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You can dramatically reduce costs by not routinely ordering coagulation studies for all patients with acute coronary syndromes, says Charlene Babcock Irvin, MD, FACEP, assistant vice chief for the Depart-ment of Emergency Medicine at St. John Hospital and Medical Center in Detroit.
The facility’s ED has stopped routinely ordering these tests and expects to save up to $700,000 this year as a result, she reports. "In this era of cost containment, ED managers need to critically evaluate whether routinely ordered tests are really necessary," she says. "Frequently, we order tests that don’t influence the management of the patient."
She points to research showing that routine prothrombin time (PT) and partial thromboplastin time (PTT) testing is not necessary for all acute coronary syndrome patients.1 "Healthy adults without evidence of bleeding disorders based on history and physical examination, and who are not taking anticoagulants, do not require these tests prior to heparinization," she says. "Residents have been asked not to routinely order these tests unless a clear indication exists."
The indications that do require these tests include active bleeding, history or evidence of liver disease, history of alcohol abuse, history or evidence of active coagulopathy, or the patient taking warfarin or Coumadin, she says. "For instance, if the patient is taking Coumadin, then clearly they are likely to have an induced coagulopathy from the medication," she says. "Those patients should not be started on heparin until their coagulation profiles come back." A good history and physical examination should identify those patients for whom the coagulation profile is indicated, she adds.
Since the change was made, ordering of coagulation testing has decreased about 30%, reports Irvin. "Previously, we ordered about 1,000 of these tests each month," she says.
When patients are taking Coumadin, it may be a reflex response to order the PT and the PTT, Irvin notes. "However when the patient is taking Coumadin, you really only need to order the PT, not both. So that should reduce further studies ordered," she says.
1. McKinley L, Wrenn K. Are baseline prothrombin time/partial thromboplastin time values necessary before instituting anticoagulation? Ann Emerg Med 1993; 22:697-702.
For more information about ordering of coagulation studies in the ED, contact:
• Charlene Babcock Irvin, MD, FACEP, Assistant Vice Chief, Department of Emergency Medicine, St. John Hospital and Medical Center, 22101 Moross, Detroit, MI 48236. Telephone: (313) 343-8797. Fax: (313) 343-7620. E-mail: email@example.com.