1
|
Hjortsø CJS, Møller MH, Perner A, Brøchner AC. Routine Versus On-Demand Blood Sampling in Critically Ill Patients: A Systematic Review. Crit Care Med 2023; 51:717-730. [PMID: 36951465 DOI: 10.1097/ccm.0000000000005852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES We aimed to provide an overview of the current evidence on routine versus on-demand blood sampling in critical care. We assessed the reported proportion of patients exposed to daily routine blood sampling, the tests performed, characteristics associated with more frequent blood sampling, and the reported benefits and harms of routine blood sampling compared with on-demand sampling. DATA SOURCES We systematically searched the Cochrane Library, the Excerpta Medica Database, and the Medical Literature Analysis and Retrieval System Online for studies assessing routine versus on-demand blood testing in critically ill patients from inception to September 2022. STUDY SELECTION Abstracts and full texts were assessed independently and in duplicate by two reviewers. STUDY EXTRACTION Data were extracted independently and in duplicate by two reviewers using predefined extraction forms. DATA SYNTHESIS Of 12,212 records screened, 298 full-text articles were assessed for eligibility. We included 70 studies; 50 nonrandomized interventional studies and 20 observational studies. Exposure to routine blood testing was 52-100% (very low certainty of evidence). Blood testing seemed to occur more frequently in medical intensive care settings with a median of 18 blood tests per patient day (interquartile range, 10-33) (very low certainty of evidence). Mixed biochemistry seemed to be the most frequently performed blood tests across all settings (five tests per patient day; interquartile range, 2-10) (very low certainty of evidence). Reductions in routine blood testing seemed to be associated with reduced transfusion rates and costs without apparent adverse patient outcomes (low certainty of evidence). CONCLUSIONS In this systematic review, routine blood testing in critically ill patients was common and varied considerably. A reduction in routine blood testing appeared to be associated with reduced transfusion rates and costs without adverse effects, but the evidence was very uncertain.
Collapse
Affiliation(s)
- Carl J S Hjortsø
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
2
|
Hooper KP, Anstey MH, Litton E. Safety and efficacy of routine diagnostic test reduction interventions in patients admitted to the intensive care unit: A systematic review and meta-analysis. Anaesth Intensive Care 2021; 49:23-34. [PMID: 33554634 DOI: 10.1177/0310057x20962113] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Reducing unnecessary routine diagnostic testing has been identified as a strategy to curb wasteful healthcare. However, the safety and efficacy of targeted diagnostic testing strategies are uncertain. The aim of this study was to systematically review interventions designed to reduce pathology and chest radiograph testing in patients admitted to the intensive care unit (ICU). A predetermined protocol and search strategy included OVID MEDLINE, OVID EMBASE and the Cochrane Central Register of Controlled Trials from inception until 20 November 2019. Eligible publications included interventional studies of patients admitted to an ICU. There were no language restrictions. The primary outcomes were in-hospital mortality and test reduction. Key secondary outcomes included ICU mortality, length of stay, costs and adverse events. This systematic review analysed 26 studies (with more than 44,00 patients) reporting an intervention to reduce one or more diagnostic tests. No studies were at low risk of bias. In-hospital mortality, reported in seven studies, was not significantly different in the post-implementation group (829 of 9815 patients, 8.4%) compared with the pre-intervention group (1007 of 9848 patients, 10.2%), (relative risk 0.89, 95% confidence intervals 0.79 to 1.01, P = 0.06, I2 39%). Of the 18 studies reporting a difference in testing rates, all reported a decrease associated with targeted testing (range 6%-72%), with 14 (82%) studies reporting >20% reduction in one or more tests. Studies of ICU targeted test interventions are generally of low quality. The majority report substantial decreases in testing without evidence of a significant difference in hospital mortality.
