory tests are often ordered together

regardless of the widely varied patient population.

Appropriate utilization of ED testing

can therefore be achieved by limiting the availability of unnecessary test ordering, applying

medical directives and test panels based on best available evidence, and encouraging the

conversation between providers and patients.

Outdated medical directives can impact test utilization and patient ow in the ED. Updating

medical directives is therefore necessary to ensure consistent implementation and improve

appropriateness of ordered tests. Effective implementation of medical orders requires

interprofessional collaboration between ED staff and a good level of knowledge and

competence among nurses initiating medical directives.

Possible risks associated with medical directives

While medical directives improve parallel processing of patients, which leads to improvement

in patient ow, wait times and patient satisfaction, ordering of inappropriate or unnecessary

laboratory tests potentially exposes patients to harm by way of inappropriate downstream

testing and treatments.

Make sure this toolkit is right for you

This toolkit is well suited for your institution if your medical directives are not reviewed or

updated by your utilization committee/medical advisory committee frequently, or if your

testing rates are on the rise you may have reason to believe that current test ordering

practices are not consistent with the Choosing Wisely Canada recommendations and

therefore best practice.

Key ingredients of this intervention:

Building your leadership team

Assembling a group of dedicated individuals with inuence and energy to lead and support

this change is an essential component of this intervention. Team members should consist

of different healthcare professionals, have a shared objective, and work effectively within an

environment of trust and interprofessional collaboration.

The composition of the team should also reect a good representation of all the key players

who can present all relevant views. Choosing Wisely is about encouraging conversations

between clinicians and patients about low-value care and unnecessary tests and treatments.

Having patient representation would also enhance this conversation and enrich the

discussions.

To drive practice-change in the ED, it is crucial to engage inuential physicians and nurse

leaders who can identify unnecessary test ordering, review the medical directives and

passionately advocate for the development and implementation of updated ones. Since

the intervention involves changing medical directives enacted by nursing teams at the ED,

having a nurse champion and a nurse educator on board should be a top priority.

Ideally, the team should include:

• Executive leader

• Physician champion

• Nursing champion

• Nurse educator

• Lab champion

• Medical imaging champion

• Decision support analyst

• Patient safety specialist

• Patient advisor

Achieving consensus among key stakeholder groups

For this intervention to work, key ED stakeholders need to establish initial agreement on

three components:

1) Necessary versus unnecessary ED tests, procedures and treatments; guided by evidence

and best practices

2) Criteria for applying or updating a medical directive

3) Implementation mechanism

Achieving consensus among physicians working in the ED is particularly important due to

variations in their practice, specialty and experience.

Engaging nursing teams

Successful engagement of nursing teams is an essential component in the development

and implementation of ED medical directives. ED nurses drive the triage process, enact

the applicable medical directives, and partner with physicians to decide on appropriate

tests. Nurse managers, educators and frontline nurses must be empowered, not only to

collaborate in the development of medical directives, but also to conduct initial and regular

assessments of competence and learning needs of staff nurses.

Implementing revised and updated medical directives must be accompanied by education

sessions for all nurses. Changes and updates have to be communicated effectively to all

nurses through department meetings, orientation, one-on-one conversations, and other

communication channels.

Addressing barriers to staff engagement and implementation

Recognizing barriers and obstacles is the rst step in overcoming them in the change process.

Addressing barriers directly and early in the process can effectively build trust, facilitate

change, and reduce resistance. Among the reasons physicians might order unnecessary

tests and procedures include: malpractice concerns, patient demands, lack of time, lack of

decision-support, availability of new diagnostic modalities, and concerns that missing a test

up front might delay diagnosis, care, and/or ow.

