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Choosing Preoperative Pathology Wisely

An audit at the Sunshine Coast University Hospital found that 41% of all pre-operative pathology tests ordered before elective surgery were unnecessary. A Choosing Wisely program introduced at the hospital to address this issue started with urology procedures, and has seen significant improvements.

Dr Lana Vestarkis, Dr Holly Thiele, Dr Anna Pietzsch
Caption (L-R): Dr Lana Vestarkis, Dr Holly Thiele, Dr Anna Pietzsch

The first Choosing Wisely recommendation from the Australian and New Zealand College of Anaesthetists is: Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery. At the Sunshine Coast Hospital we were aware that the protocols within our health service were very outdated, needed reviewing and lacked ownership, and we suspected that our practice wasn’t in line with this recommendation and evidence-based guidelines.

An audit found unnecessary preoperative pathology tests

We undertook an audit of preoperative blood tests performed at the Sunshine Coast University Hospital over a one-month period in February 2021, and compared this to local protocols and Queensland-wide evidence-based guidelines.

The results demonstrated that our local practice deviated significantly from evidence-based guidelines, and also interestingly from our own local protocols. Of the 527 patients, 41% had incorrect pathology ordered. On breaking this down by speciality, there were four departments in which over ordering of pathology occurred for more than 50% of patients. For our urology patients, 77% received blood tests that were not supported by evidence-based guidelines.

Over this one month period, the only changes to care that resulted from the overordering of blood tests were two sets of blood tests that were repeated on the day of surgery, and an iron infusion for a patient who had been missed by the anaemia screening pathway and should have been excluded from the audit. This showed us that we had the potential to reduce unnecessary pathology tests without harming patients.

The impact of these unnecessary blood tests extends beyond the dollar value which we estimated to be $109,000 over a 12-month period. There was also time lost by patients, the distress and pain of blood tests and valuable staff time spent on ordering, performing, and following up pathology results. By reducing unnecessary testing, we can free up resources that may be utilised for other important services. Additionally, as a department with a strong sustainability focus, the CO2 emissions generated from unnecessary blood tests was substantial.

Program of change is reducing unnecessary tests

We began our change program addressing departments individually. We approached each surgical speciality to present the audit data, demonstrate the safety of limited preoperative pathology, and work collaboratively to create an updated pathology protocol that was evidence based.

The protocol developed has been launched for our urology patients. In a repeat audit, compliance with evidence-based guidelines trebled from 23% to 69% with no recorded theatre delays, cancellations or patient harm, and there was a 41% decrease in unnecessary pathology tests.

Our aim is to continue ongoing education for the perioperative staff to increase compliance even further, as well as to redesign protocols for all surgical specialities.

At the Sunshine Coast we continue to reduce low value healthcare whilst not compromising patient care. We hope our findings inspire other health services to Choose Wisely in the perioperative space.

Stewardship toolkit for clinical educators

The Health Resource Stewardship for Clinical educators contains educational material about the Choosing Wisely initiative for use in universities, hospitals and health professional colleges

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