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ACB-CLIN-CHEM-GEN  September 2010

ACB-CLIN-CHEM-GEN September 2010

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Subject:

Responses to CRP demand management

From:

Trevor Gray <[log in to unmask]>

Reply-To:

Trevor Gray <[log in to unmask]>

Date:

Fri, 24 Sep 2010 20:06:07 +0100

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Dear all,
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..
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647195/
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 
reasonably well.

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: 
155158. 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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