Preoperative blood tests in elective general surgery: cost and clinical implications.
Abstract: A retrospective observational study was performed in our trust in October 2010 that examined compliance, and the financial and clinical implications of performing inappropriate preoperative blood tests on adult patients prior to elective surgery, against the 2003 NICE guidelines. An unacceptable proportion of inappropriate tests (31.3%) were being performed. None were associated with adverse outcome or changes in management. Based on our results, we estimate that an extrapolated cost of [pounds sterling] 11.2 million is being spent on inappropriate blood tests in NHS England and Wales.

KEYWORDS Preoperative blood tests / Elective surgery / Inappropriate blood tests / NICE guidelines / Coagulation screen
Article Type: Report
Subject: Medical screening (Economic aspects)
Blood (Medical examination)
Blood (Economic aspects)
Authors: Phoenix, Gokulan K
Elliott, Tamara
Chan, James K
Das, Saroj K
Pub Date: 09/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Sept, 2012 Source Volume: 22 Source Issue: 9
Product: Product Code: 8000428 Blood Test Procedures NAICS Code: 6215 Medical and Diagnostic Laboratories
Accession Number: 309315282
Full Text: Introduction: 'Routine' preoperative blood tests are performed in surgical patients to minimise the risk of perioperative morbidity and mortality from complications undetected in the patient narrative. However, numerous studies have shown that routine testing is cost ineffective, and of little clinical benefit. Consequently, NICE published guidelines on the use of routine preoperative tests for elective surgery (NICE 2003). The impact of the guidelines on clinical outcomes and costs has yet to be assessed. Aim: Current practice of routine testing within the general surgery department of a district general hospital was assessed against NICE recommendations. Besides compliance, the financial and clinical implications of performing 'inappropriate' blood tests were also examined. Method: A retrospective, observational study of adult patients that underwent elective general surgery was undertaken during October 2010. Based on NICE guidance (NICE 2003), the 'appropriateness' of blood tests including full blood count, urea and electrolytes, clotting and glucose was evaluated, based on criteria which included age, grade of surgery and ASA grade. Blood results, complications and management changes were obtained from patient records. Results: 273 blood tests were performed in 111 patients. None of the 'inappropriate' tests (n=85, 31.3%) were abnormal. Patients that developed complications (n= 5, 4.5%) had had only recommended tests.

A total of [pounds sterling] 249.94 was spent on inappropriate tests, which extrapolates to [pounds sterling] 17,000 per annum for our trust, and over [pounds sterling]11 million in the UK. Conclusion: Inappropriate blood tests did not correlate with adverse outcome or impact management in our patient cohort, and represents a source of considerable financial saving for our trust and possibly others.

Introduction

The purpose of performing 'routine' preoperative blood tests in patients undergoing elective surgery is to minimise the risk of perioperative morbidity and mortality from avoidable complications undetected in the history and examination (Munro et al 1997).

However, routine preoperative testing of healthy individuals prior to elective surgery is of little clinical benefit (SCTA 1991, Munro et al 1997, ASA 2002) and has been shown to be a highly cost ineffective practice (Allison et al 1996, Smetana et al 2003, Ferrando et al 2005, Chung et al 2009). In England approximately five million elective surgical procedures are performed annually (Health and Social Care Information Centre 2011 2011) at an estimated cost of around [pounds sterling]1 billion per annum (Audit Commission 2003). The annual cost for routine preoperative testing is not known but is estimated to be in the order of tens of millions (NICE 2003: Appendix 5). It is likely that inappropriate tests represent a major contribution to these costs.

In June 2003 the National Institute for Health and Clinical Excellence (NICE) published guidelines on the use of routine preoperative tests for elective surgery in order to improve the clinical and financial value of preoperative tests (NICE 2003). Recommendations were made for the use of chest radiographs, electrocardiographs, arterial blood gases, lung function tests, urine dipstick and four blood tests including full blood count (FBC), urea and electrolytes (U&Es), random glucose and coagulation. Tests were classed as appropriate, inappropriate or of uncertain value based on criteria including age, grade of surgery and medical fitness as judged according to the American Society of Anesthesiologists' (ASA) grading system. The information was made available in traffic light colour-coded 'look-up tables' (Figure 1).

