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Agreed admission test protocol
We had a problem based request form for A&E with a tick box, for example,  for "Chest Pain /AMI / CVA" and in small type the tests provided. 
 
To start with, there were a few comments about removing doctors' autonomy, but the consultants were persuaded that this system imposed an acceptable level of discipline to test requesting.  One of the reasons we tried this approach was because A&E doctors, particularly late at night, would forget to request the on-admission lipids which were required for an audit project and we were being asked daily for add-on lipids for patients after they had been discharged.  With the new request form, these results were always available.  Another reason was that we rarely got any clinical information and we considered that the tick box gave us at least a minimum - chest pain, abdo pain, head injury, etc.  More recently, the form was criticised at a CPA inspection for not having a separate box for clinical information.
 
One of the benefits we found was that we could change the profiles, in agreement with the consultant staff, without having a major publicity campaign to inform all the medical staff who were making the requests to either start asking for a test or to stop asking for one in a particular group of patients.  For example, the chest pain screen initially included TSH and troponin T.  However, after auditing the results, we removed both.  With the TSH, we found we had a group of regular patients admitted with chest pain post large doses of alcohol and they were getting TSH assayed monthly or more frequently.  With the Troponin-T, we found that the majority of patients were seen well within 12 hours of on-set of symptoms and we were concerned that they might be discharged on the basis of a negative TnT and enzymes which had not had time to become elevated.
 
Following discussion with the consultants in A&E, our "head injury screen" included alcohol but this decision reflects our local population.
 
One the general topic of multidiscipline request forms, all the examples I have seen still group the requests by discipline but I don't think the users need to know which lab does what if they are presenting us with only one request form.  What they really want to know if which specimen is required for which test.  I've been assured that the correct order for taking specimens is citrate, clotted, li-hep, EDTA and fluoride - for the musicians among us, it is the C-clef.  So I'd like to propose something along the following lines which shows, left to right, the correct order of taking specimens and, top to bottom, the tests which are available on each. 
 
 

Citrate

Clotted

Li-heparin

EDTA

Fluoride

D-Dimer

Factor assay

Fibrinogen

Heparin

INR

PPT

 

B12 / Folate

Ferritin

 

UE

LFT

Amylase

Bone

 

Gonadotrophins

Thyroid

 

Anticonvulsants*

Digoxin

Iron

Lithium

Troponin-T

Tumour Markers*

Uric acid

 

* Specify which

Aluminium

Ammonia

 

 

ESR

FBC

Blood Film

Glandular fever

HbA2

 

Carboxy-Haemoglobin Met-Haemoglobin

 

PTH

 

 

Glucose

Lactate

Alcohol

Ethylene Glycol

 

 
 
Regards and best wishes, Elliott
Retired but working part-time, mainly at Hairmyres Hospital, East Kilbride
 
 
 -----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]]On Behalf Of Colley, Michael
Sent: 12 August 2008 10:09
To: [log in to unmask]
Subject: Re: Agreed admission test protocol

We have a number of protocols for use in A&E and AAU
 
MEDA (Medical Admission Profile)    
U&E,Creat(= UEC),LFT,CRP (the answer to life , the universe....),Calcium Group(CG),Glucose,Full Blood Count(FBC)
 
FNOF (# neck of femur)   as MEDA, but no CRP plus TSH if not done within last 3 months
 
ABDO (abdo pain)   as MEDA but no Calcium Group, plus amylase
 
CP1 (Chest pain 1st sample)  as MEDA plus Troponin, Clotting Studies(CS) and Cholesterol but no CG
 
CVA (Stroke) as MEDA plus Chol & CS and ESR
 
TRAU (Trauma)  UEC,LFT,AMYL,FBC,CS
 
APPX  (Appendix)   UEC,CRP,FBC
 
Moreover, we do not do TSH for A&E cases unless relevant clinical info, such as Atrial Fibrillation; this is blocked by the computer system.
 
These were agreed with the A&E / AAU consultants and work quite well.
 
Michael

From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Helen Verrill
Sent: 12 August 2008 09:34
To: [log in to unmask]
Subject: Agreed admission test protocol

Having used the Anglia ICE system for GP requests for some time, we are now looking at implementing in the acute setting. This is seen as an excellent opportunity to agree some admission testing protocols for common presentations with A&E and our admission unit (and having seen the requests made during the change of house this could be well overdue!). ICE would allow us to have a 'chest pain screen' but would not prevent other tests being added if thought to be required. So far, we have had two types of response; namely 'you are turning Doctors into machines and removing their clinical autonomy' and 'wonderful, it will mean we get the tests we should have had'. Has anyone implemented this type of approach and if so, how did you agree the protocols to be followed? I've attached our proposed protocol and will collate any responses for the mailbase,

Thanks

Helen

<<Investigation Tariff.doc>>

Helen Verrill
Consultant Clinical Scientist
North Tees and Hartlepool NHS Foundation Trust

01642 624455

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