Abbasciano RG, Yusuff H, Vlaar APJ, Lai F, Murphy GJ. Blood Transfusion Threshold in Patients Receiving Extracorporeal Membrane Oxygenation Support for Cardiac and Respiratory Failure-A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth. 2021;35(4):1192-1202. PMID: 33046363.

Carson JL, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016 Nov 15;316(19):2025-2035. PMID: 27732721.

Consensus recommendations for red blood cell transfusion practice in critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19(9): 884-898. PMID: 30180125.

Mistry N, Shehata N, Carmona P, Bolliger D, Hu R, Carrier FM, Alphonsus CS, Tseng EE, Royse AG, Royse C, Filipescu D, Mehta C, Saha T, Villar JC, Gregory AJ, Wijeysundera DN, Thorpe KE, Jüni P, Hare GMT, Ko DT, Verma S, Mazer CD; TRICS Investigators. Restrictive versus liberal transfusion in patients with diabetes undergoing cardiac surgery: An open-label, randomized, blinded outcome evaluation trial. Diabetes Obes Metab. 2022 Mar;24(3):421-431. doi: 10.1111/dom.14591. Epub 2021 Nov 17. PMID: 34747087.

There is little evidence to indicate there is value in routine blood tests in asymptomatic patients; instead, this practice is more likely to produce false positive results that may lead to additional unnecessary testing. The decision to perform screening tests, and the selection of which tests to perform, should be done with careful consideration of the patient’s age, sex and any possible risk factors.

• Cancer Screening
• Should you be screened with mammography for breast cancer?
• Breast Cancer Guidelines (2011)

The primary rationale for screening asymptomatic non-pregnant patients is that the resulting treatment improves health outcomes when compared with patients who are not screened. There are no RCT or controlled observational studies in non-pregnant adults to assess the value of screening. Treating subclinical hypothyroidism (TSH ~4-10 IU/L and normal T3/T4) showed no benefits in any patient-oriented outcome such as mortality or cardiovascular disease, fatigue, weight, depression, cognitive function or quality of life.

TSH can vary up to 50% between tests and even up to 26% in one day in the same patient. The prevalence of subclinical hypothyroidism is 4-10% in the developing world.

• Don’t do screening Pap smears annually in those with previously normal results
• Don’t do Pap smears in those who have had a hysterectomy for non-malignant disease.

The potential harm from screening younger than 25 years of age outweighs the benefits and there is little evidence to suggest the necessity of conducting this test annually when previous test results were normal. Those who have had a full hysterectomy for benign disorders no longer require this screening. Screening should stop at age 70 if three previous test results were normal.

Resting echocardiography has a clear role for resolving diagnostic questions in surgical patients, such as identifying the basis for suspicious systolic murmurs or new dyspnea on exertion. Outside these indications, resting echocardiography does not contribute significant additional prognostic information to usual clinical evaluation. It is not useful as a screening tool to identify surgical patients at risk for cardiac complications.

Sources:

Fleisher LA, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 9;130(24):e278-333. PMID: 25085961.

Halm EA, et al. Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Ann Intern Med. 1996 Sep 15;125(6):433-41. PMID: 8779454.

Kristensen SD, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014 Sep 14;35(35):2383-431. PMID: 25086026.

Wijeysundera DN, et al. Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study. BMJ. 2011 Jun 30;342:d3695. PMID: 21724560.

Related Resources:

Patient Pamphlet: Echocardiogram Before Surgery: When you need it and when you don’t

Toolkit: Drop the Pre-Op – A toolkit for reducing unnecessary visits and investigations in pre-operative clinics

Asymptomatic, low-risk patients account for up to 45 percent of unnecessary “screening”. Testing should be performed only when the following findings are present: diabetes in patients older than 40-years-old; peripheral arterial disease; or greater than 2 percent yearly risk for coronary heart disease events.

Sources:

American College of Cardiology Foundation Appropriate Use Criteria Task Force, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. PMID: 21349406.

Dowsley T, et al. The role of noninvasive imaging in coronary artery disease detection, prognosis, and clinical decision making. Can J Cardiol. 2013 Mar;29(3):285-96. PMID: 23357601.

Hendel RC, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging. Circulation. 2009 Jun 9;119(22):e561-87. PMID: 19451357.

Natarajan MK, et al. Canadian Cardiovascular Society position statement on radiation exposure from cardiac imaging and interventional procedures. Can J Cardiol. 2013 Nov;29(11):1361-8. PMID: 24035289.

Taylor AJ, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. J Am Coll Cardiol. 2010 Nov 23;56(22):1864-94. PMID: 21087721.

Related Resources:

Patient Pamphlet: ECG (Electrocardiogram): When you need it and when you don’t

Patient Pamphlet: Echocardiogram Before Surgery: When you need it and when you don’t

Patient Pamphlet: Chest X-rays Before Surgery: When you need them and when you don’t

Sources:

Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008 Mar;100:S1–148. PMID: 18431959.

Carr S, Chan E, Lavine E, et al. CSACI Position statement on the testing of food-specific IgG. Allergy Asthma Clin Immunol. 2012 Jul;8(1):12. PMID: 22835332.

Cox L, Williams B, Sicherer S, et al. Pearls and pitfalls of allergy diagnostic testing: report from the American College of Allergy, Asthma and Immunology/ American Academy of Allergy, Asthma & Immunology Specific IgE Test Task Force. Ann All Asthma Immunol. 2008 Dec; 101(6):580–592. PMID: 19119701.

Stapel SO, Asero R, Ballmer-Weber BK, et al. Testing for IgG4 against foods is not recommended as a diagnostic tool: EAACI Task Force Report. Allergy. 2008 Jul;63(7):793-796. PMID: 18489614.

Unlike CK-MB and myoglobin, the release of troponin I or T is specific to cardiac injury.

Troponin is released before CK-MB and appears in the blood as early as, if not earlier than, myoglobin after AMI. Approximately 30% of patients experiencing chest discomfort at rest with a normal CK-MB will be diagnosed with AMI when evaluated using troponins. Single-point troponin measurements equate to infarct size for the determination of the AMI severity. Accordingly, there is much support for relying solely on troponin and discontinuing the use of CK-MB and other markers.

Sources:

Amsterdam et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-228. PMID: 25260718.

Eggers KM, Oldgren J, Nordenskjold A, et al. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J 2004;148:574–81. PMID: 15459585.

Kavsak PA, MacRae AR, Newman AM, et al. Effects of contemporary troponin assay sensitivity on the utility of the early markers myoglobin and CKMB isoforms in evaluating patients with possible acute myocardial infarction. Clin Chim Acta 2007;380:213–6. PMID: 17306781.

Kontos MC, de Lemos JA, Ou FS, et al. Troponin positive, MB-negative patients with non-ST-elevation myocardial infarction: an undertreated but high-risk patient group: Results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (NCDR ACTION-GWTG) Registry. Am Heart J 2010;160:819–25. PMID: 21095267.

Volz KA, McGillicuddy DC, Horowitz GL, et al. Creatine kinase-MB does not add additional benefit to a negative troponin in the evaluation of chest pain. Am J Emerg Med 2012;30:188–90. PMID: 21129891.

Newby LK, Roe MT, Chen AY, et al. Frequency and clinical implications of discordant creatine kinase-MB and troponin measurements in acute coronary syndromes. J Am Coll Cardiol 2006;47:312–8. PMID: 16412853.

Data is conflicting, and while some evidence suggested that IBS patients are at increased risk for organic disease over the long-term compared with individuals in the general population, absolute rates remain low. With respect to CRC, the risk is low in the general population <50 years of age, and IBS is not a recognized risk factor for CRC. There appears to be little or no evidence that IBS increases the risk of CRC over the short-term compared with the general population, with the exception of a study from Taiwan that suggested a 3.6 times higher 10-year risk in the IBS group compared with the non-IBS group Finally, data do not support the idea that patients may be reassured by a normal colonoscopy. Therefore, the consensus group concluded that routine colonoscopy is generally not warranted in IBS patients <50 years of age, and alarm symptoms do not appear to increase the risk of CRC sufficiently to warrant routine colonoscopy. Alarm features that warrant investigation include, but are not limited to, rectal bleeding, weight loss and anemia.

GRADE: Strong recommendation, very low-quality evidence

Sources:

Moayyedi P et al. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). J Can Assoc Gastroenterol. 2019 Apr;2(1):6-29. PMID: 31294724. https://pubmed.ncbi.nlm.nih.gov/31294724/

It is imperative that practitioners respect the pre-injury wishes of the patient. Clarifying these wishes as soon as appropriate, either with the patient or their substitute decision maker, can avoid subjecting patients and their decision makers to aggressive interventions that may not align with their goals.

Sources

Downar J, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*. Crit Care Med. 2015 Feb;43(2):270-81. PMID: 25377017.

There is insufficient evidence regarding the utility of urine drug screening and its effect on health outcomes at the individual and community level. Furthermore, results must be interpreted with caution as they have limitations in sensitivity and specificity. Nevertheless, urine drug screens may be considered when confirming substance use at baseline, helping to assess clinical stability before and during the prescription of take-home doses, ensuring medications are being taken, when screening for illicit substances during treatment to evaluate safety and treatment response, and/or if it is in alignment with patient treatment goals.

Sources:

British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.

Kolla B, Callizo G, Schneekloth T. Utility of Urine Drug Testing in Outpatient Addiction Evaluations. J Addict Med. 2019 May 1;13(3):188-92. PMID: 30418336.

McEachern J. et al. Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. Int J Drug Policy. 2019 Feb; 64:30-33. PMID: 30551003.