Common challenges in the ED:

• Competing priorities in the ED

• Staff awareness and education

• Providers rejecting the notion that they overuse tests and treatments

• Concerns that missing a test will delay treatment and ow

• Requests for testing by other specialty services

• Lack of case studies demonstrating similar Choosing Wisely implementation approaches

at ED

Recommended Approaches to Addressing Implementation Challenges

Challenge Approach Tactic

Culture Change

• Consistent reiteration of the

Choosing Wisely core message

• Reinforcement of behaviours

supporting Choosing Wisely

philosophy

• Supportive and encouraging

management/leadership

• Leading by example and visibly

driving change

• Creating a communications strategy

• Adding Choosing Wisely as an

agenda item at different ED depart-

ment meetings

• Establishing accountabilities

• Celebrating short term wins and

making it your own

• Feeling supported by leadership to

engage in transparent communi-

cation can actually be a major part

of the solution to some utilization

issues and destigmatizes ‘failure’ (or

not meeting expectations).

Staff Resistance

• Education and awareness

• Eliciting staff feedback through an

inclusive participatory approach

• Distributing Choosing Wisely

materials

• Partnering with Choosing Wisely

Canada through an awareness

campaign

• Dedicating time at each regularly

scheduled department meeting to

discuss Choosing Wisely

Resources

• Building a good case for

implementing Choosing Wisely

recommendations through robust

data collection

• Providing evidence

• Creating a sense of urgency

• Demonstrating success

• Making it fun

Implementing the intervention/Steps to implementing

Identifying unnecessary lab tests orders within medical directives

Outdated medical directives might contain tests that are:

• Not supported by the latest available evidence and best practices or relevant

guidelines

• Not necessary for the identied population

• Not appropriate for the provisional diagnosis established

• Duplicative of other tests already received, sometimes through other enacted medical

directives

An ideal approach to recognizing over-utilized, inappropriate or unnecessary testing

include:

• Reviewing medical directives regularly

• Review tests ordered under medical directive but with no corresponding medical

directive and discuss with staff rational and understanding of why

The process should be a comprehensive approach that involves physicians working

with nursing and lab champions to examine ED lab utilization data and test-ordering

behaviours. The identied tests should then be examined against up-to-date evidence and

best practices.

Increasing awareness and educational activities

To achieve the best possible outcomes, the above activities have to coexist simultaneously

with educational and administrative interventions that can improve awareness and

communication. Evidence shows that continuous education of clinicians can signicantly

improve appropriate utilization.

In addition to having regular educational sessions and access to relevant materials,

interventions in the form of one-on-one conversations with clinicians have proved helpful.

Nurse educators can use educational feedback strategies to effectively raise awareness

on unnecessary test-ordering patterns and behaviours. The face-to-face approach also

includes discussions about unintended negative consequences of inappropriate testing on

patient care and the health care system in general. The strategy has been one of the most

efcient and successful intervention in reducing overutilization in ED.

Changes to medical directives and ordering patterns

The rst step to revise, update or create a medical directive involves stakeholder

engagement. Representatives from each health care profession who will be affected

by the medical directive must be involved in the development. An information service

representative should also be involved to assess and advise on system impact. The

originator of the medical directive is responsible for developing an educational program

designed to educate staff on the medical directive.

Medical directives must reect evidence-based practice or best practice. Proposed

medical directives must be submitted for review and go through an approval process.

Please see Appendix 1 as an example of a medical directive manual created by NYGH.

Medical Directives Approval Process

Stakeholder Engagement

Choosing Wisely Committee

Patient & Family Advisory Council

Medical Director for Approval

Pharmacy & Therapeutics Input

Medical Directive

Includes

Medication?

