To Bleed or Not to Bleed: Improving Pathology ordering in the ED

Mrs Matilda Schmidt1
1Rbwh Queensland Health, Herston, Australia

Considerable “just in case” pathology ordering was identified in the RBWH ED. Several initiatives to reduce low value pathology ordering were proposed, including beta HCG (bHCG) and Group and Hold (G&H) requests. In the case of bHCG, many female patients with low risk of pregnancy as their clinical presentation received serum quantitative bHCG tests. These tests contribute to a delay in results that can delay treatment or further investigations. Additionally, unnecessary G&H requests were identified. A large number of G&H tests are requested and never needed to generate a transfusion for patients.


–              Reduce unnecessary pathology including duplicate tests

–              Reduce delays in determining pregnancy status

–              Reduce the number of G&Hs that do not initiate a transfusion request in 72h

Additional steps were taken to encourage POC bHCG testing. Access to POC cartridges and ability to record POC results were improved. The number of quantitative bHCG tests ordered has reduced by 76%, a saving of $74,425 per year. The proportion of quantitative bHCG tests returning a negative result suggests a reduction in “just in case” ordering, falling from 75% to 27%. A 46% reduction in G&Hs ordered results in a saving of $110,012 per year. There has also been a significant increase in the proportion of G&Hs which are crossmatched, illustrating a reduction in “just in case” ordering. Implementation of clinician-led quality improvement initiatives improves appropriateness of pathology ordering within a large emergency department. While education and engagement of clinical champions had some impact, the most effective, rapid change resulted from implementing a forcing function that requires clinicians to stop and think about the value of care they are providing.

Matilda is a Clinical Nurse and Nurse Practitioner Candidate in the Emergency and Trauma Centre at RBWH. Throughout her 10 years of ED experience she has developed a passion for quality improvement and reducing unnecessary waste within the ED which have a flow on effect to the patient care provided.