While confirmatory urine drug tests such as gas or liquid chromatography/mass spectrometry offer higher sensitivity and specificity and can provide qualitative and quantitative information, they are much more costly and can take days to weeks for results. This delay in results impacts the utility of confirmatory urine drug tests. Point-of-care immunoassays, in contrast, can provide real-time data to inform treatment and support shared decision-making.

Sources:

Beck O, Carlsson S, Tusic M, Olsson R, Franzen L, Hulten P. Laboratory and clinical evaluation of on-site urine drug testing. Scand J Clin Lab Invest. 2014 Nov; 74(8):681–6. PMID: 25046332.

British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.

Witnessed or supervised urine drug screens remain a core component of many addiction treatment programs. There is insufficient evidence linking witnessing urine samples to improved patient-centred clinical outcomes.

Sources:

British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.

Naltrexone is an evidence-based intervention for substance use disorders, including alcohol use disorder. Naltrexone is contraindicated in acute hepatitis and liver failure. In patients without suspected liver disease, pre-initiation liver function screening should not delay naltrexone treatment initiation. Based on available research, there is minimal risk of hepatoxicity associated with naltrexone prescribed at standard dose to treat alcohol use disorder (50mg). Additionally, the delay in treatment may result in patients being lost to care and not receiving an intervention that has the potential to support recovery. Periodic monitoring of liver enzymes is recommended for the alcohol use disorder population as part of comprehensive care.

Sources:

Anton, R. et al. Combined Pharmacotherapies and Behavioural Interventions for Alcohol Dependence. The COMBINE Study: A Randomized Controlled Trial. JAMA. May 2006;295(17), 2003-2017. PMID: 16670409.

Bolton M. et al. Serious adverse events reported in placebo randomized controlled trials of oral naltrexone systematic review and meta-analysis. BMC Medicine. 2019 Jan;17(10). PMID: 30642329.

Croop R. The Safety Profile of Naltrexone in the Treatment of Alcoholism. Arch Gen Psychiatry. 1997 Dec;54(12):1130-1135. PMID: 9400350.

Yen M, Ko H, Tang F, Lu R, Hong J. Study of hepatotoxicity naltrexone in the treatment of alcoholism. Alcohol. 2006 Feb;38(2):117-120. PMID: 16839858.

The incidence of mental health problems in children has increased in the last two decades, with suicide surpassing homicide as the second leading cause of death in teenagers. Most children with acute mental health issues do not have underlying medical etiologies for these symptoms. A large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs. Any diagnostic testing should be based on a thorough history and physical examination. Universal requirements for routine testing should be abandoned.

Sources:

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163. PMID: 31978283.

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818. PMID: 25941283.

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677. PMID: 24342816.

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663. PMID: 24219903.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807. PMID: 24642041.

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department—epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22(2):85-89. PMID: 16481922.

Children presenting with unprovoked, generalized seizures or simple febrile seizures who return to their baseline mental status rarely have blood test or CT scan findings that change acute management.

Blood tests such as electrolyte panels should not be routinely ordered and are only indicated in specific circumstances based on history and clinical examination findings.

CT scans are associated with radiation-related risk of cancer, increased cost of care, and added risk if sedation is required to complete the scan. A head CT scan may be indicated in patients with a new focal seizure, new focal neurologic findings, or high-risk medical history (such as neoplasm, stroke, coagulopathy, sickle cell disease, age <6 months).

Sources:

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000; 55(5):616-623. Reaffirmed October 17, 2020. PMID: 10980722.

Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550. PMID: 17101884.

McKenzie KC, Hahn CD, Friedman JN; Canadian Paediatric Society, Acute Care Committee. Emergency management of the paediatric patient with convulsive status epilepticus. Paediatr Child Health. 2021;26(1):50-57. PMID: 33552322.

American Academy of Pediatrics, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the children with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. PMID: 21285335.

Viral infections occur frequently in children and are a common reason to seek medical care. The diagnosis of a viral illness is made clinically and usually does not require confirmatory testing. Additionally, there is a lack of consistent evidence to demonstrate the impact of comprehensive viral panel (i.e., panels simultaneously testing for 8-20+ viruses) results on clinical outcomes or management, especially in emergency department settings. Hence, most national and international clinical practice guidelines do not recommend their routine use. Additionally, some viral tests are quite expensive, and obtaining nasopharyngeal swab specimens can be uncomfortable for children. Comprehensive viral panel testing can be considered in high-risk patients (eg, immunocompromised) or in situations in which the results will directly influence treatment decisions such as the need for antibiotics, performance of additional tests, or hospitalization. Testing for specific viruses might be indicated if the results of the testing may alter treatment plans (e.g., antivirals for influenza) or public health recommendations (e.g., isolation for SARS-CoV-2). For more specific recommendations related to diagnosis and management of SARS-CoV-2, please see https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/).

Sources:

Gill, PJ, Richardson, SE, Ostrow O. Testing for respiratory viruses in children: to swab or not to swab. JAMA Pediatr. 2017;171(8):798-804. PMID: 28672402.

Noël KC, Fontela PS, Winters N, et al. The clinical utility of respiratory viral testing in hospitalized children: a meta-analysis. Hosp Pediatr. 2019;9(7):483-494. PMID: 31167816.

Parikh K, Hall M, Mittal V, et al. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014;134(3):555-562. PMID: 25136044.

Innis K, Hasson D, Bodilly L, et al. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5. PMID: 33323392.

Patients with spinal cord injury and other conditions that cause neurogenic bladder are at higher risk of developing complications of urinary tract infections, which can drive over-investigation and over-treatment. However, several high-quality studies have demonstrated that screening for and treating asymptomatic bacteriuria (outside of pregnancy and urologic procedures) increase the risk of microbial resistance and the emergence of symptomatic urinary tract infection (UTI). Clinicians should order urine cultures if there are signs and symptoms of a urinary tract infection. Clinicians should treat suspected UTI only with evidence bacteriuria with accompanying signs or symptoms.

Sources:

Craven BC, Alavinia SM, Gajewski JB, et al. Conception and development of Urinary Tract Infection indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project. J Spinal Cord Med. 2019 Oct;42(sup1):205-214. PMID: 31573440. https://pubmed.ncbi.nlm.nih.gov/31573440/

Kavanagh A, Baverstock R, Campeau L, et al. Canadian Urological Association guideline: Diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction – Executive summary. Can Urol Assoc J. 2019;13(6):156-165. PMID: 30763235. https://pubmed.ncbi.nlm.nih.gov/30763235/

Patients on stable doses of non-biologic DMARDs (e.g., methotrexate, sulfasalazine) without specific comorbidities (e.g., obesity, diabetes mellitus, renal disease, liver disease, alcohol use, concomitant use of hepatotoxic or myelosuppressive medications) are at a low overall risk of toxicity. More frequent blood draws pose an unnecessary burden to patients. Patients new to treatment, on escalating doses, or with abnormal baseline labs typically require more frequent monitoring.

Sources:

Hideto Kameda, Takao Fujii, Ayako Nakajima, Ryuji Koike, Akira Sagawa, Katsuaki Kanbe, Tetsuya Tomita, Masayoshi Harigai, Yasuo Suzuki & Japan College of Rheumatology subcommittee on the guideline for the use of methotrexate in patients with rheumatoid arthritis (2019) Japan College of Rheumatology guideline for the use of methotrexate in patients with rheumatoid arthritis, Modern Rheumatology, 29:1, 31-40, DOI: 10.1080/14397595.2018.1472358. PMID: 29718746.

Jo Ledingham, Nicola Gullick, Katherine Irving, Rachel Gorodkin, Melissa Aris, Jean Burke, Patrick Gordon, Dimitrios Christidis, Sarah Galloway, Eranga Hayes, Andrew Jeffries, Scott Mercer, Janice Mooney, Sander van Leuven, James Galloway, on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868, https://doi.org/10.1093/rheumatology/kew479. PMID: 28339817.

Nakafero G, Grainge MJ, Card T, Mallen CD, Zhang W, Doherty M, Taal MW, Aithal GP, Abhishek A. What is the incidence of methotrexate or leflunomide discontinuation related to cytopenia, liver enzyme elevation or kidney function decline? Rheumatology (Oxford). 2021 Dec 1;60(12):5785-5794. doi: 10.1093/rheumatology/keab254. PMID: 33725120.

Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O’Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016 Jan;68(1):1-26. doi: 10.1002/art.39480. Epub 2015 Nov 6. PMID: 26545940.

Yazici, Y et al. “Long term safety of methotrexate in routine clinical care: discontinuation is unusual and rarely the result of laboratory abnormalities.” Annals of the rheumatic diseases vol. 64,2 (2005): 207-11. doi:10.1136/ard.2004.023408. PMID: 15208176.

Avoid ordering these autoantibodies in patients with arthralgia (joint pain) but who do not meet the CSA criteria or have arthritis (>one swollen joint) on physical exam. EULAR defines CSA at risk for developing Rheumatoid Arthritis (RA) as having 3 or more parameters including new joint symptoms <1 year, symptoms located in metacarpophalangeal (MCP) joints, morning stiffness >60 min, most severe symptoms in the morning, 1st degree relative with RA, and difficulty making a fist and positive MCP squeeze test on physical exam. Even in CSA with positive RF and ACPA, more than 30%-60% of patients will not develop RA over the next two years. Most musculoskeletal pain causing global disability is not related to rheumatoid arthritis. Inappropriate testing of RF serology in patients with low likelihood of RA is associated with low positive predictive value (PPV) and increased cost.