Collapse
Affiliation(s)
- Katherine P Hooper
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew H Anstey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.,Intensive Care Unit, St John of God Subiaco Hospital, Perth, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia.,Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.,Intensive Care Unit, St John of God Subiaco Hospital, Perth, Australia
| |
Collapse
|
3
|
Chaves MHM, Wolf ARDS, Nascimento KAL, Nawcki D, Feustel GM, Bettega PVC, Ignacio SA, Brancher JA, Tannous LA, Werneck RI, Souza PHC, de Barros MMT, Johann ACBR. Sialochemical analysis in polytraumatized patients in intensive care units. PLoS One 2019; 14:e0222974. [PMID: 31581248 PMCID: PMC6776458 DOI: 10.1371/journal.pone.0222974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/11/2019] [Indexed: 02/07/2023] Open
Abstract
The profiles of polytraumatized patients in intensive care units were characterized. Serum and salivary markers were compared with normality between Classes I and II of APACHE II and between periods of hospitalization; these results were correlated. This was a prospective study on saliva charts and collection (n = 70). Profile: male, 27 years old, blunt traumas and collisions. Serum parameters with normality: decrease in pH, creatinine at admission to Class I, and at 48 and 72 hours in both classes; K+ at 48 h in Class II; Ca+ on admission in both classes and at 72 h in Class I. Increase in urea at 72 h in Class II, glucose at all times and in all classes, and Ca+ at 48 h in both classes. Class II had high Na+ at 48 and 72 h compared to Class I. In Class I, creatinine reduction occurred in 48 h and 72 h compared to admission and an increase of Ca+ at 48 h with admission. In Class II, pH and Na+ increased at 48 h and 72 h compared to admission. K+ decreased from admission to 48 h and increased from 48 h to 72 h. Urea increased from 48 to 72 hours. Creatinine decreased from admission to 48 and 72 hours. Ca+ increased from admission to 48 hours and decreased from 48 to 72 hours. There was an increase in the saliva levels in both classes and times in relation to normality. There was an increase in urea at admission, glucose at 72 h, and Ca+ at 48 h in Class II compared with Class I. Class I urea increased from admission to 48 h and Ca+ decreased from admission to 48 h. Class II urea decreased from 48 h to 72 h. Strong or very strong positive correlation was identified between blood and creatinine saliva at all times and regular and negative Ca+ at 72 h. This study provides evidence that salivary and serum biomarkers can be used together to monitor the evolution of the clinical symptoms of ICU patients.
Collapse
Affiliation(s)
- Maria Heloisa Madruga Chaves
- School of Life Sciences, Department of Nursing, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | | | - Kelly Aline Lima Nascimento
- School of Life Sciences, Department of Nursing, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Danielle Nawcki
- School of Life Sciences, Department of Nursing, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Gabriele Muller Feustel
- School of Life Sciences, Department of Nursing, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Patricia Vida Cassi Bettega
- School of Life Sciences, Department of Dentistry, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Sergio Aparecido Ignacio
- School of Life Sciences, Department of Dentistry, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - João Armando Brancher
- School of Life Sciences, Department of Dentistry, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Luana Alves Tannous
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Renata Iani Werneck
- School of Life Sciences, Department of Dentistry, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Paulo Henrique Couto Souza
- School of Life Sciences, Department of Dentistry, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | | | | |
Collapse
|
4
|
|
5
|
Abstract
Laboratory testing is ubiquitous among hospitalized patients and is more common among patients in the intensive care unit (ICU). Despite its high cost and prevalence, there are few data to support the current practice of laboratory testing in most ICUs. Although testing offers considerable potential benefits, it is not without risk, including misleading results, iatrogenic anemia, and therapeutic actions of uncertain benefit. Laboratory testing should be conducted as part of a therapeutic approach to a clinical problem, mindful of pretest probability of disease, the performance of the selected test, and the relative benefits and risks of testing. Considering the indication for a particular test can lead to a more rational approach to laboratory testing and better use of available tests.
Collapse
Affiliation(s)
- Michael E Ezzie
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, The Ohio State University Medical Center, 201 Davis HLRI, 473 West 12th Avenue, Columbus, OH 43210, USA
| | | | | |
Collapse
|
6
|
Fus AM, Kim MH, Haw JM, Trohman RG, Stephan E. A written policy increases compliance with guidelines for therapeutic anticoagulation prior to elective direct current cardioversion of atrial fibrillation. J Cardiovasc Nurs 2007; 22:417-21. [PMID: 17724424 DOI: 10.1097/01.jcn.0000287039.30810.2e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic anticoagulation before elective direct current cardioversion (DCC) of atrial fibrillation reduces the risk of embolic stroke. Direct current cardioversion is performed by a variety of practitioners, and variable adherence to preprocedural anticoagulation guidelines is common. OBJECTIVE We assessed the impact of a written policy on guideline compliance. METHODS : Anticoagulation status and transesophageal echocardiogram (TEE) results were reviewed in 55 patients (32 men/23 women; ages 18-83 years) who underwent elective DCC during the 6-month period before a written anticoagulation policy was sent to physicians who perform, prepare, or refer patients for this procedure. The nurse assigned to each DCC was responsible for documenting anticoagulation status. In accordance with guidelines, therapeutic anticoagulation was defined as a normalized ratio range > or = 2.0 for at least 3 weeks or a negative TEE with a normalized ratio range > or = 2.0 or a partial thromboplastin time > 50 seconds at the time of DCC. Immediately after policy implementation, anticoagulation status and TEE results were reviewed in 53 patients (42 men/11 women; ages 21-84 years) and 1 year post-policy implementation. RESULTS Before policy implementation, 14 of 52 patients (27%) had DCC performed without adequate anticoagulation or a negative TEE. Immediately postimplementation, only 2 of 50 patients (4%) had DCC performed without adequate anticoagulation or a negative TEE (P = .002). One year post-policy implementation, only 4 of 48 patients (8%) had DCC performed without adequate anticoagulation or a negative TEE (P = .03). CONCLUSIONS Implementing a written policy greatly reduces the number of patients undergoing DCC without adequate anticoagulation or a negative TEE. The impact of this intervention was quickly demonstrable and persisted during follow-up. Supplementing published recommendations with guideline-driven policies may reduce variations in clinical practice and improve quality of care.