Medical Directives Authorization Form

Medical Directive & Order Set Committee

ED Practise Advisory Council

Medical Advisory Committee for Final Approval

Yes

Measuring your performance

1) Outcome Measures:

To capture and track the high-level improvement you are trying to achieve:

• Percentage reduction of rates of ED lab tests conducted per 1,000 ED visits

• Percentage reduction of patients who received one or more ED lab tests per 1,000 ED

visits

• Difference in volumes for an identied test, or a group of tests, in the time period

before Choosing Wisely implementation and the time period after Choosing Wisely

implementation

2) Process Measures:

To capture and track the process and steps leading to the desired outcome:

• Percentage of ED staff engaged in the Choosing Wisely campaign

• Percentage of medical directives revised/updated

• Number of newly developed medical directives

• Number of education sessions targeting medical directives and choosing wisely

3) Balance Measures:

To capture and track any possible negative or unintended consequences of the

intervention:

• Percentage of visits that had an add-on request note attached to the order.

Sustaining early successes

Updating and implementing changes to ED medical directives with concurrent educational

and awareness campaign will signicantly improve the chance of reducing the utilization of

unnecessary and inappropriate testing in ED. To sustain this early success, several steps

should be taken to ensure that the practice change will be maintained:

• Medical directives must be updated regularly (every 2-3 years)

• Annual review of the implemented medical directive should be conducted by the ED

leadership to assess appropriateness and relevancy

• Medical Directives Committee must perform random monthly audits to evaluate the

utilization and appropriateness of medical directives

• ED tests utilization data should be analysed and reported regularly to monitor overall

performance

• Continuous support of ED staff through providing the right education, tools and

resources

• Establishing passion for best practice and improving patient care

• Celebrating success

• Proling leaders and teams that are spearheading best practice initiatives

References

1) Federation of Health Regulatory Colleges of Ontario (FHRCO). Website http://www.

regulatedhealthprofessions.on.ca/orders,-directives,-delegation.html (Accessed

February 10,2017)

2) Ivana Lapić, Dunja Rogić. Laboratory Utilization in The Emergency Department – Are

The Requested Tests Patient-Oriented? SIGNA VITAE 2015; 10(SUPPL 1): 81-83

3) Miyakis, S., Karamanof, G., Liontos, M., & Mountokalakis, T. D. (2006). Factors

Contributing to Inappropriate Ordering of Tests in an Academic Medical Department

and The Effect of an Educational Feedback Strategy. Postgraduate Medical Journal,

82(974), 823–829. http://doi.org/10.1136/pgmj.2006.049551

Resources

QI resources:

1) Health Quality Ontario, QI Tools & Resources

https://quorum.hqontario.ca/en/Home/QI-Tools-Resources/QI-Essentials

2) Institute for Healthcare Improvement, Model for Improvement

http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

Appendix 1 - North York General Hospital Medical Directive Manual

Cardiorespiratory Investigations and Interventions for NUMBER: XII-919

Adult Patients in the Emergency Services Program

PROGRAM: Emergency Services Program

ORIGINATOR: Clinical Nurse Educator, Emergency Services Program

Medical Directive & Order Set Committee ORIGINAL DATE REVIEWED: November 18, 2016 Medical

Advisory Committee ORIGINAL DATE APPROVED: December 13, 2016

DATE RENEWED: N/A

DATE OF IMPLEMENTATION: December 2016 PAGE 1 OF 2

PHYSICIAN’S ORDER(S):

1) CBC

2) Electrolytes (CO2, Na, K, Cl)

3) Creatinine

4) Urea

5) Random Glucose

6) Capillary Blood Glucose (if signs/symptoms of hypoglycemia present) – also refer to Medical Directive XII-905:

Management of Hypoglycemia in Adults

7) Troponin (if cardiac symptoms present)

8) INR (if the patient is on warfarin)

9) Digoxin Level (if suspecting toxicity/reported overdose of medication)

10) Theophylline Level (if suspecting toxicity/reported overdose of medication)

11) Electrocardiogram

12) Saline Lock

Include the following tests if the patient also complains of right upper quadrant or epigastric pain:

1) Lipase

2) ALT

3) ALP

4) Total Bilirubin

Include the following test if patient presents with two or more of the following: temperature < 36ºC or > 38ºC (rectal or

oral); tachypnea (respiratory rate > 20/min); tachycardia (HR > 90/min); hypotension (SBP < 90 mmHg); altered level of

consciousness:

1) Lactate

Refer to Medical Directive XII-68: Administration of Chewable Acetylsalicylic Acid (ASA) to Adult Patients in the

Emergency Services Program.