Sources:

Ahrari A, Barrett SS, Basharat P, Rohekar S, Pope JE: Appropriateness of laboratory tests in the diagnosis of inflammatory rheumatic diseases among patients newly referred to rheumatologists. Joint Bone Spine 2020, 87(6):588-595. PMID: 32522598.

Bos WH, Wolbink GJ, Boers M, Tijhuis GJ, de Vries N, van der Horst-Bruinsma IE, Tak PP, van de Stadt RJ, van der Laken CJ, Dijkmans BA et al: Arthritis development in patients with arthralgia is strongly associated with anti-citrullinated protein antibody status: a prospective cohort study. Ann Rheum Dis 2010, 69(3):490-494. PMID: 19363023.

Briggs AM, Woolf AD, Dreinhöfer K, Homb N, Hoy DG, Kopansky-Giles D, Åkesson K, March L: Reducing the global burden of musculoskeletal conditions. Bull World Health Organ 2018, 96(5):366-368. PMID: 29875522.

Ruta S, Prado ES, Chichande JT, Ruta A, Salvatori F, Magri S, Salinas RG: EULAR definition of “arthralgia suspicious for progression to rheumatoid arthritis” in a large cohort of patients included in a program for rapid diagnosis: role of auto-antibodies and ultrasound. Clinical Rheumatology 2020, 39(5):1493-1499. PMID: 31933033.

Ten Brinck RM, van Steenbergen HW, van Delft MAM, Verheul MK, Toes REM, Trouw LA, van der Helm-van Mil AHM: The risk of individual autoantibodies, autoantibody combinations and levels for arthritis development in clinically suspect arthralgia. Rheumatology (Oxford) 2017, 56(12):2145-2153. PMID: 28968865.

Rapid genomic tests are increasingly available both pre- and postnatally and can decrease time to diagnosis compared to standard tests. Yet, there is often an added cost to their use and their utility and cost-effectiveness are not entirely established. Before pursuing testing in an expedited timeframe, gathering a patient’s values and preferences is crucial, particularly as it relates to potential decision points in a pregnancy. While genetic information may be valued at an earlier stage in a disease course and rapid results may be preferred by patients, balancing the potential increased cost against conventional genetic turnaround times is particularly important when results are not expected to have immediate management implications.

Sources:

Meng L, et al. Use of exome sequencing for infants in intensive care units: ascertainment of severe single-gene disorders and effect on medical management. JAMA Pediatr. 2017 Dec 4;171(12):e173438. PMID: 28973083.

Stoll K, et al. Supporting Patient Autonomy and Informed Decision-Making in Prenatal Genetic Testing. Cold Spring Harb Perspect Med. 2020 Jun 1;10(6):a036509. doi: 10.1101/cshperspect.a036509. PMID: 31615869.

Petrikin JE, et al. The NSIGHT1-randomized controlled trial: rapid whole-genome sequencing for accelerated etiologic diagnosis in critically ill infants. NPJ Genomic Med. 2018;Feb 9;3:6. PMID: 29449963.

Young C, et al. Rapid Genome-wide Testing: A Review of Clinical Utility, Cost-Effectiveness, and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 Sep 20. PMID: 31721549.

When there is a specific condition suspected based on clinical features or where clinical criteria are available, targeted testing is more appropriate than broad panel or genomic testing. The advantages of targeted testing are that the gene(s) or chromosomal region(s) being tested are well known to be associated with specific risks, often have management guidelines available if a pathogenic variant is found, and it is simpler to convey the specific limitations and benefits of doing targeted testing. The analytic validity, clinical validity and clinical utility are important domains in genetic testing evaluation and are easier to determine for a targeted test rather than for a broad or genomic test where the phenotype may not be anticipated, or the gene may be of moderate or low risk. Broad panel or genomic tests increase anxiety with increased number of variants of uncertain significance (VUS), increase the risk of misinterpretation or misattribution to less well understood gene or genomic region, and lead to increased costs of unnecessary screening and surgeries.

Sources:

Adams VA, et al. Insights and Considerations for Large Panel Genetic Tests. Informed DNA. 2019 Oct 22.

Lynce F et al. How far do we go with genetic evaluation? Gene, Panel, and Tumour Testing. Am Soc Clin Oncol Educ Book. 2016; 35:e72-e78. PMID: 27249773.

National Academies of Sciences, Engineering, and Medicine et al. An Evidence Framework for Genetic Testing. Washington (DC): National Academies Press (US); 2017 Mar 27. PMID: 28418631.

Genome-wide diagnostic testing, including whole exome sequencing and microarray analysis, has become widely used as a first-line test for patients with a variety of clinical presentations. While these broad tests can provide a good diagnostic yield, they also have technical limitations and are unable to reliably diagnose some specific genetic conditions, including spinal muscular atrophy (SMA), congenital adrenal hyperplasia (CAH), Facioscapulohumeral Muscular Dystrophy (FSHD), imprinting disorders (Beckwith-Wiedemann syndrome, Prader-Willi syndrome, Angelman syndrome, Russel-Silver syndrome, etc.), and repeat expansion disorders (Fragile X syndrome and related disorders, Huntington disease, Myotonic Dystrophy, Friedreich’s ataxia, Spinocerebellar ataxia, etc.), among others. The mechanism underlying the condition must be considered to determine whether a test can rule out or rule in a diagnosis; if a disorder is being considered as part of the differential diagnosis and cannot reliably be detected by genome-based testing, then a disease- or gene-specific molecular diagnostic test is required. When an incorrect test is ordered, it may give a false sense of reassurance if a negative result is returned, and it could delay diagnosis for the patient. In addition, this is potentially a poor use of resources.

Sources:

Nimkarn S, et al. 21-Hydroxylase-Deficient Congenital Adrenal Hyperplasia. GeneReviews® [Internet]. 2002 Feb 26. PMID: 20301350.

Preston MK, et al. Facioscapulohumeral Muscular Dystrophy. GeneReviews®. 1999 Mar 8.

Prior TW, et al. Spinal Muscular Atrophy. GeneReviews®. 2000 Feb 24.

Wallace SE, et al. Resources for Genetics Professionals — Genetic Disorders Caused by Imprinting Errors and Uniparental Disomy Not Detectable by Sequence Analysis. GeneReviews®. 2017 Mar 14.

Wallace SE, et al. Resources for Genetics Professionals — Genetic Disorders Caused by Nucleotide Repeat Expansions and Contractions. 2017 Mar 14 GeneReviews®

Assessment of an increased risk of inherited disease should be available to all individuals considering a pregnancy. Genetic counselling for possible carrier screening should be offered to individuals identified as being at elevated risk of transmission of an inherited condition based on family history, ethnic background, or past medical/obstetrical history. When the a priori risk is elevated, carrier testing may be offered. Expanded carrier testing using large panels yields few carrier pairs (at most 1% even with larger panels) and therefore is not recommended as a routine test at this time. Additionally, the utilization of limited laboratory, clinical and genetic counselling resources requires stewardship. Since the evidence is limited, routine carrier screening of all individuals is not recommended at this time. However, this may be revisited if evidence of effectiveness and efficiency is established and implementation strategies are proposed.

Sources:

Hussein N, et al. Preconception risk assessment for thalassaemia, sickle cell disease, cystic fibrosis and Tay-Sachs disease. Cochrane Database Syst Rev. 2021 Oct 11;10(10):CD010849. PMID: 34634131.

Peyser A, et al. Comparing ethnicity-based and expanded carrier screening methods at a single fertility center reveals significant differences in carrier rates and carrier couple rates. Genet Med. 2019 Jun;21(6):1400-1406. PMID: 30327537.

Wilson RD et al. Joint SOGC-CCMG Opinion for Reproductive Genetic Carrier Screening: An Update for All Canadian Providers of Maternity and Reproductive Healthcare in the Era of Direct-to-Consumer Testing. J Obstet Gynaecol Can. 2016 Aug;38(8):742-762.e3. PMID: 27638987.

Whole exome sequencing (WES) is a next generation sequencing method that includes the protein-coding sequence of the genome. WES covers >99% of sequence variants, and several studies have demonstrated that >98% of relevant sequence variants identified on targeted panels were identified on WES. Most clinical laboratories use the same sequencing methods for WES and gene panels. Thus, the additional diagnostic yield of panel sequencing after WES is likely to be low.

Sources:

Dunn P, et al. Next Generation Sequencing Methods for Diagnosis of Epilepsy Syndromes. Front. Genet. 2018 Feb 7;9:20. PMID: 29467791.

Kong SW, et al. Measuring coverage and accuracy of whole-exome sequencing in clinical context. Genetics in Medicine. 2018 Dec;20(12):1617-1626. PMID: 29789557.

LaDuca H, et al. Exome sequencing covers >98% of mutations identified on targeted next generation sequencing panels. PLoS One. 2017; 12(2): e0170843. PMID: 28152038.

Sun Y, et al. Next-generation diagnostics: gene panel, exome, or whole genome? Hum Mutat. 2015 Jun;36(6):648-55. PMID: 25772376.

Intellectual developmental disorders (IDD) affect 2.5% of the population. Inherited metabolic disorders (IMD’s) may present with IDD and often other neurologic or systemic features and some IMD’s are treatable. Despite years of implementing a biochemical testing algorithm on a research basis in one province, the yield of testing was not increased for IMD’s.

