Significant changes have been made in North York General Hospital's (NYGH) Charlotte & Lewis Steinberg Emergency and Preoperative Assessment Clinic to reduce the number of routine tests administered to patients. In fact, patients will hardly notice them at all — they won't miss undergoing unnecessary tests that won't help with a diagnosis and would prefer to skip the possibility of avoidable harm, which can result from inappropriate testing.
These changes, implemented in our latest Choosing Wisely Canada project, have produced impressive results.
Supported by ARTIC (Adopting Research to Improve Care), a joint program of the Council of Academic Hospitals of Ontario and Health Quality Ontario, NYGH and hospitals in the Joint Centres for Transformative Healthcare Innovation partnered together for the Choosing Wisely: An Idea Worth Spreading project, which supported a coordinated group effort to implement Choosing Wisely recommendations across several institutions at the same time. At the completion of the project, all the participating Joint Centres hospitals significantly reduced unnecessary tests within their institutions. As lead hospital for the project, NYGH achieved and sustained a 44% reduction in lab tests ordered through the Emergency Department (ED) and a 37% ED reduction in preoperative tests.
“Up to 30% of medical care is thought to be unnecessary and this can have a negative impact on both patients and the health care system,” said Dr. Donna McRitchie, Co-lead of the NYGH project and Executive Champion. “Our physicians and staff are committed to incorporating Choosing Wisely recommendations into our daily work because we know it can be a powerful tool to improve care.”
Give the test a rest
North York General's ED sees more than 110,000 emergency visits a year. After evaluating the number of lab tests ordered in the hospital, it was determined that approximately 40% came from the ED. Many of the tests were unnecessary and being generated as part of automatic order sets.
“To reduce the number of lab tests in the ED, lab staff worked closely with emergency physicians and frontline staff to review with them which order sets* should be change to reflect the most up-to-date practices,” said Manuel Giraldo, Pathology and Core Lab Manager. “We have also been able to introduce new, more sensitive tests, so it is important that patients understand that we are not taking away care — but providing them with tests that are more beneficial.”
Drop the preop
NYGH's Preoperative Assessment Clinic was seeing more than 900 patients a month before embarking on Choosing Wisely recommendations. Many of the patients coming to the clinic were undergoing low- to moderate-risk surgery and considered low- to moderate-risk patients. Some of the tests they were receiving were needless and were producing results that lead to more testing, even though the results would not impact their surgery.
“Surgery can be stressful for patients and by having them take tests that aren't helpful adds further uncertainty for them and their families,” said Linda Jussaume, Surgery Program Director. “We had a multidisciplinary team look at how we could provide more patient-focused, evidenced-based individualized care prior to surgery and these impressive results have led to better care.
Members of the Preoperative Assessment Clinic have implemented and sustained Choosing Wisely initiatives that have reduced preoperative lab tests by 37%. From left: Valeria Thompson, Sharon Goss, Karen Rose, Antoniette Morra, Angie Grossi, Inga Nikkarinen and Ilana Johnson.
Implementing Choosing Wisely recommendations also provides an opportunity for physicians and patients to have conversations about what tests are necessary and the benefits of choosing not to do certain routine tests. At NYGH, Patient and Family Advisors (PFAs) played an integral role in our approach to reducing tests in the ED and Preoperative Assessment Clinic. Through a series of videos, PFAs have helped to lead a public discussion around Choosing Wisely from the perspective of patients and families.
“Choosing Wisely was designed with the specific purpose of engaging both patients and health care providers,” said Jennifer Zadravec, Manager of Medical Imaging. “At NYGH we have a passionate group of PFAs who see the value of Choosing Wisely and the important role patients and families have in starting a discussion with their doctors to see if the tests and treatments they are receiving align with current recommendations.”
NYGH is building on the momentum that started as a result of the ARTIC project and has started tackling Choosing Wisely initiatives in our Medical Imaging and Surgery departments. Together, with the Joint Centres and PFAs, North York General Hospital is spreading insights and learnings from this ARTIC project so that this important work continues to spread and improve care.
* Order sets are pre-approved evidence-based grouping of orders to standardize patient care based on a condition, disease or procedure.