Recommendations Made By You

There have been many initiatives to improve the utilization of health care resources in general, but none have been as large or have gained as much momentum as Choosing Wisely, which began in the United States in 2012 and came to Canada in 2014. It has since expanded, spreading to other countries around the globe. For Choosing Wisely Canada (CWC), over 50 professional societies have contributed to more than 330 recommendations — and it is growing!

In 2018, the CSMLS agreed to become a campaign partner with CWC, joining other organizations such as Canadian Society for Transfusion Medicine, Canadian Association of Pathologists, Canadian Hematology Society, Canadian Agency for Drugs & Technologies in Health, Canadian Foundation for Healthcare Improvement and the University of Alberta (UofA).

The importance of CWC within the laboratory system was missing the medical laboratory professional’s voice. CSMLS and the UofA Medical Laboratory Science Division came together to create such CWC recommendations. We are pleased to present the results and recommendations of this national project to you.

Medical Laboratory Science

14 Things Clinicians and Patients Should Question

by
Canadian Society for Medical Laboratory Science
Last updated: April 2024

  • Don’t collect more blood than what is needed. Use short draw tubes, consider add-on testing, and reduce or combine duplicate orders.

    Phlebotomy is not a risk-free event for the patient or the health care worker. While rare, injury from needlestick and/or pathogen exposure can occur. Cumulative blood loss due to multiple phlebotomy episodes can result in iatrogenic anemia, particularly in the elderly, children, or those with medical conditions. This anemia can lead to worsened patient outcomes. Employing mechanisms that limit the amount of blood taken has been shown to lessen the severity of iatrogenic anemia. This can range from using smaller-volume collection tubes, consulting about the possibility of add-on testing to previously drawn samples, or adopting a maximum blood volume policy. Addressing duplicate requisitions can limit a patient from being phlebotomized twice.

    • Auta A, Adewuyi EO, Tor-Anyiin A, Edor JP, Kureh GT, Khanal V, Oga E, Adeloye D.Global prevalence of percutaneous injuries among healthcare workers:a systematic review and meta-analysis.Int J Epidemiol 2018;47(6):1972-80.
    • Chandrashekar S. Hospital-Acquired anemia: A hazard of hospitalization. Glob J Transfus Med 2018;3:83-7.
    • Dale JC, Ruby SG.Specimen collection volumes for laboratory tests:A College of American Pathologists Study of 140 Laboratories.Arch Pathol Lab Med 2003;127:62-68.
    • Loh, TP, Saw S, Sethi SK.Clinical value of add-on chemistry testing in a large tertiary-care teaching hospital.Lab Med 2012;43(2):82-85.
    • Society for the Advancement of Blood Management.Anemia prevention and management program implementation guide.The Center for Hospital Innovation & Improvement 2015.Available from: http://sabm.org/wp-content/uploads/2018/08/anemia_prevention_management_program_implementation_guide.pdf.
    • Whitehead N, Williams LO, Meleth S, Kennedy SM, Ubaka-Blackmoore N, Geaghan SM, et al.Interventions to prevent iatrogenic anemia:a Laboratory Medicine Best Practises systematic review.Crit Care 2019;23:278.
  • Don’t proceed with testing or reporting when sample quality or identification is suspect.

    The quality of specimens received in the laboratory is paramount to obtaining accurate results. Proceeding with testing in the presence of poor sample quality may give misleading results. This contributes to delays and unnecessary repeat examinations. Any level of error should be avoided to decrease negative impact on clinical decisions and patient care. Laboratory professionals should be proactive in ensuring that all types of specimens are collected in a high quality manner with correct identification, regardless of which health professional group is performing the act.

    • Chavan PD, Bhat VG, Polandia PP, Tiwari MR, Naresh C.Reduction in sample rejections at the pre-analytical phase – Impact of training in a tertiary care oncology center.J Lab Physicians 2019;11(3):229-33.
    • Ho J, Marks GB, Fox GJ.The impact of sputum quality on tuberculosis diagnosis:a systematic review.Int J Tuberc Lung Dis 2015;19(5):537-44.
    • Howanitz PJ, Lehman CM, Jones BA, Meier FA, Horowitz GL.Clinical laboratory quality practices when hemolysis occurs.Arch Pathol Lab Med 2015;139:901-6.
    • Lippi G, von Meyer A, Cadamuro J, Simundic AM.Blood sample quality.Diagnosis 2019;6(1):25-31.
    • O’Neill E, Richardson-Weber L, McCormack G, Uhl L, Haspel RL.Strict adherence to a blood bank specimen labeling policy by all clinical laboratories significantly reduces the incidence of “wrong blood in tube”.Am J Clin Pathol2009;132:164-8.
  • Don’t collect extra blood tubes in anticipation of test orders.