There are significant harms associated with over-investigation. Although the cost of biochemical testing is inexpensive compared to molecular or specialized tests, it is still a significant burden on the health care system. The cost of the tests is not the only consideration, since significant human resources are required for pre-test counselling, coordination of sample collection, transport and analysis, interpretation of results and follow-up. Even more importantly, there may be harm to children and families subjected to further blood draws and urine tests, extending the diagnostic odyssey as repeat testing is often required for a positive or uncertain result. There is extensive literature on the harms of false positives from newborn screening, but this is balanced against the yield of testing for treatable IMD’s on the newborn screen and efficacy of early intervention. Similar data of the benefits of screening all children with IDD for IMD’s does not exist.

There are well-recognized red flags suggestive of an IMD in children with IDD and it would be appropriate to do targeted metabolic testing in those situations (so called “intellectual disability plus”). Consideration should also be given to patients who did not have newborn screening (NBS) for IMD. Further biochemical testing may also be a valuable tool when molecular testing is negative or uncertain, to provide functional evidence of pathogenicity.

Sources:

Carmichael N et al. “Is it going to hurt?”: the impact of the diagnostic odyssey on children and their families. J Genet Couns. 2015 Apr;24(2):325-35. PMID: 25277096.

Gross SD et al. From public health emergency to public health service: the implications of evolving criteria for newborn screening panels. Pediatrics. 2006 Mar;117(3):923-9. PMID: 16510675.

Kwon C and Farrell PM. The Magnitude and Challenge of False-Positive Newborn Screening Test Results. Arch Pediatr Adolesc Med. 2000;154(7):714-718. PMID: 10891024.

Richards S. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med. 2015 May;17(5):405-24. PMID: 25741868.

Sayson B et al. Retrospective analysis supports algorithm as efficient diagnostic approach to treatable intellectual developmental disabilities. Mol Genet Metab. 2015 May;115(1):1-9. PMID: 25801009.

Vallance et al. Diagnostic yield from routine metabolic screening tests in evaluation of global developmental delay and intellectual disability. Paediatr Child Health. 2020 Dec 19;26(6):344-348. PMID: 34676012.

Watchful waiting refers to a policy of taking no immediate action with respect to a situation or course of events but of following its development intently. Different areas in medicine employ watchful waiting and have found it not to impact patient outcome in select situations. Given the increased availability, genetic testing is often requested early in a patient’s presentation. However, genetic conditions and our ability to understand and diagnose them frequently evolve over time. Early investigation may result in increased cost due to repeated application of non-targeted testing, with concomitant increased likelihood of detecting variants of uncertain significance, as well as poorer result interpretation for reports reliant on complete phenotyping. When the phenotype is incomplete or unclear, and there are no red flags, such as deteriorating patient status, potential for change in management, or information necessary for timely reproductive counseling, watchful waiting may be appropriate.

Sources:

Allanson et al. J Craniofac Genet Dev Biol. Time and natural history: the changing face. 1989;9(1):21-8. PMID: 2793999.

Baynam et al. Phenotyping: targeting genotype’s rich cousin for diagnosis. J Paediatr Child Health. 2015 Apr;51(4):381-6. PMID: 25109851.

Galia et al. Whole body magnetic resonance in indolent lymphomas under watchful waiting: The time is now. Eur Radio. 2018 Mar;28(3):1187-1193. PMID: 29018927.

Lieberthal et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131(3):e964-99. PMID: 23439909.

Reistrup et al. Watchful waiting vs repair for asymptomatic or minimally symptomatic inguinal hernia in men: a systematic review. Hernia. 2021 Oct;25(5):1121-1128. PMID: 32910297.

Rittenmeyer et al. The experience of adults who choose watchful waiting or active surveillance as an approach to medical treatment: a qualitative systematic review. JBI Database System Rev Implement 2016 Feb;14(2):174-255. PMID: 27536798.

Vissers et al. A clinical utility study of exome sequencing versus conventional genetic testing in pediatric neurology. Genet Med. 2017 Sep;19(9):1055-1063. PMID: 28333917.

Serum total bile acids tests (TBA) are used primarily for the evaluation and monitoring of intrahepatic cholestasis of pregnancy (ICP), a condition affecting 1-2% of pregnant women in North America.

ICP is associated with an increased risk of perinatal complications including premature birth, intrauterine asphyxia, fetal bradycardia and even stillbirth. Severe ICP is defined when serum TBA is above 40 umol/L, and the likelihood of stillbirth is significantly increased when the serum TBA concentration is >100mmol/L, which makes it a good prognostic marker.

However, in non-pregnant individuals with suspected cholestasis, TBA is not an effective test to assess liver dysfunction compared to traditional liver panel tests (e.g., bilirubin, albumin, ALT, GGT and ALP).

In the context of familial intrahepatic cholestasis, the serum TBA is considered as a tier 2 investigation which is ordered by pediatric gastroenterologists only. The urine bile acids profile is the appropriate test for the investigation of disorders of bile acid synthesis, not serum TBA.

Sources :

Azer, S.A. et al. Use of bile acids as potential markers of liver dysfunction in humans: A systematic review. Medicine (Baltimore). 2021 Oct 15;100(41):e27464. PMID: 34731122.

Fawaz R et al. Guideline for the Evaluation of Cholestatic Jaundice in Infants: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2017 Jan;64(1):154-168. PMID: 27429428.

Piechota, J. et al. Intrahepatic cholestasis in pregnancy: Review of the literature. J Clin Med. 2020 May 6;9(5):1361. PMID: 32384779.

Ovadia, C. et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet. 2019 Mar 2;393(10174):899-909. PMID: 30773280.

Global developmental delay and intellectual disability (GDD/ID) affect 3% of the paediatric population. Since its differential diagnosis is broad, community –based clinicians tend to order copper and ceruloplasmin tests to screen for Wilson’s and Menkes disease (mutations in ATP7A or ATP7B).

However, a recent study determined that neither Wilson’s nor Menkes disease have been identified using these tests in children with global developmental delay/intellectual disability.

In addition, false abnormal copper and ceruloplasmin results lead to an increase in the number of total referrals and unnecessary follow ups (4% in the above study). Children with Wilson’s disease are more likely to present with hepatic manifestations than neurologic symptoms, while those with Menkes disease show multiple abnormalities including developmental delay and epilepsy typically within the first 3 months of life.

Sources :

Shribman, S. et al. Clinical presentations of Wilson disease. Clinical presentations of Wilson disease. Ann Transl Med. 2019 Apr;7(Suppl 2):S60. PMID: 31179297.

Vairo, F.P.E. et al. A systematic review and evidence-based guideline for diagnosis and treatment of Menkes disease. Mol Genet Metab. 2019 Jan;126(1):6-13. PMID: 30594472.

Vallance, H. et al. Diagnostic yield from routine metabolic screening tests in evaluation of global developmental delay and intellectual disability. Paediatr Child Health. 2020 Dec 19;26(6):344-348. PMID: 34676012.

The CSES recently completed a Systematic Review and Position Statement on lateral epicondylitis. There is ongoing controversy regarding the non-operative treatment of lateral epicondylitis. All English-language randomized trials comparing non-operative treatment of patient > 18 years of age with lateral epicondylitis were included. The available evidence does not support the use of non-operative treatment options including corticosteroids, PRP, or AB in the treatment of lateral epicondylitis.

Canadian Shoulder and Elbow Society

Source:

Lapner P, Alfonso A, Hebert-Davies J, Pollock JW, Marsh J, King GJW; Canadian Shoulder and Elbow Society (CSES). Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis. JSES Int. 2021 Dec 18;6(2):321-330. doi: 10.1016/j.jseint.2021.11.010. PMID: 35252934.

History, physical examination, and appropriate radiographs remain the primary diagnostic modalities in pediatric orthopaedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include the work up of injury or pain (spine, knees and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies are costly and frequently require sedation in the young child (under 5 years old) Additionally, a significant dose of radiation is delivered to the patient during a CT scan.

Canadian Paediatric Orthopaedic Group

Sources:

Piccolo CL, Galluzzo M, Ianniello S, Trinci M, Russo A, Rossi E, Zecconlini M, Laporta A, Guglielmi G, Muiele V. Pediatric musculosketetal injuries: role of ultrasound and magnetic resonance imaging. Mesculoskelet Surg. 2017 Mar; 101(Supple 1):85-102. PMID: 28155066.

LaBella CR, Hennrikus W, Hewett TE. Anterior cruciate ligament Injuries: Diagnosis, Treatment, and Prevention. Pediatrics 2014;133(5):e1437-e1450. PMID: 24777218.

Tuite MJ, Kransdort MJ, Beaman FD, Adler RS, Amini B, Appel M, Bernard SA, Dempsey ME, Fries IB, Greenspan BS, Khurana B, Mosher TJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR. Appropriateness Criteria® Acute Trauma to the Knee. American College of Radiology. Revised 2014.

Deyle GD. The role of MRI in musculoskeletal practice: a clinical perspective. J Man Manip Ther. 2011 Aug;19(3):152-161 PMID: 22851878.

Bateni C, Bindra J, Haus B. MRI of sports injuries in children and adolescents: what’s different from adults. Current Radiology Reports. 2014;2:45.

When neuroma resection is performed by an experienced surgeon and the anatomical appearance of the specimen is not unexpected, pathological examination is not necessary and does not change management. If the surgical findings are atypical, pathological examination may be useful and performed.

Canadian Orthopaedic Foot and Ankle Society

Source:

Raouf T, Rogero R, McDonald E, Fuchs D et al. Value of Preoperative Imaging and Intraoperative Histopathology in Morton’s Neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-1036. doi: 10.1177/1071100719851121. Epub 2019 May 29. PMID: 31142153.

