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Shellharbour Hospital: Supporting JMOs to Choose Blood Tests Wisely

Blood tests ordered that do not provide information that change treatment or patient outcomes are unnecessary, bring inconvenience for patients, increase medical staff workload, and add extra costs. As part of their Choosing Wisely work, Shellharbour Hospital has introduced an education program to support junior medical officers (JMOs) choosing blood tests wisely.

Dr Jacqui Irvine, the Southern Illawarra Hospital Group (SIHG) Director of Medical Services, has been leading a Choosing Wisely project at Shellharbour Hospital (SHH) focussing on reducing *unnecessary testing of inpatients. The initial focus group decided to work on reducing blood tests that did not contribute to care. This would reduce the number of needles for patients and the number of resultant unnecessary follow-up investigations. It would also reduce the workload for medical staff.

Guidance and expectation setting for JMOs

Luke Hegedus, Medical Student Paramedic, members of the SHH Medical team Dr Dhanya Sanjeev, Dr Samantha Kurniawan and Dr Qian-ao Chen, and Dr Jacqui Irvine, SIHG Director Medical Services
Caption (L-R): Luke Hegedus (medical student paramedic), Dr Dhanya Sanjeev, Dr Samantha Kurniawan and Dr Qian-ao Chen (members of the SHH Medical Team), and Dr Jacqui Irvine (SIHG Director Medical Services)

All physicians agreed to the project for reduction and supported their medical teams in reducing testing.

It was identified by the junior medical staff that a lack of clear direction from more experienced staff and a belief that they would be criticised for not doing bloods were key reasons for over-ordering. We decided to introduce team ‘blood rounds’ every afternoon where registrars and JMOs would discuss the ongoing care needs of their patients - including planning of any blood tests. Registrars agreed to provide explicit instructions daily to JMOs on what blood tests patients required and when. Consultants supported this by providing guidance to the registrar and JMO during rounds and in teaching with reinforcement of the concept of testing only when it makes a difference to the patient. Consultants also committed to ensuring that they were supporting a lower-ordering culture by responding in an educative and non-critical manner when tests were not ordered as per their expectations.

There is no such thing as ‘routine bloods’

An additional opportunity was identified in noting that there are some tests that are commonly ordered as a panel when a single test is all that is required, and when there is a significant cost difference between the test and the panel. These were summarised on a ‘prompt card’ for quick reference. The reverse side of the card had the slogan that the JMOs and Registrars felt best captured their feelings and goals … “there is no such thing as routine bloods”.

Reducing pathology testing

Choosing Wisely is now embedded into SHH Site Orientation and the project goals and successes are discussed in handover and education sessions. Pathology costs have been used as a readily available proxy for volume and frequency of test ordering. We also review data on compliance against best practice test ordering in order to ensure safety in the test reduction and to identify which tests we need to focus more attention on. Since project implementation, the SHH inpatient teams have reduced pathology testing by an incredible 20% each month.

Dr Irvine said, “Our SHH results for 2020 were a reduction of 20.2% (almost $400,000) decrease in pathology costs for SHH hospital. This is a fantastic achievement by the team and we are keen to continue our work with this project.”

*unnecessary = tests, treatments and procedures where evidence shows they provide no benefit, or in some cases, lead to harm.

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