    Frequently called “just-in-case,” “rainbow draws,” or simply “extra tubes,” blood collected before tests are ordered is frequently unused and ultimately discarded. This represents a waste of laboratory resources and a challenge for specimen management. Excessive phlebotomy is a recognized contributor to iatrogenic anemia, which is linked to worsened patient outcomes.

    • Gray A. Drawing extra blood tubes in the ED.Med Lab Observer [online] 2012.Available from: https://www.mlo-online.com/home/article/13004874/drawing-extra-blood-tubes-in-the-ed
    • Humble RM, Hounkponou HG, Krasowski MD.The “Rainbow” of extra blood tubes – Useful or wasteful practise?JAMA Int Med 2017:177(1):128-9.
    • Loh TP, Saw S, Sethi SK.Extra blood tubes – an affordable excess? [letter].Clin Chim Acta 2010:411:1544-5.
    • Snozek CLH, Hernandez JS, Traub SJ.“Rainbow Draws” in the emergency department:clinical utility and staff perceptions.J Appl Lab Med 2019:4(2);229-234.
  • Don’t support repeat test ordering (re-testing) at a frequency that is not backed by evidence.

    Many analytes have known stability profiles or minimum retesting intervals. In most cases, values will not change during this time. These intervals may be longer than traditional or historical test repeat ordering frequency. Ordering tests more frequently is unlikely to provide clinically meaningful results, and may contribute to iatrogenic anemia. Iatrogenic anemia can worsen patient outcomes. Laboratorians can play an active role in drawing awareness to and/or acting to reduce these types of orders.

    • Chami N, Simons JE, Sweetman A, Don-Wauchope AC.Rates of inappropriate laboratory test utilization in Ontario.Clin Bioch 2017:50;822-7.
    • Compton M, Szklarski P, Booth G.Duplicate type and screen testing waste in the clinical laboratory.Arch Path Lab Med 2018; 142(3):358-63.
    • Eaton K, Levy K, Soong C, et al.Evidence-based guidelines to eliminate repetitive laboratory testing.JAMA Int Med 2017:177(12);1833-9.
    • Lang T, Croal B.National minimum retesting intervals in pathology.A final report detailing consensus recommendations for minimum retesting intervals for use in pathology.2015.Report by The Royal College of Pathologists.Available from: https://www.rcpath.org/uploads/assets/253e8950-3721-4aa2-8ddd4bd94f73040e/g147_minretestingintervalsinpathology_dec15.pdf
    • Tchou MJ, Girdwood ST, Wormser B, Poole M, David-Rodriguez S, Caldwell JT, et al.Reducing electrolyte testing in hospitalized children by using quality improvement methods.Pediatrics 2018:141(5):e20173187.
  • Don’t routinely repeat critical results for most common analytes before reporting.

    With modern instrumentation, analytical precision is very high when the result is within the reportable range and no delta checks have failed. Providing that sample integrity and performance validity has been confirmed, repeating critical values rarely changes the result. However, turnaround time is significantly increased. This can delay clinical action, negatively impact patient care, and increase the likelihood of unnecessary investigations.

    • Lehman CM, Howanitz PJ, Souers R, Karcher DS.Utility of repeat testing of critical values.A Q-probes analysis of 86 clinical laboratories.Arch Pathol Lab Med 2014:138:788-93.
    • Motie PB, Zare-Mirzaie A, Kadivar M.Does routine repeat testing of critical laboratory values improve their accuracy?Med J Islam Repub Iran 2015;29:176.
    • Onyenekwu CP, Hudson CL, Zemlin AE, Erasmus RT.The impact of repeat-testing of common chemistry analytes at critical concentrations.Clin Chem Lab Med 2014;52(12):1739-45.
    • Sun SP, Garcia J, Hayden JA.Repeating critical hematology and coagulation values wastes resources, lengthens turnaround time, and delays clinical action.Am J Clin Path 2018:149;247-52.
  • Don’t support ordering system mechanisms that contribute to over-testing. Encourage the development of an evidence-based utilization management program that may include interventions such as unbundling order sets, reflex testing algorithms, and decision-support technology.