[FIGURE 1 OMITTED]

However, despite the clinical evidence and publication of the NICE guidelines there remains a misconception that routine preoperative testing in the absence of clinical indications is necessary to identify previously unsuspected or undiagnosed conditions. This retrospective audit assesses the current practice of routine preoperative blood testing within the general surgery department of a district general hospital against the NICE recommendations. As well as compliance, the financial and clinical implications of performing inappropriate blood tests were examined.

Method

All patients aged 16 and over, who underwent elective colorectal, vascular or breast surgery between 1st and 31st October 2010 (31 days) at the Hillingdon Hospital NHS Trust, London were included in this retrospective observational study. The study population was obtained from the scheduled elective admission lists for the entire general surgical department in colorectal, vascular and breast surgery.

Basic demographic data (including age and gender), name of the procedure, ASA grade, indications for blood tests (if documented), complications and any changes to clinical management were obtained from patient medical records.

Every surgical procedure was graded according to the 2006 edition of the British United Provident Association (BUPA) Schedule of Procedures (BUPA 2006). The procedure was categorised into one of four grades of surgery: minor (grade 1), intermediate (grade 2), major (grade 3) and major plus (grade 4). This grading system was the same as that used in the NICE guidelines. All operations listed in the NICE guidelines had identical grades of surgery to those in BUPA, with the latter providing a more comprehensive list of operations and grades of surgery. Examples of operations and associated grades of surgery can be seen in Table 1.

Defined complications and changes in management (anaesthetic, surgical and non-clinical) associated with each blood test were taken from the NICE guidelines (NICE 2003 Appendix 1). However, details of any undefined complications and changes in management (not present in the guidelines) were also recorded, with the likelihood of an association with the result of a particular blood test being decided amongst authors GP and TE, with SD acting as arbitrator.

The results of the preoperative blood tests: FBC, U & Es, random glucose and clotting, were obtained from the trust's online pathology system, Sunquest Information Systems[R]. Trust stated reference ranges (mean [+ or -] 2 standard deviations) were used to identify results as either normal or abnormal.

Tests were categorised as appropriate or inappropriate, according to the NICE guidelines. For the purpose of this audit any test of uncertain value was placed into the former category.

Costings were obtained from the trust's pathology department, and reflect both sample analysis and staff cost. The costs per test were: [pounds sterling] 1.94 for a FBC, [pounds sterling] 1.60 for U & Es, [pounds sterling] 3.50 for a coagulation screen and [pounds sterling] 1.60 for a random glucose. All prices were inclusive of VAT.

Results

In total, 121 patients met the inclusion criteria of this study. The medical records of 10 patients were unavailable. Of the 111 patients, 42 were male and 69 female, giving a male-to-female ratio of 1.2:2. The median (SD) age was 52 (15.4) years (range 17-84).

Thirty (27%) of the patients were classed as having an ASA grade of 1; 70 (63%) were ASA grade 2; 11 (10 %) were ASA grade 3; and none were grade 4.

Twenty-two (19.8%) patients underwent minor surgery, 41 (36.9%) intermediate, 17 (15.3%) major and 31 (28%) major plus. Fifty-nine patients (53.2%) underwent day case procedures.

A total of 273 preoperative blood investigations were performed of which 188 (68.9%) were recommended. Twenty-two (11.5%) of the recommended tests were abnormal. None of the 85 (31.1%) inappropriate tests that were performed were abnormal.

Complications occurred in 5 (4.5%) patients. Four of the five patients with complications had preoperative blood tests, all of which were recommended. In those four patients, the results of the blood tests were normal (n=3) or 'abnormal' (n=1), as according to trust stated reference ranges. Details of these cases are stated below. A summary of the audit findings can be seen in Table 2.

Full blood count

Ninety-two FBCs (33.7% of total) were performed of which 81 (88%) were recommended. Fourteen (17.3%) were abnormal; 12 tests had a haemoglobin (Hb) between 11-12g/dL[L.sup.-1] and two patients had platelet counts between 500-550 x [10.sup.3]/[mu] L. There were no complications or changes in management observed in the patients with abnormal blood results.

