Today’s clinical hematology laboratory offers a large array of blood product tests contributing to a full service laboratory profile that also includes chemistry, immunology, microbiology, molecular diagnostics, and immunohematology tests. These practice areas comprise more than 4000 different laboratory tests for clinical use, of which, approximately 500 are ordered on a daily basis. An estimated 7 to 10 billion laboratory tests are performed each year in the United States.

Accordingly, test utilization is an ongoing and essential aspect of clinical stewardship. The hematology lab benefits greatly from advanced diagnostic automation, but as with any specialization in the lab, measures must be taken to maximize the utility of laboratory staff and analyzers.

Tips to Refine Test Utilization
The following information is a summary of initiatives adopted from ClinLab Navigator, a resource for laboratory professionals with more than 700 laboratory test interpretations, test utilization guidelines, and transfusion guidelines. These are general tips that laboratories can customize and implement to help reduce excessive, ineffective, unnecessary, and redundant testing.

General Lab Utilization Reduction Tips

• Educate physicians about appropriate test utilization on a continual basis via a laboratory e-newsletter
• Respond promptly to physician calls regarding test ordering and interpretation
• Design test requisitions to encourage optimal test ordering
• Discontinue obsolete tests
• Discontinue low volume tests, especially if you are running more quality control samples than patients
• Have pathologists review lab tests incorporated into clinical pathways
• Have pathologists review orders for esoteric tests being sent to reference laboratories
• Renegotiate pricing for send-out tests on a regular basis
• Review send-out test volumes annually and bring high volume tests in house
• Store specimens in lab for one week for add-on tests
• Eliminate replicate testing of normal and abnormal results
• Eliminate large volume venipuncture tubes
• Decrease laboratory error rate to reduce number of repeat test orders
• Set allowable time intervals for repeat testing in hospital information system
• Implement autoverification whenever feasible
• Merge outpatient and inpatient electronic medical records to reduce number of tests ordered on admission
• Discourage writing of daily orders and set limits for mandatory rewriting of orders
• Compare physician test utilization for a specific diagnosis-related group (DRG) with their peers
• Discourage routine ordering of preoperative screening tests
• Improve turnaround times to reduce tendency to reorder pending tests
• Determine which confirmatory tests should be performed during the inpatient versus the outpatient setting
• Evaluate reference ranges periodically to decrease follow-up testing for slightly abnormal results
• Establish guidelines to determine medical necessity of new test requests
• Ask clinicians to refer point-of-care vendors to the medical director of the laboratory

Hematology-Specific Test Utilization Reduction Tips

• For disseminated intravascular coagulation (DIC) Panel, fibrin degradation products (FDP) and soluble fibrin monomer complexes (SFMC) replaced by quantitative D-Dimer
• Implement standardized heparin protocol dosages based on body weight to realize a decreased number of bleeding episodes due to heparin overdose
• Continuously review hematology analyzer rules to reduce manual differential rate below 30%
• Replace manual reticulocyte with automated counts
• Implement prothrombin time autoverification for outpatients
• Discontinue bleeding time
• Discontinue band neutrophil counts
• Discontinue RBC folate testing
• Encourage physicians to routinely order CBC instead of CBC with differential
• Encourage physicians to order urinalysis with automatic reflex to microscopic exam if positive for blood, protein, or leukocyte esterase
• Implement urinalysis autoverification
• Do not perform Protein C and S for patients receiving warfarin

Hospital Transfusion Service
Recipient Testing

• Use immediate spin crossmatch or electronic crossmatch
• Use anti-IgG instead of polyspecific AHG
• Perform elutions on DAT positive samples only if transfused within last 3 months
• Eliminate recipient anti-A,B testing
• Eliminate autocontrol
• Eliminate weak D testing
• Eliminate reading antibody screen after immediate spin
• Eliminate antigen typing for clinically insignificant antibodies

Donor Testing Policies

• Use anti-A,B to confirm group O units instead of separate anti-A and anti-B
• Confirm Rh type only on Rh negative units

Cord Blood

• Perform ABO and Rh typing only if mother is group O or Rh negative
• Do not perform elution if DAT is positive
• Introduce thawed plasma policy to decrease fresh frozen plasma (FFP) wastage
• Monitor surgeon specific transfusion data annually
• Discontinue shed blood collection after open heart surgery

Conclusion
These general tips are meant to be incorporated into current hematology-related operations in order to assist in establishing proper utilization of hematology laboratory testing resources. For more information, visit www.clinlabnavigator.com.

WHERE TO FIND
Hematology Analyzers
Suppliers
Abbot Diagnostics
Beckman Coulter
CellaVision
Clinical Diagnostics Solutions
Horiba Medical
Mindray
Siemens
Sysmex