    Over-testing is a recognized problem, and evidence supports multi-faceted interventions that capitalize on advances in computer-based ordering technology. Bundling of tests may provide results that are not necessary for the ordering professional and may lead to duplication of testing or unnecessary follow-up. Order sets should be regularly reviewed. Research supports increased collaboration of all health care providers, including laboratory personnel, in combating over-testing. Laboratory professionals can be involved at all stages of interventions from problem recognition, feedback provision, to participation in the creation of supportive education materials and ordering guidelines.

    • Ferraro S, Panteghini M.The role of the laboratory in ensuring appropriate test requests.Clin Bioch 2017;50(10-11):555-61.
    • Jackups R, Szymanski J, Persaud S.Clinical decision support for hematology laboratory test utilization.Int J Lab Hem 2017;39:128-35.
    • Krasowski M, Chudzik D, Dolezal A, Steussy B, Gailey M, Koch B, et al.Promoting improved utilization of laboratory testing through changes in an electronic medical record:Experience at an academic medical center.BMC Med Inform Decision 2015;15(1):11.
    • Rubinstein M, Hirsch R, Cornish N.Effectiveness of practises to support appropriate laboratory test utilization.A laboratory medicine best practises systematic review and meta-analysis.Am J Clin Path 2018;149(30):197-221.
    • NazerianP, Vannit S, Fanelli A, Fallai L, Duranti C, Ognibene A, et al.Appropriate use of laboratory test requests in the emergency department:a multilevel intervention.Eur J Emerg Med 2019;26(3):205-11.
  • Don’t allow standing orders for repeat testing without a stop or review date.

    Standing orders without an expiry or review date allow testing to be performed repetitively for extended periods of time. This type of testing is rarely clinically necessary without regularly reviewing the validity of the order. This contributes to overutilization of laboratory tests, and may exacerbate the development of iatrogenic anemia.

    • Raad S, Elliot R, Dickerson E, Khan B, Diab K.Reduction of laboratory utilization in the intensive care unit.J Int Care Med 2017:32(8);500-7.
    • Studnicki J, Bradham D, Marshburn J, Foulis P, Straumfjord J.Measuring the impact of standing orders on laboratory utilization.Lab Med 1992:23(1);24-8.
    • Wertheim B, Aguirre A, Bhattacharyya R, Chorba J, Jadhav A, Kerry V, et al.An educational and administrative intervention to promote rational laboratory test ordering on an academic general medicine service.Am J Med 2017:130(10);47-53.
    • Iturrate E, Jubelt L, Volpicelli F, Hochman K.Optimize your electronic medical record to increase value:Reducing laboratory overutilization.Am J Med 2016;129(2):215-20.
  • Don’t recommend tests that are not in response to a specific clinical question.

    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.

    • Squires JE, Cho-Young D, Aloisio LD, Bell R, Bornstein S, Brien SE, et al. Inappropriate use of clinical practices in Canada: a systematic review. CMAJ. 2022 Feb 28;194(8):E279-E296. doi: 10.1503/cmaj.211416.
    • McDonald EG, Saleh RR, Lee TC. Mindfulness-Based Laboratory Reduction: Reducing Utilization Through Trainee-Led Daily ‘Time Outs’. Am J Med.
      2017 Jun;130(6):e241-e244. doi: 10.1016/j.amjmed.2017.01.011.
    • White TE, Wong WB, Janowiak D, Hilborne LH. Strategies for laboratory professionals to drive laboratory stewardship. Pract Lab Med. 2021 Jul 24;26:e00249. doi: 10.1016/j.plabm.2021.e00249.
  • Don’t collect specimens from patients approaching end-of-life if the results do not serve the patient’s indicated therapy goals.

    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.

    • Geijteman ECT, Graaf MVD, Witkamp FE, et al. Interventions in hospitalised patients with cancer: the importance of impending death awareness. BMJ Supportive & Palliative Care 2018;8:278-281
    • Binda F, Clari M, Nicolò G, Gambazza S, Sappa B, Bosco P, Laquintana D. Quality of dying in hospital general wards: a cross-sectional study about the end-of-life care. BMC Palliat Care. 2021 Oct 12;20(1):153. doi: 10.1186/s12904-021-00862-8.
    • Magelssen M, Åsten P, Godal E, et al. Blood sampling from dying patients: an ethical dilemma. Clin Ethics. 2012;7(3):107-10. doi:10.1258/ce.2012.012022
    • Cardona-Morrell M, Kim JCH, Turner RM, Anstey M, Mitchell IA, Hillman K. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem, Int J for Qual Health Care
      2016;28(4);456-69, https://doi.org/10.1093/intqhc/mzw060
  • Don’t perform a manual differential on a complete blood count (CBC) if a recent valid automated differential result remains unchanged.