The overall clinical penetrance in terms of iron overload-related clinical symptoms is less than 30% in HFE-associated hereditary hemochromatosis. Ferritin is the most reliable biomarker to quantify iron load but may be falsely elevated during an acute phase response as in inflammation, stress, or infections. In the investigation of clinical hereditary hemochromatosis, don’t order HFE C282Y testing unless BOTH the ferritin and the transferrin saturation are elevated. A normal ferritin rules out a clinically treatable hemochromatosis syndrome and is therefore an appropriate first line test. Transferrin saturation can be added on to the same blood sample if the ferritin is elevated.

Sources:

Adams PC, Reboussin DM, Press RD, Barton JC, Acton RT, Moses GC, Leiendecker-Foster C, McLaren GD, Dawkins FW, Gordeuk VR, Lovato L, Eckfeldt JH. Biological variability of transferrin saturation and unsaturated iron-binding capacity. Am J Med 2007;120:999.e1-7. PMID: 17976429.

Allen KJ, Gurrin LC, Constantine CC et al. Iron-overload-related disease in HFE hereditary hemochromatosis. N Engl J Med 2008;358:221–230. PMID: 18199861.

Porto G, Brissot P, Swinkels DW et al. EMQN best practice guidelines for the molecular genetic diagnosis of hereditary hemochromatosis (HH). Eur J Hum Genet 2016;24:479-95. PMID: 26153218.

Rossi E, Olynyk JK, Jeffrey GP. Clinical penetrance of C282Y homozygous HFE hemochromatosis. Expert Rev Hematol 2008;1:205–216. PMID: 21082925.

Tarr H, Chen Y. An iron deficient patient with opposite iron profiles within five days. Clin Lab 2012;58:1331-2. PMID: 23289209.

Waalen J, Felitti VJ, Gelbart T, Beutler E. Screening for hemochromatosis by measuring ferritin levels: a more effective approach. Blood 2008;111:3373-6. PMID: 18025154.

The lifespan of a red blood cell (RBC) is approximately 90-120 days, thus the effects of a patient’s change in behaviour, diet, or newly adjusted medications will not be reflected in the HbA1c measurement until most of the previous RBCs in circulation are replaced (~90 days). Therefore, testing at time intervals earlier than 3 months does not allow enough time to pass to reach the treatment target or new steady-state. Overtesting may lead to unnecessary regimen changes, adverse effects, and higher costs. Testing at 6-month intervals may be considered when glycemic targets are consistently achieved. In pregnant patients with pre-existing diabetes, more frequent HbA1c measurements may be appropriate based on clinical guidelines (i.e. at each trimester).

Sources:

American Diabetes Association Professional Practice Committee; Glycemic Targets: Standards of Medical care in Diabetes. Diabetes Care. 2022 Jan;45 Suppl 1:S83-S96. doi: https://doi.org/10.2337/dc22-S006. PMID: 34964868.

Baek J, Rajeswaran V, Tran S, Alexander L, Jaskolka D, Usmani S, Yip P, Mukerji G. A Multimodal Intervention for Reducing Unnecessary Repeat Glycated Hemoglobin Testing. Can J Diabetes. 2022 Jun 30:S1499-2671(22)00170-8. doi: 10.1016/j.jcjd.2022.06.006. PMID: 36008251.

Driskell OJ, Holland D, Waldron JL, Ford C, Scargill JJ, Heald A, Tran M, Hanna FW, Jones PW, Pemberton RJ, Fryer AA. Reduced testing frequency for glycated hemoglobin, HbA1c, is associated with deteriorating diabetes control. Diabetes Care. 2014 Oct;37(10):2731-7. doi: 10.2337/dc14-0297. PMID: 25249670.

McCarter RJ, Hempe JM, Chalew SA. Mean blood glucose and biological variation have greater influence on HbA1c levels than glucose instability: an analysis of data from the Diabetes Control and Complications Trial. Diabetes Care. 2006 Feb;29(2):352-5. doi: 10.2337/diacare.29.02.06.dc05-1594. PMID: 16443886.

National Institute for Health and Care Excellence (NICE); Diabetes in pregnancy: management from preconception to the postnatal period. 2020 Dec.

Ohde S, Deshpande GA, Yokomichi H, Takahashi O, Fukui T, Yamagata Z. HbA1c monitoring interval in patients on treatment for stable type 2 diabetes. A ten-year retrospective, open cohort study. Diabetes Research and Clinical Practice. 2018 135, 166–171. doi: 10.1016/J.DIABRES.2017.11.013. PMID: 29155151.

Tissue transglutaminase IgA antibody (anti-tTG IgA) is the recommended first-line screening test for celiac disease as it provides the best diagnostic sensitivity and specificity. Serum IgA concentrations should be considered to rule out IgA deficiency. The addition of tissue transglutaminase IgG antibody (anti-tTG IgG), or deamidated gliadin peptide antibodies (anti-DGP IgG or IgA) in the initial screening will reduce the diagnostic performance and may cause misleading results. In particular, testing of anti-DGP antibodies result in a higher false positive rate that can lead to further unnecessary testing and/or endoscopy. Anti-tTG IgG and anti-DGP IgG testing should be reserved for individuals with IgA deficiency. Implementation of an automated reflexive algorithm in the laboratory can streamline the ordering process.

Sources:

Husby S, Koletzko S, Korponay-Szabó I, et al. European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for Diagnosing Coeliac Disease 2020. J Pediatr Gastroenterol Nutr. 2020 Jan;70(1):141-156. doi: 10.1097/MPG.0000000000002497. PMID: 31568151.

Husby S, Murray JA, Katzka DA. AGA Clinical Practice Update on Diagnosis and Monitoring of Celiac Disease-Changing Utility of Serology and Histologic Measures: Expert Review. Gastroenterology. 2019 Mar;156(4):885-889. doi: 10.1053/j.gastro.2018.12.010. Epub 2018 Dec 19. PMID: 30578783.

Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA; American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013 May;108(5):656-76; quiz 677. doi: 10.1038/ajg.2013.79. Epub 2013 Apr 23. PMID: 23609613.

Renal calculi analysis is a laborious and expensive test. In Alberta, 16% of repeated renal calculi tests occurred within ~5 years (88% were repeated within 3 years). However, the repeated test only rarely demonstrated a change in stone composition (5.5% of all repeats). Similarly, the first epidemiology study of urolithiasis in New Brunswick found that 14% of renal calculi tests were repeated within 3 years, and in all cases, there was no compositional change. Both Canadian Urological Association and American College of Physicians do not recommend routinely monitoring calculi composition for recurrent stones. A calculi analysis may be repeated if there are significant systemic and/or urinary abnormalities, or patients do not respond to treatment.

Sources:

Chen VY, Chen Y. The first epidemiology study of urolithiasis in New Brunswick. Can Urol Assoc J 2021;15(7):E356-60. http://dx.doi.org/10.5489/cuaj.6888. PMID: 33382373.

Paterson R, Fernandez A, Razvi H, Sutton R. Evaluation and medical management of the kidney stone patient. Can Urol Assoc J 2010;4(6):375-9. PMID: 21191493.

Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014;161(9):659-67. PMID: 25364887.

Sadrzadeh SM, Orton D, Burgess E, et al. Utilization of renal calculi analyses in Calgary. Clin Biochem 2016;49:1429.

Screening for monoclonal gammopathies should only be performed in patients with unexplained “CRAB” symptoms (hyperCalcemia, Renal insufficiency, Anemia, or lytic Bone lesions) or diseases associated with monoclonal gammopathies. For such patients, serum protein electrophoresis (SPE) should be the initial screening test with follow-up immunofixation electrophoresis (IFE) if indicated. If SPE is negative, serum free light chain (SFLC) testing may be ordered since SPE/IFE + SFLC offers the best sensitivity for detection of monoclonal proteins. If SFLC testing is not available, or if amyloidosis is suspected, 24-hour urine protein electrophoresis (UPE) may be ordered with follow-up IFE if indicated. Random UPE should not be ordered as there is very limited evidence supporting its sensitivity.

Sources:

Ansari AA, Tipu HN, Ahmed D, Farhan M. Evaluation of serum free light chain in diagnosis and monitoring of plasma cell disorders. Crit Rev Immunol 2019; 39(3): 203-210. DOI: 10.1615/CritRevImmunol.2019032260. PMID: 32421964.

Bergstrom DJ, Kotb R, Louzada ML, Sutherland HJ, Tavoularis S, Venner CP, for the Myeloma Canada Research Network Consensus Guideline Consortium. Consensus guidelines on the diagnosis of multiple myeloma and related disorders: recommendations of the Myeloma Canada Research Network Consensus Guideline Consortium. Clin Lymphoma Myeloma Leuk 2020; 20(7): e352-e367. DOI: 10.1016/j.clml.2020.01.017. PMID: 32249195.

Jenner E. Serum free light chains in clinical lab diagnostics. Clin Chim Acta 2014; 427: 15-50. DOI: 10.1016/j.cca.2013.08.018. PMID: 23999048.

McTaggart MP, Lindsay J, Kearney EM. Replacing urine protein electrophoresis with serum free light chain analysis as a first-line test for detecting plasma cell disorders offers increased diagnostic accuracy and potential health benefit to patients. Am J Clin Pathol 2013; 140(6): 890–897. DOI: 10.1309/AJCP25IHYLEWCAHJ. PMID: 24225758.

