Avoid Routine Lab Testing in Clinically Stable Hospitalized Adults

by Joseph Esherick, M.D., FAAFP, FHM

The Society of Hospital Medicine in collaboration with the Choosing Wisely organization has advocated against routine daily lab testing for hospitalized adults since September 2013.  At that time SHM wrote, "Hospitalized patients frequently have considerable volumes of blood drawn (phlebotomy) for diagnostic testing during short periods of time. Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients and can contribute to anemia. This anemia, in turn, may have significant consequences, especially for patients with cardiorespiratory diseases. Additionally, reducing the frequency of daily unnecessary phlebotomy can result in significant cost savings for hospitals."  The reality also is that lab errors do occur and if you order 20 labs on a healthy patient, 1 test on the average will be "abnormal" and represent a false positive result.  This false positive result can then snowball into further inappropriate testing at times. 

The basic dictum is asking the question, "will the results of this test change management?"  If the answer is "no", then why order the test.  It is this same mentality from which daily routine chest x-rays are no longer advocated in clinically stable mechanically ventilated patients.  There is also plenty of data that recommend against routine preop lab testing or routine preop echocardiograms for non-cardiac surgery in stable patients. 

Recently, there has been a new push to minimize routine daily lab testing in clinically stable hospitalized adults.  The October 16, 2017 issue of JAMA has reiterated these Choosing Wisely initiatives that repetitive laboratory testing in the face of clinical stability is "low value care."  The authors of this article state strongly that, "Routine daily laboratory testing of hospitalized patients reflects a wasteful clinical practice that threatens the value of health care."  They continue by stating that, "laboratory tests influence nearly 60% to 70% of all medical decisions. Excessive phlebotomy can lead to hospital-acquired anemia, increased costs, and unnecessary downstream testing and procedures. Efforts to reduce the frequency of laboratory orders can improve patient satisfaction and reduce cost without negatively affecting patient outcomes."  When 2/3 of our medical decisions are based on the influence of lab testing, you can see how there can be a domino effect that propagates the tendency to perform more unnecessary testing in clinically stable patients further increasing our healthcare costs.

Some simple interventions can be done at all institutions to reduce unnecessary routine daily lab testing in clinically stable patients:

  • Clinician education that Choosing Wisely initiatives and SHM recommend against this practice
  • Clinician education about the patient-related charges for each ordered lab/test
  • Electronic health record pop-ups to justify the need for daily labs
  • Eliminating the option of ordering daily labs for a given period of time on patients (e.g., ordering daily CBC and basic metabolic panels for a week)

These evidence-based guidelines have been instituted at high-functioning hospitals without affecting patient safety and have led to marked institutional cost savings, earlier hospital discharges and improved patient satisfaction scores.  So, please stop ordering routine daily labs on clinically stable hospitalized adults.

Eaton KP, Levy K, Soong C, Pahwa AK, Petrilli C, Ziemba JB, Cho HJ, Alban R, Blanck JF, Parsons AS. Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing. JAMA Intern Med. Published online October 16, 2017. doi:10.1001/jamainternmed.2017.5152

http://www.choosingwisely.org/clinician-lists/society-hospital-medicine-adult-repetitive-cbc-chemistry-testing/