    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.

    • Shen JZ, Hill BC, Polhill SR, Evans P, Galloway DP, Johnson RB, et al. Optimization of laboratory ordering practices for complete blood count with differential. Am J Clin Pathol. 2019;151(3):306-15. doi: 10.1093/ajcp/aqy146.
    • Phelan MP, Nakashima MO, Good DM, Hustey FM, Procop GW. Impact of interventions to change CBC and differential ordering patterns in the emergency department. Am J Clin Pathol. 2019 Jan 7;151(2):194-197. doi: 10.1093/ajcp/aqy128.
    • Starks RD, Merrill AE, Davis SR, Voss DR, Goldsmith PJ, Brown BS, et al. Use of middleware data to dissect and optimize hematology autoverification. J Pathol Inform. 2021;12:19. doi: 10.4103/jpi.jpi_89_20.
    • Tran A, Hudoba M, Markin T, Roland K. Sustainable laboratory-driven method to decrease repeat, same-day WBC differentials at a tertiary care center. Am J Clin Pathol. 2022;157(4):561-5. doi: 10.1093/ajcp/aqab146.
  • Don’t process transfusion orders that do not adhere to best practices without discussing with the ordering clinician.

    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).

    • Kron AT, Collins A, Cserti-Gazdewich C, Pendergrast J, Webert K, Lieberman L, et al. A prospective multi-faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study. Transfusion. 2021;61(2):410-422. doi: 10.1111/trf.16243.
    • Czempik PF, Wilczek D, Herzyk J, Krzych ŁJ. Appropriateness of allogeneic red blood cell transfusions in non-bleeding patients in a large teaching hospital: a retrospective study. J Clin Med. 2023;12(4):1293. doi: 10.3390/jcm12041293.
    • Hill-Strathy M, Pinkerton PH, Thompson TA, Wendt A, Collins A, Cohen R, et al. Evaluating the appropriateness of platelet transfusions compared with evidence-based platelet guidelines: An audit of platelet transfusions at 57 hospitals. Transfusion. 2021;61(1):57-71. doi: 10.1111/trf.16134.
  • Don’t report results on tests with low specificity without alerting clinicians to the possibility of false positives.

    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.

    • Whiting PF, Davenport C, Jameson C, et al. How well do health professionals interpret diagnostic information? A systematic review. BMJ Open 2015;5:e008155. doi: 10.1136/bmjopen-2015-008155
    • Manrai AK, Bhatia G, Strymish J, Kohane IS, Jain SH. Medicine’s uncomfortable relationship with math: calculating positive predictive value. JAMA Intern Med. 2014;174(6):991–93. doi:10.1001/jamainternmed.2014.1059
    • Morgan DJ, Pineles L, Owczarzak J, et al. Accuracy of practitioner estimates of probability of diagnosis before and after testing. JAMA Intern Med.
      2021;181(6):747–755. doi:10.1001/jamainternmed.2021.0269
    • Stovitz, S.D. The inability to calculate predictive values: an old problem that has not gone away. Med.Sci.Educ. 2020; 30:685–8.
  • Don’t process urine culture orders for asymptomatic patients that lack appropriate indications from the ordering clinician.

    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.

    • Piggott KL, Trimble J, Leis JA. Reducing unnecessary urine culture testing in residents of long term care facilities. BMJ. 2023 Aug 9;382:e075566. doi: 10.1136/bmj-2023-075566.
    • Claeys KC, Trautner BW, Leekha S, Coffey KC, Crnich CJ, Diekema DJ, et al. Optimal urine culture diagnostic stewardship practice-results from an expert modified-delphi procedure. Clin Infect Dis. 2022 Aug
      31;75(3):382-9. doi: 10.1093/cid/ciab987.
    • Vaughn VM, Gupta A, Petty LA, Malani AN, Osterholzer D, Patel PK, et al. A statewide quality initiative to reduce unnecessary antibiotic treatment of asymptomatic bacteriuria. JAMA Intern Med. 2023 Sep 1;183(9):933-41. doi:10.1001/jamainternmed.2023.2749.
  • Don’t wake patients at night for phlebotomy for testing deemed safe by clinical teams to proceed in the morning.