Ferritin is recognized as the most sensitive and specific marker of iron storage, and low ferritin alone is diagnostic of IDA in the general population, i.e. uncomplicated cases of IDA. The measurement of iron is a poor biomarker for IDA as it is susceptible to preanalytical factors such as diurnal variation, diet, and exercise, and ultimately does not represent iron storage. In patients with complicating comorbidities (e.g. infection, autoimmune disease, kidney disease, or cancer), ferritin is an acute phase reactant and may be falsely elevated. In this setting, ordering a fasting transferrin saturation is useful to help diagnose iron deficiency together with the ferritin result.

Sources:

Guideline for the laboratory diagnosis of functional iron deficiency; https://onlinelibrary.wiley.com/doi/10.1111/bjh.12311
Iron deficiency without anaemia: a diagnosis that matters. Clinical Medicine 2021 Vol 21, No 2: 107–13. PMID: 33762368.

Liu K, Kaffes AJ. Iron deficiency anaemia: a review of diagnosis, investigation and management. Eur J Gastroenterol Hepatol. 2011; 24(2):109-16. PMID: 22157204.

Short MW, Domagalski JE. Iron Deficiency Anemia: Evaluation and Management. Am Fam Physician. 2013 Jan 15;87(2):98-104.

WHO Guideline on use of ferritin concentrations to assess iron status in individuals and populations.

Routine biochemical screening frequently bundles redundant tests when one is sufficient from a screening, diagnostic or monitoring perspective. For example, ALT is a more specific test to detect liver injury compared to AST. AST is rarely needed if the ALT is normal, and AST should only be ordered by physicians with experience in treating liver disorders or monitoring of diagnosed liver fibrosis with a validated score (e.g. FIB-4). Creatinine alone is sufficient to check kidney function because laboratories automatically report estimated GFR; urea is often an unnecessary addition. Uncoupling bundled tests within order sets for initial screening reduces low value testing.

Sources:

Barrett BJ, Randell EW, Mariathas HH, Mohammadi A, Darcy S, Wilson R, Brian Johnston K, Parfrey PS. The effect of laboratory requisition modification, audit and feedback with academic detailing or both on utilization of blood urea testing in family practice in Newfoundland, Canada. Clin Biochem. 2020 Sep;83:21-27. doi: 10.1016/j.clinbiochem.2020.05.008. Epub 2020 May 22. PMID: 32450078.

Mathura P, Boettger C, Hagtvedt R, Sweeney C, Williams S, Suranyi Y, Kassam N, Gill M. Reduction of urea test ordering in the emergency department: multicomponent intervention including education, electronic ordering, and data feedback. CJEM. 2022 Sep;24(6):636-640. doi: 10.1007/s43678-022-00333-w. Epub 2022 Jul 20. PMID: 35857240.

Mohammed-Ali Z, Bhandarkar S, Tahir S, et al. Implementing effective test utilization via team-based evaluation and revision of a family medicine laboratory test requisition. BMJ Open Quality 2021;10:e001219. doi:10.1136/ bmjoq-2020-001219. PMID: 33731485.

Strauss R, Cressman A, Cheung M, et al Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative BMJ Quality & Safety 2019;28:809-816. PMID: 31073091.

Direct bilirubin is a sub-component of total bilirubin. Total bilirubin assays measure both direct (conjugated and delta) and indirect (unconjugated) bilirubin. When total bilirubin is low or undetectable there is no value in measuring the direct bilirubin level. Limiting direct bilirubin testing to individuals with elevated total bilirubin has been demonstrated to decrease unnecessary testing. Additionally, implementation of a laboratory reflexive testing algorithm for infants, where direct bilirubin is automatically tested when total bilirubin is elevated, has been proposed to accelerate the identification of biliary atresia while also reducing the need for additional blood collections.

Sources:

Katzman BM and Karon BS. Test Utilization Proposal for Reflex Bilirubin Testing: Why Order Two Tests When One Will Do? J App Lab Med, July 2021;6(4):980-984. PMID: 33454760.

Lam L, Musaad S, Kyle C, and Mouat S. Utilization of Reflex Testing for Direct Bilirubin in the Early Recognition of Biliary Atresia. Clinical Chemistry, May 2017;63(5): 973–979. PMID: 28283556.

Zhang G-M and Hu Z-D. Conjugated bilirubin as a reflex test for increased total bilirubin in apparently healthy population. J Clin Lab Anal. Feb 2018;32(2):e22233. PMID: 28523701.

Urine drug tests (UDTs) have a limited but important role in managing patients with substance use disorders and should be guided by a care plan that will be meaningfully changed by the results. The unregulated drug market is encumbered by an evolving milieu of drug additives and contaminates which can complicate the interpretation of simplistic urine drug testing. In particular, testing by immunoassay without confirmation by mass spectrometry can fail to detect potent drugs that can be harmful. Immunoassays are also well known for false positives that can mislead patient management. Mass spectrometry testing delivers the most reliable and comprehensive results, but with delayed turnaround time. Clinicians that are considering drug testing should consider consulting with the laboratory for advice on choosing the best test methodology available and for help interpreting the results.

Sources:

American Society of Addiction Medicine, Appropriate Use of Drug Testing in Clinical Addiction Medicine Consensus Document.

Centre for Addition and Mental Health (CAMH), Canadian Opioid Use Disorder Guideline.

CLSI. Toxicology and Drug Testing in the Medical Laboratory. 3rd ed. CLSI guideline C52. Kyle, P.B., Fuller, D.C., Garg, U., Hammett-Stabler, C.A., Hoess, E., Johnson-Davis, K., Kapur, B.M., Langman, L.J., LeGatt, D.F., Loughmiller, D., Pesce, A., Sadek, W., Smith, M.P., Watson, I.D., Wolf, C.E., Wu, A., Zhang, Y.V. Clinical and Laboratory Standards Institute; 2017.

Jannetto PJ, Langman LJ. Using Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients. J Appl Lab Med. 2018 Jan 1;2(4):471-472. PMID: 33636905.

Rifai, N., Horvath, A.R., Wittwer, C.T. (2018) Tietz Textbook of Clinical Chemistry. Sixth Edition, Elseiver, St. Louis, 882-883.

Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol 2009; 47: 286-91. PMID: 19514875.

Positive allergen specific IgE (sIgE) tests represent sensitization and not necessarily clinical allergy. This means that IgE against specific allergens may be detectable even when a patient is clinically tolerant of a given food or environmental allergen. The positive predictive value (PPV) of this testing is low unless the specific allergen tests are carefully chosen based on a review of the patient’s clinical history correlated to specific food and/or environmental exposures. Screening panels and indiscriminate batteries of specific allergen tests should be avoided. Positive specific allergen test results in the absence of clinical allergy lead to incorrect diagnosis of allergy, unsuitable treatment and, in the case of food allergies, inappropriate dietary restrictions with potentially negative health consequences.

Sources:

Bird JA, et al. Food allergen panel testing often results in misdiagnosis of food allergy. J Pediatr. 2015;166(1):97-100. PMID: 25217201.

Kapur S, et al. Atopic dermatitis. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):43-52. PMID: 30275844.

Muraro A, et al. EAACI Food Allergy and Anaphylaxis Guidelines: diagnosis and management of food allergy. Allergy. 2014;69(8):1008-25. PMID: 24909706.

NIAID-Sponsored Expert Panel, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(Suppl 6):S1-58. PMID: 21134576.

Clinicians play an important role in reducing environmental impact from clinical laboratory activity. The production, transportation and disposal of laboratory products have an environmental impact which includes, but is not limited to: tourniquets, needles, tubes, labels, and plastic specimen collection bags. Within the laboratory, additional waste is generated from the specimens, reagents and materials used for testing. The large amounts of energy and water consumed to generate results has a significant carbon footprint as well. Moreover, spurious results frequently lead to unnecessary medical follow-up or misguided therapy with further waste of resources and extension of the carbon footprint. Reducing blood work frequency (as appropriate), reflecting on appropriateness of laboratory orders (Using Labs Wisely) and rethinking laboratory orders (checking previous results instead of reordering, limiting duplication) are potential strategies to reduce environmental impact.

Laboratory testing contributes to a significant carbon footprint due to the required infrastructure (i.e. electricity, HVAC, water) and generated waste (i.e. biohazardous waste, plastic consumables). For example, a laboratory with 10 automated analyzers can consume enough water to fill an Olympic-sized pool annually. This is especially relevant as laboratories move towards increased automation and expanding test menus with a constant focus on throughput and turnaround time. While individual laboratories have agency on some of the contributing factors, the carbon footprint of laboratory testing is largely determined by the inherent design of the instrumentation. As such, it is vital that laboratories establish partnerships with the in vitro diagnostics industry to push for material, hardware, and software changes that allow for laboratory testing in an environmentally sustainable manner. There is a growing international movement in sustainable laboratory medicine with some associations already having published formal guidance in this space.

Gloves don’t need to be used for most routine healthcare interactions with certain exceptions. Unnecessary use of gloves is common, leads to increased costs, generates waste and may inadvertently increase rates of cross-contamination. A study in the Netherlands found that >100 disposable gloves were used in the ICU per patient per day contributing to the highest carbon footprint compared to other commonly used products.

Disposal of unused medical supplies is common in ICUs, particularly at the time of patient transfer. Practices such as centralized supply carts, as-needed in-room restocking, and keeping emergency medication immediately available but unopened, have been suggested to minimize waste generated from unused items.

Treating Asymptomatic Bacteriuria (ASB) does not improve clinical outcomes (including altered mental state) but may increase adverse events from 1% to 7%. In older patients with ASB and altered mental state, antibiotics should be avoided without clear signs/symptoms of infection.