PERSONS AUTHORIZED TO CARRY OUT THIS DIRECTIVE:

Nurses in the Emergency Services Program

EDUCATIONAL REQUIREMENT:

The nurse will sign off to conrm review of this medical directive.

Cardiorespiratory Investigations and Interventions for NUMBER: XII-919

Adult Patients in the Emergency Services Program

PAGE 2 OF 2

CONSENT:

All authorized nurses will obtain patient/substitute decision maker (SDM) informed verbal consent prior to initiating

orders under the authority of this medical directive.

Note: Consistent with the Health Care Consent Act, 1996; “a treatment may be administered without consent to

a person who is incapable with respect to the treatment, if, in the opinion of the health practitioner proposing the

treatment,

• there is an emergency; and

• the delay required to obtain a consent or refusal on the person’s behalf will prolong the suffering that the person is

apparently experiencing or will put the person at risk of sustaining serious bodily harm”.

MONITORING REQUIREMENT:

Assess for complications of venipuncture, e.g. hematoma formation (most common). Notify the Emergency Department

Physician:

• To review the ECG upon completion

• Of lab results agged in PowerChart as critical

SITUATIONAL CIRCUMSTANCES REQUIRED:

Adult patients registered to the Emergency Services Program prior to assessment by the Emergency Department

Physician, who present with any of the following:

• Known/suspected cardiorespiratory event (collapse/decreased level of consciousness)

• Chest pain (in isolation or with other symptoms). If chest pain is suspected to be musculoskeletal in origin (reported

mechanism of injury), perform ECG only (no lab work, no saline lock)

• Two or more of the following: chest pain, palpitations, shortness of breath, diaphoresis, weakness, lethargy,

dizziness, syncope, pallor, epigastric pain)

RISK AND MITIGATION STRATEGIES

Risk: Complications of venipuncture, e.g. hematoma formation (most common).

Mitigation Strategy: All nurses implementing the directive are trained in proper venipuncture technique.

Risk: Patient leaves the ED after initiation of the directive but prior to results being reviewed by the MD. Mitigation

Strategy: Nurse will notify the Emergency Department Physician of any abnormal lab results.

NO CONTRAINDICATIONS TO THE IMPLEMENTATION OF THE DIRECTIVE (NOT APPLICABLE)

DOCUMENTATION AND COMMUNICATION

Nurses will enter the orders authorized in this medical directive in PowerChart, using a medical directive specic CareSet

or Order Set. The Nurse will also document implementation of this medical directive on the ED face sheet (to facilitate

MD review of orders initiated), until eCare with CPOE has been implemented in the ED.

This toolkit was prepared by:

Donna McRitchie, BSc, MD, MSc, FRCSC

Vice President, North York General Hospital

Assistant Professor, Faculty of Medicine, University of Toronto

Kuldeep Sidhu, MD, CCFP(EM), FCFP

Chief of Emergency Medicine and Program Medical Director, North York General

Hospital

Andrea Ennis, RN, BScN, MNS,

Clinical Team Manager – Emergency Services Program, North York General Hospital

Marwan Asalya, MHA

Project Manager, Choosing Wisely: An Idea Worth Spreading, North York General

Hospital

This toolkit has been peer-reviewed by:

JereyTybergMD,MBA,FRCPC,FACEP

Chief of Staff, Royal Victoria Regional Health Centre

www.ChoosingWiselyCanada.org

info@ChoosingWiselyCanada.org

This Choosing Wisely Canada Toolkit is licensed under the Creative Commons Attribution-

NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license,

visit http://creativecommons.org/licenses/by-nc-nd/4.0/.