Collapse
Affiliation(s)
- Allison M Fus
- Rush University Medical Center, Chicago, IL 60612, USA.
| | | | | | | | | |
Collapse
|
7
|
Pilsczek FH, Rifkin WD, Walerstein S. Overuse of prothrombin and partial thromboplastin coagulation tests in medical inpatients. Heart Lung 2005; 34:402-5. [PMID: 16324959 DOI: 10.1016/j.hrtlng.2005.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION In the monitoring of anticoagulant therapy, prothrombin time (PT) is used to measure the effect of warfarin, whereas the partial thromboplastin time (PTT) measures the therapeutic effect of unfractionated heparin. Low molecular weight heparin (LMWH) does not require routine monitoring. OBJECTIVE We collected data on the frequency of simultaneous PT and PTT requests, where only one or neither is indicated, and estimated the potential cost savings if ordering was appropriate. METHODS The study was performed at Nassau University Medical Center, a major teaching institution in East Meadow, New York. Inpatient charts were reviewed consecutively until 50 patients prescribed warfarin alone, intravenous heparin alone, or LMWH alone were selected. We then determined which coagulation tests were performed each day for these patients by review of their computerized laboratory results. The costs of laboratory tests were obtained from the hospital laboratory and were used to calculate potential savings. RESULTS PT and PTT coagulation tests were requested together in all 50 patients. Seventeen patients on LMWH alone had 30 sets of PT/PTT performed (60 tests). Seventeen patients on intravenous heparin had 87 PTs performed. Twelve patients on warfarin had 60 PTTs performed. In total, 232 unneeded PT or PTTs were ordered in these 50 patients, or 4.6 per patient during hospitalization. CONCLUSION The review of the records of 50 medical inpatients found that PT and PTT were invariably requested together, despite a lack of indication. The 50 patients incurred a total of $2434 in unneeded costs. If representative of common clinical practice, significant cost savings may be possible. Education, computerization, and information on costs of individual tests may reduce unneeded investigations.
Collapse
Affiliation(s)
- Florian H Pilsczek
- Division of Infectious Diseases, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Belfer 610, Bronx, NY 10461, USA
| | | | | |
Collapse
|
8
|
Flabouris A, Bishop G, Williams L, Cunningham M. Routine blood test ordering for patients in intensive care. Anaesth Intensive Care 2000; 28:562-5. [PMID: 11094676 DOI: 10.1177/0310057x0002800515] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Current practice is for a number of blood tests to be routinely performed on intensive care unit (ICU) patients. A survey of routine blood testing amongst ICUs in Australia and New Zealand was conducted. Ninety-six ICUs completed the survey form. Blood electrolytes, liver function, arterial blood gases and full blood count were the most frequently ordered tests. Routine blood testing was not practised in 12.6% of ICUs. The presence or absence of written guidelines did not influence the frequency of the most commonly performed routine blood tests. Clinical and operational factors specific to each ICU appear to impact on such blood tests and guidelines for their use.
Collapse
Affiliation(s)
- A Flabouris
- Department of Critical Care, Liverpool Hospital, Sydney, New South Wales
| | | | | | | |
Collapse
|
9
|
Thorpe S, Thomas AN. The use of a blood conservation pressure transducer system in critically ill patients. Anaesthesia 2000; 55:27-31. [PMID: 10594430 DOI: 10.1046/j.1365-2044.2000.01129.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We tried to determine if a blood conservation pressure transducer system reduced blood transfusions, increased haemoglobin concentration or reduced line infections in critically ill patients. One hundred patients were randomly allocated to conventional or blood conserving systems attached to systemic and pulmonary arterial catheters. Intravascular lines were cultured after removal. There were no significant differences in transfusions or haemoglobin concentration. Blood conservation: median units transfused, 2 (range 0-19); mean haemoglobin at 7 days, 11.2 g.dl-1 (SD, 1.0). Conventional: median units, 2 (range 0-34); mean haemoglobin at 7 days, 11.1 g.dl-1 (SD 1.0). Thirty-seven of 99 arterial lines were colonised in the controls compared with 29 of 96 in the blood conservation group. Patients who required haemofiltration in both groups had significantly increased transfusion requirements. Haemofiltration: median 6 units (range 0-34) vs. non-haemofiltered: median 1 (range 0-14; p < 0.001). There were no significant differences in transfusions, haemoglobin concentration or line colonisation with the blood conservation system. There is considerable potential for blood conservation during haemofiltration.
Collapse
Affiliation(s)
- S Thorpe
- Department of Intensive Care, Hope Hospital, Stott Lane, Salford, UK
| | | |
Collapse
|