Ensuring proper medication disposal is crucial to minimize health risks, preventing misuse and adverse effects. Less than 1% of patients return unused medication, increasing the likelihood of accidental ingestion by children and pets. Flushing medications down the toilet, a prevalent disposal method, poses risks of antibiotic resistance and water contamination. The improper disposal introduces pharmaceutical residue into water systems, threatening aquatic life. Education on safe disposal and encouraging return to designated collection sites can reduce these risks. Regulatory measures, such as those implemented in British Columbia, aim to address pharmaceutical waste through recycling regulations, highlighting the importance of comprehensive strategies to minimize environmental harm.

Reducing paper usage has been shown to minimize the risk of prescription errors. Decreasing paper prevents waste and recycling needs, hence is environmentally beneficial.

In pharmacy settings, when the risk of body fluids exposure and infection transmission is low, maintaining safety standards in most routine healthcare interactions can most often be achieved by using proper hand hygiene without additional precautions. Do not use gloves in place of hand hygiene or when hand hygiene alone is sufficient. The pharmacy staff should reserve the use of gloves to situations in which the safeguard of pharmacy staff is required due to risk of infection, or to comply with infection prevention and control (IPAC) and National Association of Pharmacy Regulatory Authorities (NAPRA) standards and/or guidelines. Refraining from using latex or nitrile gloves when not medically necessary is an important aspect of environmental stewardship to be considered by healthcare professionals. Minimizing the use of gloves can help reduce environmental waste associated with disposable medical supplies, contributing to sustainability efforts in healthcare facilities. Approximately 500 boxes of gloves were found to emit 2 tonnes of CO2 emissions. Limiting the use of gloves is highly effective in promoting environmental sustainability.

Interventions that do not align with patient goals produce needless environmental impacts. Ensuring that care setting aligns with a patient’s goals of care can have an important impact on the carbon footprint of a hospital admission. An acute care unit (ward bed) generates 5.5kg of solid waste and 45kg CO2e (218 km by car) per hospital day, as compared to 7.1kg of solid waste and 138 kg CO2e (670 km by car) in an intensive care unit. By integrating routine cognitive and frailty screening for older patients (a low carbon, high value clinical intervention), internists can unmask dementia and discuss the risks of frailty with patients and caregivers which leads to more patients choosing conservative care better aligned with their prognosis and goals, and stands to reduce acute care days.

Point-of-care-testing (POCT) should be strategically utilized only in scenarios where it significantly influences immediate treatment decisions and offers a distinct advantage over traditional laboratory testing. Unlike laboratory-based tests, POCT may lead to more frequent false results potentially causing misdiagnoses, incorrect treatment decisions, and unnecessary additional testing or procedures contributing to further increased costs and medical waste. POCT’s reliance on single use, fossil-derived plastics, not only generates considerable waste but also poses environmental and health risks through potential toxic emissions from incineration.

Disposal of non-contaminated waste leads to CO2 emissions due to the need for high-temperature incineration. The carbon footprint of disposal of biohazardous clinical waste via high temperature incineration is 1074 kg CO2e/ton compared to regular waste (172–249 kg CO2e/ton) and recycling (21–65 kg CO2e). Various studies have shown that non-contaminated waste generated in the operating room during a primary joint replacement is on average between 5.2 kg and 6.2 kg. Thus, implementing correct waste segregation practices of non-contaminated materials, will aid in reducing the overall impact of emissions on the environment.

Ensuring proper medication disposal is crucial to minimize health risks, preventing misuse and adverse effects. Less than 1% of patients return unused medication, increasing the likelihood of accidental ingestion by children and pets. Flushing medications down the toilet, a prevalent disposal method, poses risks of antibiotic resistance and water contamination. The improper disposal introduces pharmaceutical residue into water systems, threatening aquatic life. Education on safe disposal and encouraging return to designated collection sites can reduce these risks. Regulatory measures, such as those implemented in British Columbia, aim to address pharmaceutical waste through recycling regulations, highlighting the importance of comprehensive strategies to minimize environmental harm.

In addition to increasing healthcare costs and blood draws from patients, redundant diagnostic testing for rheumatic disease adds carbon emissions through sample procurement, equipment, and processing. Beyond the tests themselves, patient transport to/from facilities and sample transport (including, for some tests, across institutions, provinces, or countries) adds to the carbon footprint. Ordering providers need to consider the reliability and validity of prior results, as well as the patients’ clinical evolution, when deciding whether repeat testing could be justified.

Because repeat testing may occur if test results performed elsewhere are not readily available, integrating electronic medical records across systems to facilitate rapid retrieval of external test results may curb redundant testing without contributing to providers’ administrative burden. Within a single health system, testing algorithms could prevent inadvertent repeat testing.

The incidence of mental health problems in children has increased in the last two decades, with suicide surpassing homicide as the second leading cause of death in teenagers. Most children with acute mental health issues do not have underlying medical etiologies for these symptoms. A large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs. Any diagnostic testing should be based on a thorough history and physical examination. Universal requirements for routine testing should be abandoned.

Children presenting with unprovoked, generalized seizures or simple febrile seizures who return to their baseline mental status rarely have blood test or CT scan findings that change acute management.

Blood tests such as electrolyte panels should not be routinely ordered and are only indicated in specific circumstances based on history and clinical examination findings.

CT scans are associated with radiation-related risk of cancer, increased cost of care, and added risk if sedation is required to complete the scan. A head CT scan may be indicated in patients with a new focal seizure, new focal neurologic findings, or high-risk medical history (such as neoplasm, stroke, coagulopathy, sickle cell disease, age <6 months).

Viral infections occur frequently in children and are a common reason to seek medical care. The diagnosis of a viral illness is made clinically and usually does not require confirmatory testing. Additionally, there is a lack of consistent evidence to demonstrate the impact of comprehensive viral panel (i.e., panels simultaneously testing for 8-20+ viruses) results on clinical outcomes or management, especially in emergency department settings. Hence, most national and international clinical practice guidelines do not recommend their routine use. Additionally, some viral tests are quite expensive, and obtaining nasopharyngeal swab specimens can be uncomfortable for children. Comprehensive viral panel testing can be considered in high-risk patients (eg, immunocompromised) or in situations in which the results will directly influence treatment decisions such as the need for antibiotics, performance of additional tests, or hospitalization. Testing for specific viruses might be indicated if the results of the testing may alter treatment plans (e.g., antivirals for influenza) or public health recommendations (e.g., isolation for SARS-CoV-2). For more specific recommendations related to diagnosis and management of SARS-CoV-2, please see https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/).

Inappropriate laboratory testing wastes time, effort, and energy, and may result in patient harm. Research demonstrates that focused testing strategies in response to clear clinical questions improves the utility of laboratory results. Laboratory professionals can play an important role in clinical conversations with the ordering professional to ensure testing addresses a specific clinical indication.

Preserving and respecting patient dignity and autonomy is the responsibility of all health care professionals. While there have been positive advancements, futile tests and interventions at the end of life are not uncommon. Phlebotomy can cause discomfort and significant imposition, and the tests may not be in line with the patient’s wishes. In these cases, medical laboratory professionals should be willing to advocate for the patient and question whether the diagnostic tests are essential.

Automated differentials consider thousands of cells, compared to a standard of 100 on a manual differential. On a properly validated modern instrument, auto-diffs are highly reliable. Manual differentials are laborious, time-consuming, and prone to variation. A

complete-blood-count with differential (CBC w/diff) is a common test, often ordered repeatedly on in-patients. In most cases, a repeated white blood cell differential within 24 hours does not add clinical value.

Blood products are finite, valuable resources. They need careful inventory management to prevent shortages, and a strained national supply adds stress to the system. Restrictive transfusion approaches are evidence- based, and vitally important to patient safety. Inappropriate transfusions put patients at additional risks that can cause poor outcomes. Medical laboratory professionals have an important role to play in screening transfusion orders carefully to minimize potential harms and healthcare costs, and advocating for programs that decrease inappropriate transfusion practices such as Using Blood Wisely (Choosing Wisely Canada).

Many individuals, including healthcare professionals, can have trouble applying probabilistic diagnostic information into evidence-based decisions. This also includes those ordering the diagnostic tests. This is becoming increasingly important as more testing is promoted for low-risk patients, such as genetic tests. Performance capabilities of every laboratory test varies and is highly influenced by population prevalence. Laboratorians can advocate for practices that enhance interpretation of test results to improve clinical decision-making.

Asymptomatic bacteriuria is a common, yet insignificant, finding that can lead to inappropriate treatment, including provision of unnecessary antimicrobials. This can exacerbate the development and spread of antimicrobial resistant organisms, which has significant healthcare cost and patient safety ramifications. Medical laboratory professionals can support antimicrobial stewardship by ensuring that urinalysis with culture only be performed on patients with appropriate symptoms by consulting with the ordering clinician or providing clear decision support systems.

Impaired sleep is associated with increased patient discomfort and harm. The laboratory may contribute to sleep disturbances by waking patients for phlebotomy. Research in several institutions shows that scheduling changes, or actions to reduce inappropriate testing, can positively impact the issue of impaired sleep. Medical laboratory professionals should collaborate with clinical colleagues to redesign workflow or implement other measures to promote sleep.

Several studies have found decreased overall environmental costs with reusable equipment as compared to single-use disposable equipment. Some examples relevant to critical care include laryngoscopy handles and blades, blood pressure cuffs, pulse oximeters and sterile surgical/procedural gowns and drapes. The benefit however is not universal for all equipment or ICUs and depends on local practices and hospital electricity source and sterilization practices.

Sources:

Duffy J, Slutzman JE, Thiel CL, Landes M. Sustainable Purchasing Practices: A Comparison of Single-use and Reusable Pulse Oximeters in the Emergency Department. West J Emerg Med. 2023 Nov;24(6):1034-1042. PMID: 38165184.