    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.

    • Tapaskar N, Kilaru M, Puri TS, Martin SK, Edstrom E, Leung E, et al. Evaluation of the order SMARTT: An initiative to reduce phlebotomy and improve sleep-friendly labs on general medicine services. J Hosp Med. 2020 Aug;15(8):479-482. doi: 10.12788/jhm.3423.
    • Ramarajan V, Chima HS, Young L. Implementation of later morning specimen draws to improve patient health and satisfaction. Lab Med 2016;47(1):e1-4. https://doi.org/10.1093/labmed/lmv013
    • Grossman MN, Anderson SL, Worku A, Marsack W, Desai N, Tuvilleja A, et al. Awakenings? Patient and hospital staff perceptions of nighttime disruptions and their effect on patient sleep. J Clin Sleep Med.
      2017;13(2):301–306
    • Ramazani SN, Gottfried JA, Kaissi M, Lynn J, Leonard MS, Schriefer J, et al. Improving the timing of laboratory studies in hospitalized children: a quality improvement study. Hosp Pediatr July 2021; 11 (7): 670–8.
    • Morse AM, Bender E. Sleep in Hospitalized Patients. Clocks & Sleep. 2019; 1(1):151-165. https://doi.org/10.3390/clockssleep1010014

How the List was Created (1-7)

Project leadership was established as a team of individuals from the Canadian Society of Medical Laboratory Science (CSMLS) and the Medical Laboratory Science program at the University of Alberta. A working group (herein referred to as the “Expert Panel”) of experienced medical laboratory professionals (MLPs) from across Canada were recruited through advertisement by the CSMLS. Expert Panel members were selected based on maximal representation of geography, years and variety of working experience, and professional designation. All traditional disciplines of medical laboratory science (chemistry, hematology, blood bank, microbiology, and histology) were represented by at least two members. There were five virtual synchronous meetings as well as asynchronous technology-enabled discussions over approximately one year. Potential CWC list items were generated through Expert Panel members, a national CSMLS survey, and a meeting at the 2019 CSMLS annual convention. A modified Delphi process was used to reduce a long list to a short list of items. We used scoping reviews to generate evidence for items on the short list. Items with the strongest evidence were sent to the CSMLS Board of Directors for approval.

How this list was created (8-14)

The Canadian Society for Medical Laboratory Science (CSMLS) formed a committee of medical laboratory professional (MLP) subject matter experts. They met in early 2023 to develop a strategy to create new recommendations. Subcommittees were formed to explore multiple sources of potential list items, including the list of deprioritized items from the first iteration to identify MLP recommendations in 2018-2019, laboratory-related items published by other societies in Choosing Wisely Canada and several other countries, and through leading discussions at their local sites. A long list of items was discussed at a meeting in June 2023, and forty-two were deemed potential candidates for further consideration. The committee then went through an asynchronous prioritization exercise to identify the most important recommendations with respect to frequency, potential for waste, potential for harm, and professional barriers to future action. The prioritization exercise identified the most important recommendations, which were subjected to analysis of the quality of published evidence supporting each recommendation. The draft recommendations were approved by the Board of Directors of the CSMLS in December 2023.

About the Canadian Society for Medical Laboratory Science

The Canadian Society for Medical Laboratory Science is the national certifying body for medical laboratory technologists and medical laboratory assistants, and the national professional society for Canada’s medical laboratory professionals. Our purpose is to: 1) promote and maintain a nationally accepted standard of medical laboratory technology by which other health professionals and the public are assured of effective and economical laboratory services, and 2) promote, maintain and protect the professional identity and interests of the medical laboratory professional and of the profession.

Our members practice in hospital laboratories, private medical laboratories, public health laboratories, government laboratories, research and educational institutions. Incorporated in 1937 as the Canadian Society of Laboratory Technologists, the society has over 14,500 members in Canada and in countries around the world.

To understand the collected evidence that supports these recommendations, please see our searchable recommendation database.

Do you have questions on how the recommendation validation process was conducted? Contact research@csmls.org for more information. You can also find general information in the volunteer presentation.