Choosing Wisely and COVID-19 pathology retesting intervals

In July 2021 the Illawarra Shoalhaven Local Health District (ISLHD) began to admit patients with COVID-19 into the Wollongong Hospital A5 ward. This started as a clinical service for a small number of local patients with COVID-19 and a larger number of patients transferred from Sydney hospitals. As COVID-19 cases from the ISLHD area increased, there was a greater proportion of local patients admitted. The ward was staffed by a very capable team of junior medical officers (JMOs), consultants from the relevant specialities and nursing staff redeployed to work in the COVID-19 ward.

During the COVID-19 response it was identified that the pathology testing undertaken for this cohort of patients was far greater than for the average inpatient. The COVID Team observed a large volume of pathology tests on a daily basis. Taking blood tests is invasive, often uncomfortable for patients, and contributed to unnecessary close contact between staff and patients. Furthermore, it wasn’t clear that this was clinically indicated or had a positive impact on patient care.

After discussion with the JMOs, two root causes were identified for this unnecessary testing:

• There were no clear pathology guidelines established for COVID-19 patient care
• Lack of communication between senior and junior staff about repeat interval pathology testing requirements for patients with COVID-19.

Infectious Diseases physician, Dr Simeon Crawford noted “…the Senior Medical Officers (SMOs) were all independently coming to the conclusion that frequent pathology ordering didn’t add much to COVID patient care outside of specific clinical indications, and the JMOs and nursing staff were having to spend several hours collecting blood tests each morning because the phlebotomists didn’t visit the COVID Ward”.

Dr Crawford commenced a literature review of COVID patient pathology ordering and initiated a discussion with his colleagues (Spiros Miyakis, Nick Adams, Niladri Ghosh, Omar Shum and Peter Newton) on how to address this issue. The ISLHD Choosing Wisely Program Team approached Dr Crawford to work together to achieve a collaborative solution that would be available to all ISLHD clinicians working with COVID-19 patients.

The objectives of the project were to:

• Establish appropriate interval pathology testing for COVID-19 patients in A5 ward, to reduce unnecessary tests
• Establish standard guidelines in an orientation document for all JMOs who commence work with COVID patients, to improve patient care.

The solutions deployed were:

• Include pathology ordering guidelines within the COVID-19 Ward Medical Officer Orientation Manual, to help standardise patient care and reduce unnecessary testing.
• Provide SMO support for JMOs to work within these guidelines.
• Provide a laminated pathology check sheet at all workstations as a quick reference guide for clinicians.

At the commencement of the project, every COVID Ward patient was having at least 9 pathology tests each day as a standard group ordered by the JMOs. Frequency of ordering of these 9 tests was tracked throughout the project. Within one month the volume of all 9 tests being ordered together had dropped by 81% without adversely impacting patient care. The interval between pathology tests had also improved i.e. not every day unless clinically indicated.

Resulting outcomes:

• JMO confidence improved with provision of guidelines and senior clinician support
• Reduction in low benefit interventions for patients whilst maintaining patient safety and comfort, which improved the patient experience
• Reduced direct exposure time between staff and patients on the COVID-19 ward.