McGain, F, McAlister, S. Reusable versus single-use ICU equipment: what’s the environmental footprint?. Intensive Care Med 49, 1523–1525 (2023). PMID:37962641.

McGain F, McAlister S, McGavin A, Story D. A life cycle assessment of reusable and single-use central venous catheter insertion kits. Anesth Analg. 2012 May;114(5):1073-80. Epub 2012 Apr 4. PMID: 22492185

Overcash, M. A Comparison of Reusable and Disposable Perioperative Textiles: Sustainability State-of-the-Art 2012. Anesthesia & Analgesia 114(5):p 1055-1066, May 2012. PMID: 22492184.

Sanchez, SA, Eckelman MJ, Sherman, JD. Environmental and economic comparison of reusable and disposable blood pressure cuffs in multiple clinical settings, Resources, Conservation and Recycling, Volume 155, 2020, 104643, ISSN 0921-3449, https://doi.org/10.1016/j.resconrec.2019.104643.

Sherman, J, Raibley, LA, Eckelman, MJ. Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes. Anesthesia & Analgesia 127(2):p 434-443, August 2018. PMID: 29324492.

Supplies used for isolation precautions contribute to waste generated in ICUs. Eliminating no longer necessary isolation/infectious precautions reduces this waste and consequently the carbon footprint of ICUs.

Sources:

Anstey MH, Trent L, Bhonagiri D, Hammond NE, Knowles S, McGain F; George Institute for Global Health and the Australian and New Zealand Intensive Care Society Clinical Trials Group; Steering Committee members; Coordinating centre List of investigators; Site List of investigators. How much do we throw away in the intensive care unit? An observational point prevalence study of Australian and New Zealand ICUs. Crit Care Resusc. 2023 Jun 26;25(2):78-83. PMID: 37876601.

Hunfeld N, Diehl JC, Timmermann M, van Exter P, Bouwens J, Browne-Wilkinson S, de Planque N, Gommers D. Circular material flow in the intensive care unit-environmental effects and identification of hotspots. Intensive Care Med. 2023 Jan;49(1):65-74. Epub 2022 Dec 8. PMID: 36480046.

Routine preoperative tests for low risk surgeries results in unnecessary delays, potential distress for patients and significant cost for the health care system. Numerous studies and guidelines outline lack of evidence for benefit in routine preoperative testing (e.g., chest X-ray, echocardiogram) in low risk surgical patients. Economic analyses suggest significant potential cost savings from implementation of guidelines.

Sources:

Benarroch-Gampel J, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012 Sep;256(3):518-28. PMID: 22868362.

Chee YL, et al. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008 Mar;140(5):496-504. PMID: 18275427.

Chung F, et al. Elimination of preoperative testing in ambulatory surgery. Anesth Analg. 2009 Feb;108(2):467-75. PMID: 19151274.

Fleisher LA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007 Oct 23;50(17):e159-241. PMID: 19713422.

Fritsch G, et al. Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Acta Anaesthesiol Scand. 2012 Mar;56(3):339-50. PMID: 22188223.

Institute of Health Economics. Routine preoperative tests – are they necessary? [Internet]. 2007 May [cited 2014 Feb 10].

May TA, et al. Reducing unnecessary inpatient laboratory testing in a teaching hospital. Am J Clin Pathol. 2006 Aug;126(2):200-6. PMID: 16891194.

National Institute for Clinical Excellence. Preoperative tests: The use of routine preoperative tests for elective surgery [Internet]. 2003 Jun [cited 2014 Feb 10].

Related Resources:

Patient Pamphlet: Chest X-rays Before Surgery: When you need them and when you don’t

Patient Pamphlet: Echocardiogram Before Surgery: When you need it and when you don’t

Patient Pamphlet: Heart Tests Before Surgery: When you need an imaging test and when you don’t

Running a CBC and electrolyte panel on a patient produces 0.3597kg CO2e (1.75km by car). Daily bloodwork seldom changes outcomes, exposes patients to harms (venipuncture associated pain, wake from sleep), and is associated with negative outcomes including anemia and need for transfusions. Routine and repetitive bloodwork can be safely discontinued through targeted interventions without increasing outcomes like re-admission, ICU admission, or mortality.

Sources:

Spoyalo K, Lalande A, Rizan C, Park S, Simons J, Dawe P, et al. Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients. BMJ open quality. 2023;12(3). PMID: 37402596.

Silverstein WK, Weinerman AS, Born K, Dumba C, Moriates CP. Reducing routine inpatient blood testing. BMJ. 2022;379:e070698. PMID: 36288811.

Gloves are unnecessary for most routine healthcare interactions and are usually not needed unless there is anticipated contact with blood, body fluids, secretions and excretions, mucous membranes, draining wounds or non-intact skin. A group in the UK calculated that on average, 107 non-sterile gloves are used per patient per day in the ICU, representing an excessive amount of unnecessary waste. With the carbon footprint of a single glove estimated to be 0.026kgCO2, that equates to 2.7kgCO2e per day (13.5km by car).

Sources:

Jeffries SD, Tu Z, Xu H, Harutyunyan R, Hemmerling TM. Use of hand sanitiser as a potential substitution for nonsterile gloves in reducing carbon emissions. British Journal of Anaesthesia. 2023;131(1):e22-e5. PMID: 37149477.

Infection Prevention and Control (World Health Organization). Glove Use Information Leaflet 2009.

Canada’s Drug and Health Technology Agency (2023). CADTH Health Technology Review: Non-sterile glove use.

Hunfeld N, Diehl JC, Timmermann M, van Exter P, Bouwens J, Browne-Wilkinson S, et al. Circular material flow in the intensive care unit—environmental effects and identification of hotspots. Intensive Care Medicine. 2023;49(1):65-74. PMID: 36480046.

Rizan C, Reed M, Bhutta MF. Environmental impact of personal protective equipment distributed for use by health and social care services in England in the first six months of the COVID-19 pandemic. J R Soc Med. 2021 May;114(5):250-263. PMID: 33726611.

Disposal of unused medical supplies is common during patient transfers. To minimize waste, suggested practices include centralized supply carts, as-needed room restocking, and keeping emergency medications available but unopened.

Sources:

Morrow, J., Hunt, S., Rogan, V., Cowie, K., Kopacz, J., Keeler, C., Billick, M. B., & Kroh, M. (2013). Reducing waste in the critical care setting. Nursing leadership (Toronto, Ont.), 26 Spec No 2013, 17–26. https://doi.org/10.12927/cjnl.2013.23362. PMID: 24860948.

Wohlford, S., Esteves-Fuentes, N., & Carter, K. F. (2020). Reducing Waste in the Clinical Setting. The American journal of nursing, 120(6), 48–55. PMID: 32443125.

Yu, A., & Baharmand, I. (2021). Environmental Sustainability in Canadian Critical Care: A Nationwide Survey Study on Medical Waste Management. Healthcare quarterly (Toronto, Ont.), 23(4), 39–45. PMID: 33475491.

Despite advancements in patient care, unnecessary tests and interventions at the end of life are still common. Invasive procedures, like dialysis, bloodwork, and imaging, can cause discomfort and impose on patients, often misaligning with their wishes. In these situations, nurses should advocate for their patients by questioning the necessity of such diagnostic procedures, ensuring that the patient’s preferences and quality of life are prioritized.

Sources:

Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. International journal for quality in health care: journal of the International Society for Quality in Health Care, 28(4), 456–469. PMID: 27353273.

Kass, J. S., Lewis, A., & Rubin, M. A. (2018). Ethical Considerations in End-of-life Care in the Face of Clinical Futility. Continuum (Minneapolis, Minn.), 24(6), 1789–1793. PMID: 30516606.

McCormack, R., Sui, J., Conroy, M., & Stodart, J. (2011). The usefulness of phlebotomy in the palliative care setting. Journal of palliative medicine, 14(3), 297–299. PMID: 21265635.

Arterial blood gas testing is one of the most ordered tests in the ICU environment and is often done routinely rather thanrestricting it to assess a change in oxygenation, ventilation or acid-base that cannot be assessed through other means. The evidence indicates that 33-66% of ABG tests may not be clinically warranted and that redundant testing can besafely reduced.

Chest radiographs are indicated following procedures requiring verification after insertion (e.g., endotracheal intubation),or to provide information for a specific question related to a change in patient’s clinical condition. Blood tests should only be performed to monitor specific conditions or answer specific clinical questions.

Sources:

Chandran J, D’Silva C, Sriram S, Krishna B. Clinical utility of arterial blood gas test in an intensive care unit: An observational study. Indian J Crit Care Med. 2021 Feb;25(2):172-175. PMID: 33707895.

Choosing Wisely Canada. Canadian Critical Care Society, Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists: Twelve Tests and Treatments to Question . [Internet]. 2022 Jul. Updated August 2024 [cited 2024 Jan 11].

Martínez-Balzano CD, Oliveira P, O’Rourke M, Hills L, Sosa AF; Critical Care Operations Committee of the UMass Memorial Healthcare Center. An educational intervention optimizes the use of arterial blood gas determinations across ICUs from different specialties: A quality-improvement study. Chest. 2017 Mar;151(3):579-585. Epub 2016 Nov 3. PMID: 27818327.

Walsh OM, Davis K, Gatward J. Reducing inappropriate arterial blood gas testing in a level III intensive care unit: a before-and-after observational study. Crit Care Resusc. 2023 Oct 18;22(4):370-377. PMID: 38046871.