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Clinical pathology selected abstracts

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Editor: Deborah Sesok-Pizzini, MD, MBA, professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and chief, Division of Transfusion Medicine, Children’s Hospital of Philadelphia.

Optimization of laboratory ordering practices for CBC with differential

May 2019—Over 5 billion laboratory tests are performed in the United States each year, and more than 20 percent are considered unnecessary. The American Board of Internal Medicine Foundation initiated the Choosing Wisely campaign in 2012 to increase awareness of wasteful or unnecessary medical tests, procedures, and treatments. Studies have shown that tests ordered without a clear rationale not only waste resources but are also a source of iatrogenic anemia, which has been associated with increased blood transfusions, lengths of stay, and mortality. The most common tests performed in the clinical hematology laboratory are the CBC and CBC with differential. The Choosing Wisely campaign recommends eliminating repeat CBC and chemistry testing for stable patients. Furthermore, it is recommended that the CBC with differential be repeated only in specific situations, such as for risk or symptoms of anemia, signs of infection, or a disease or treatment that affects blood cells. The authors conducted a study to determine if a reduction in CBC and CBC with differential tests could be achieved without negatively impacting patient care. They compared the quantity of testing and distribution of repeated tests before, during, and after an educational intervention. After collecting data on hospital ordering patterns, the team collected data about total CBC and CBC with differential orders from comparable hospitals. An analysis of these data showed that the CBC with differential test was ordered 10-fold more frequently than CBC tests. The trauma burn intensive care unit (TBICU) ordered the most CBC with differential tests, with repeat testing ordered every four to 12 hours. Therefore, the educational intervention was targeted at reducing the ordering of CBC with differential tests in the TBICU. The most significant change that resulted from this intervention was a decrease in the number of CBC with differential tests ordered and an increase in the number of CBC tests ordered for TBICU patients. The intervention also significantly decreased the number of CBC with differential tests performed within 22 hours of each other for TBICU patients. One reason for ordering the CBC with differential was to use it as an early marker for sepsis and to look for bandemia. The investigators analyzed data pre- and post-intervention to ensure that less frequent testing did not negatively impact or delay the diagnosis of sepsis. The authors concluded that the intervention reduced the number of CBC with differential tests ordered and tests repeated every 12 hours without negatively impacting patients. These results were sustainable after the intervention. The authors also noted improvement in other hospital units, most likely through staff members sharing information between units.

Shen JZ, Hill BC, Polhill SR, et al. Optimization of laboratory ordering practices for complete blood count with differential. Am J Clin Pathol. 2019;151:306–315.

Correspondence: Dr. Robin G. Lorenz at rlorenz@uabmc.edu

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