Coagulation screens, AST and daily urea top the list of inpatient tests hospitals are cutting

Design

Process evaluation of a national quality improvement collaborative

Population

157 Canadian hospitals (91 academic, 64 community, 2 paediatric), 2021 to 2026

Primary outcome

Engagement, data submission and types of intervention used

Effect

91 hospitals (58%) submitted testing data; 78% of projects used multimodal interventions

Choosing Wisely Canada's Using Labs Wisely collaborative has grown since 2021 to 157 hospitals across six provinces, 58% academic and 41% community. This process evaluation describes how the programme works rather than its effect on outcomes.

The collaborative benchmarks eight low-value inpatient tests, adjusted for bed-days: coagulation profiles, AST, urea, CK-MB, serum or red cell folate, vitamin B12, ESR and urine cultures. Urea, AST and coagulation testing were the ones hospitals most often targeted. Most improvement projects (78%) used several levers together: education, audit and feedback, changes to order sets, and ordering rules.

For a ward physician, the list is a ready-made audit. Each of these tests is commonly ordered by habit, on admission bundles or as daily repeats, when it will not change management. The usual harms are downstream: incidental results that prompt further tests, iatrogenic anaemia from repeated phlebotomy, and treatment of asymptomatic bacteriuria from unprompted urine cultures.

• Remove routine coagulation screens from admission order sets unless the patient is anticoagulated, bleeding or due a procedure.
• Order AST only when a liver question is being asked; ALT alone often answers a screening question.
• Stop daily urea and electrolytes in stable patients and set an explicit review date instead.
• Send a urine culture only for urinary symptoms or sepsis without a source, not as part of an admission screen.
• Drop CK-MB from chest pain panels; troponin has replaced it for detecting myocardial injury.

Why it matters

Most unnecessary inpatient testing is set by default order sets, which one team can change.

Don't overread it

This evaluation reports participation and methods, not whether patient outcomes or costs improved.

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