This was an innovation project supported by the former Better Care Victoria Innovation Fund.
Testing is considered ‘unnecessary’ if it is not clinically indicated, shows no evidence of benefitting the patient, and/or is more appropriate to defer to a different setting, such as an outpatient clinic.
Unnecessary testing can expose patients to harm, impact patient flow, and result in inefficient use of clinical resources and excessive expenditure.
Building on earlier work, Eastern Health used a clinician-led approach to reduce unnecessary testing across its emergency, intensive care and general medicine programs.
Nine tests were targeted for reduction:
- venous blood gas (VBG)
- coagulation studies (COAG)
- corrected calcium (CCa)
- C-reactive protein (CRP)
- urine micro and culture (UMC)
- chest x-ray (CXR)
- limb CT scans (CT-L)
- urea and electrolytes (U&E)
- full blood examination (FBE).
By ensuring patients only received diagnostic tests that were evidence-based, beneficial to clinical decision-making, and appropriate for the hospital setting, Eastern Health sought to improve the efficiency of its hospitals and reduce inconvenience, discomfort and potential harm to patients.
- Ensure that tests ordered are clinically appropriate, contribute to patient management and are appropriate to the patient treatment setting
- Reduce inconvenience, discomfort and potential harm to patients caused by unnecessary diagnostic testing
- In the emergency program:
- reduced target tests numbers by 38,890 over two years through the introduction and embedding of test reduction strategies
- achieved aggregate reductions in VBG, COAG, CCa, CRP and UMC testing over two years, ranging from 31 per cent (2,986) for UMC to 46 per cent (5,619) for VBG
- implemented CXR test reduction strategies for the first time, resulting in an 8 per cent (3,005) annual reduction
- reduced annual CT-L scans by 8 per cent (29) at the Box Hill Hospital emergency department
- In the general medicine program:
- achieved a combined annual reduction of 4,983 target tests over three general medicine clinics
- decreased ordering in three of the four target tests, with annual reductions ranging from 5 per cent (1,376) for U&E to 12 per cent (1,774) for CRP
- Reduced annual CXR orders by 26 per cent (1,503) across two intensive care units
- Reduced risk of patient harm, improved efficiencies, and saved on unnecessary costs
December 2020 – NUTs information is now included in Eastern Health orientation packages for all medical staff, with information sessions provided throughout the year. Eastern Health is seeking to spread the project further and has established collaborations with Choosing Wisely Australia and associated health services, NPS Medicine Wise and Monash University.
Despite this, sustainability is an ongoing challenge that is being continually addressed through a combination of ongoing education, clinician engagement, embedded test ordering decision support, and clinician feedback.
Additional work in the emergency departments since the completion of this project has focused on the use of evidence-based pathways to reduce unnecessary CT pulmonary angiogram, CT neck and CT brain.