Responses received below:
We did it at heartlands electronically, the computer
automatically stops repeat testing in a 48 hour period. We
get virtually no calls asking us to circumvent the rules.
This stopped 50K of repeat testing in the first year.
Additionally we have put clinical presentation based
requesting into acute medicine and CRP is only on 1 or 2
profiles, still early days but this has made around 30%
reduction in initial tests.
CRP was one of the many challenges in my demand management
work in Cardiff mainly because and evidently based on good
evidence and audit work ESR is not the best marker of
infection or inflamatory, so ESR was taken out from GP
request form and was offered only on very special cases
such as arteritis, PAN and instead they were encouraged
based on quality use of pathology to request for CRP...
For the quality use of CRP we tried on two fronts one was
to stop it being requested by junior from surgical teams
perioperatively to ensure they have a baseline figure to
compare after the operation and monitor early
infection..not sure if this practice is everywhere these
days..we demonstrated in this work that CRP can be
increased even after surgery due to surgical
trauma..irrespective of infection..
The other way to manage it was the repeat requesting
interval and for that you have to set an interval within
the LIS whereby any repeat CRP will have to be vetted
before analysis and it seems that a 24 hours as the
interval that we could all agree on.
Within our Trust we have a 48 hour automated rejection
rule. This means that the CRP won't be repeated if it's
within 48 hours. There are a few locations excluded from
this rule e.g. NICU and ITU. We do however get some people
call to ask for them to be reinstated but I think it works
We have a block on repeating within 24 hours - this saves
around 300 requests a month on a workload of approx 4000.
Two respondents referred me to this useful paper:
H D Hutton, H S Drummond and A A Fryer. "The rise and fall
of C-reactive protein: managing demand
within clinical biochemistry". Ann Clin Biochem 2009; 46:
155–158. DOI: 10.1258/acb.2008.008126
I appreciated the Meerkat response:
My answer to this type of demand was to suggest that the
clinicians asked management for funding or alternatively
which test they would like you to stop in order to fund
CRP. No funds = no test, simples.
I would strongly advise the use of an intermediate
sensitivity assay with range to 3 figures but with
sufficient bottom end performance to allow the neonatal
paediatricians to detect occult sepsis, but not
sufficiently sensitive (ultra) to allow the GPs and
cardiologists to open the ?CHD floodgates. There is no
doubt that CRP now has its place on the main analysers and
is well established in many protocols requiring a quicker
answer than the equally non-specific ESR. But don't expect
the ESR requests to diminish, since it also has its long
(if not well-) established place in protocols.
Not sure I agree with below - we have some consultants who
exhibit very little sense about CRP:
We have tried several approaches (see attached papers). I
must confess that most only work for CRP for a short
period of time due to the turnover of junior doctors and
the 'risk avoidance' mentality. We generally find that
consultants are sensible about both limiting CRP
requesting and the limitations of ESR, but this isn't
communicated/policed consistently or with any degree of
regularity to their juniors.
Finally there are always the cup half empty brigade:
Nothing works. The escalation in CRP requests is unabated
despite huge intervention.
So looks like 24 or 48 hours ban on repeats (they managed
72 hours in Australia), lots of talking and educating,
cajoling and threatening, but general pessimism it's going
to make any difference! Much like everything else really
Many thanks for responses
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