Daily Labs

Potential Harms of Excessive Labs

Hospital Acquired Anemia

In addition to pain experienced by patients due to phlebotomy, hospital acquired anemia can also occur with repeated testing:

  • A retrospective study of 17,676 patients, researchers determined that nearly 20% of hospitalized patients developed “moderate to severe hospital acquired anemia” (hemoglobin decrease from normal to less than 11 g/dL). (Salisbury AC, et al. Arch IM 2011)

How much does hemoglobin drop with every 100mL of blood collected?

  • 0.2mg/dL
  • 0.5mg/dL
  • 0.7mg/dL

Abnormal or decreasing hemoglobin values often lead to repeat testing which inevitably continues the downward trend. The development of hospital acquired anemia is associated with which of the following:

  • Increased blood transfusions
  • Extended length of stay
  • Higher hospital charges
  • Mortality

Cost

Match the Charge of the Daily Labs (UVA Lab Charges 2017)

  • CBC w/ Differential (Manual)
    $185
  • CBC
    $102

Match the Charge to the Daily Lab (UVA Lab Charges 2017)

  • BMP
    $210
  • CMP
    $396

Match the Charge to the Daily Lab (UVA Lab Charges 2017)

  • Magnesium
    $92
  • Phosphorus
    $70

Labs Lead to Further Testing

While laboratory expenditure often accounts for less than 5% of most hospital budgets, their impact is profound with laboratory test results influencing nearly of all medical decisions to pursue further testing or procedures.

Studies on Savings

  • An 11 week intervention to reduce routine blood work on surgery services reduced hospital charges per patient day from $147.73 to $108.11 (p=0.002). (Stuebing EA, et al. Arch Surgery 2011)
  • A one month intervention using checklists, visual reminders, and provider education led to an estimated annual cost savings of $709,644 and prevention of excess phlebotomy of approximately 48 liters of blood per year. (Ko A, Murry JS, et al. J Surg Res 2016)
  • Other studies have revealed an estimated cost savings from reducing routine phlebotomy ranging from $91,793 to $163,751 per year. (Procop GW, et al. Am J Clin Path 2014; Konger RL, et al. Am J Clin Pathol. 2016)

Safety

Although reducing repetitive laboratory testing can decrease costs, patient safety should remain at the forefront.

True or False

  • Several studies have confirmed no increase in adverse patient outcomes when laboratory testing is reduced.

Studies on Safety

Several studies have confirmed no increase in adverse patient outcomes when laboratory testing is reduced.

  • Attali et al. found a significant decrease in laboratory testing over three years did not result in increased readmission rates or missed diagnoses. (Attali M, et al. Mt Sinai J Med. 2006)
  • Vidyarthi et al. similarly found an eight percent cumulative reduction in laboratory testing over three years with no impact on readmission rate or mortality (Vidyarthi et al. Am J Med Qual 2015)

These studies are reassuring in considering to not order daily labs on every patient.

Conclusion

What are some ways to better think about the ordering of daily labs?

  • Discuss the ordering of morning labs while running the list in the afternoon.
  • Discuss with your attending during morning rounds whether a lab is necessary for a patient.
  • Don’t routinely order daily labs on admission and if they are ordered by an admitting team, consider removing them if you are accepting the patient.
  • During handoff, ask the covering/night teams not to order morning labs on your patients, unless there is a change in clinical status.

Lab Charges

CBC: $102

CBC w/ Diff (Automatic): $132

CBC w/ Diff (Manual): $185

BMP: $210

CMP: $369

Magnesium: $92

Phosphorus: $70

Please continue to think critically about the ordering of labs for patients as you manage their care.

Interested in Learning More?

If you are interested in learning more about the ordering of daily labs, look at this recently published paper in JAMA Internal Medicine: "Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing" 

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