When I was a young man ( and I still think I am)  we saw patients and obtained a history and examination and then made appropriate requests.  Now the patient arrives and has lots of blood taken (or at least lots of tests done) and we work out what has happened afterwards.  It appears that anybody can make a request these days, although we are at the start of a long road in Wales to ensure that requests are made only by those who have been trained and accredited. This might even include doctors!

So what happened to doctors?  There have been various discussions about the ability of junior doctors (and senior ones) to request and interpret appropriately.  Why do we spend £250K training doctors and then not allowing them to use a brain cell?  Is this modernisation? 

 

 

What do others think?

John

 

 

A few weeks ago I posted a query on the mailbase regarding the use of standardised clinically based protocols for tests requested in A&E / Emergency Admission Unit. I promised I would compile a summary of replies and also attached our agreed protocol. Thanks to all who responded, it's been a useful exercise,

Helen

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.

We tried this approach but as the nurses do most of the initial requesting, it never really worked and caused lots of add on tests. We now have a specific A&E form , with a Biochemistry profile which is the same for all patients. The only additional tests we routinely allow are bHCG and coagulation for specific conditions. This has almost completely eliminated add-ons and streamlined requesting in A&E,. The cost of doing additional tests is offset by the savings in not doing the tests that are on the routine request form , eg. Cardiac enzymes, TFTs . There are also labour saving costs in terms of data entry, and requesting in A&E is very simple and liked by the medical staff as they have all the results available when they see the patient. I realise this is form based but thought you may be interested in a more radical approach that works very well for all concerned.

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.

We implemented this for A&E and CDU (acute admissions units) over two years ago. The main objective was to minimize the number of times the out-of-hours BMS staff needed to be contacted for "add on" tests so improving the use of time for both junior doctors and BMSs. We were therefore deliberately fairly generous with what was in the profiles. These were discussed extensively with the consultants in both areas.

A further observation - it is often NOT doctors making these initial admission requests but nursing staff - so that the results might be available when the doctor sees the patient.

We have four clinical profiles:
"Abdo Pain": FBC, U&E. Glu, Amyl, LFT
"Infection?" : FBC, Clotting, U&E, Glu, LFT, CRP
"Self-poisoning": FBC, INR, U&E, Glu, LFT, Alcohol, Salicylate, Paracetaol
"Chest pain": FBC, U&E, LFT, Cardiac enzymes
I agree the content is subject to lots of debate but they are well used and have cut down add on interruptions
We tried on a medical ward (cardiology) - they wouldn't entertain one click when they could make six (even though they requested the same things in 95% of cases). Clinical freedom an all that

<<admission_profile_0908.doc>>

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

01642 624455

Please consider resources and print this e-mail only if essential

------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/