However, in two patients with normal recommended preoperative FBCs, complications were observed. These are detailed below: An 81-year-old male was transfused with packed red blood cells (RBC) following an elective Hartmann's; day 1 post-operative Hb was 8.4g/d[L.sup.-1]. A high estimated blood loss was noted in the medical record. The preoperative FBC, which was recommended, showed a preoperative Hb of 13.4g/d[L.sup.-1]. The preoperative FBC was taken six days prior to surgery. The post-transfusion Hb was 10.0g/d[L.sup.-1]

A 62-year-old male was transfused with two units of packed RBCs following an axillo-femoral bypass procedure. A high estimated blood loss was noted in the medical record. The preoperative Hb was normal (14g/d[L.sup.-1]). The postoperative Hb was far lower (10.2g/d[L.sup.-1]), and a decision to transfuse was made on the severity of clinical signs and symptoms. Following transfusion the Hb was 12.4g/d[L.sup.-1].

Coagulation screen

Eighty-eight (32.2%) coagulation tests were performed; 58 (65.9%) were not recommended, with no written indications as to their use. Of the 30 (34.1%) appropriate tests, one was 'abnormal'. A summary of the case is stated below: A 75-year-old male had a preoperative coagulation screen (INR 1.4) four days prior to a haemorrhoidectomy. The test was both recommended and indicated; the patient was on warfarin for atrial fibrillation (AF). Subsequently the warfarin was stopped and a treatment dose of low molecular weight heparin was commenced two days prior to surgery, as per hospital protocol. The INR was 1.2 when repeated on the day of surgery. Post-haemorrhoidectomy the patient developed rectal bleeding immediately, prompting a return to theatre for control of bleeding. The operative notes stated poor haemostasis as a possible explanation.

Urea and electrolytes

Ninety-two (33.7%) samples were analysed, 77 (83.7%) were recommended. Seven (9.1%) of the recommended tests were abnormal. None of the 15 inappropriate tests were abnormal.

Glucose

One patient had an inappropriate random blood glucose performed. The test was normal.

Other complications

Two patients developed abscesses postoperatively. The first patient was a 71-year-old female who had had a laparoscopic cholecystectomy which was converted to open surgery. She was found to have an intra-abdominal abscess two days post-operatively. The preoperative FBC, U&E and clotting tests were all normal, and recommended. The other patient was a 34-year-old female who had had an excision of a lesion of the breast, subsequently developing a breast abscess. She did not undergo any preoperative investigations.

Costs

In total [pounds sterling]249.94 (inclusive of VAT) was spent on inappropriate blood tests (n=85) in the 111 patients included in this study. Within the trust, a total of 2201 operations are performed in colorectal, vascular and breast surgery per year. The number increases to 7578 with the inclusion of urology and orthopaedic operations. Therefore, it is estimated that between [pounds sterling]5,000 and [pounds sterling]17,000 is spent on inappropriate blood tests per annum within the Hillingdon Hospital NHS Foundation Trust, and approximately [pounds sterling]11.25 million on the five million elective operations performed in England per year.

A breakdown of the costs for each individual test in 2010 is shown in Table 3.

Discussion

Routine preoperative testing of healthy individuals prior to elective surgery is of little clinical benefit (SCTA 1991, Munro et al 1997, ASA 2002). Retrospective and prospective studies have shown that routine testing seldom reveals unsuspected and undiagnosed disease in an asymptomatic patient (Turnbull & Buck 1987), surgical outcomes are rarely predicted based on the results (Johnson & Mortimer 2002, Chung et al 2009, Sarayrah & Habaiben 2009) and on the whole management is also unaffected (Johnson & Mortimer 2002, Bryson et al 2006). Furthermore testing in the absence of a clinical indication has been shown to produce a high incidence of false positive and false negative results (Macpherson 1993, Velanovich 1996, Roizen & Lichtor 2003) resulting in unnecessary and potentially harmful treatments (Lopez-Argumedo & Asua 1999) as a result of the former, and dangerous outcomes as a consequence of the latter (Eiicho 2005).

In financial terms routine testing is a highly cost ineffective practice (Allison & Bromley 1996, Smetana & Macpherson 2003, Ferrando et al 2005, Chung et al 2009) with the rationalisation of tests proven to reduce costs substantially (Ranasinghe et al 2010).

Consequently in June 2003 NICE published guidelines to improve the value of preoperative tests (NICE 2003). This retrospective audit assessed the current practice of routine preoperative blood testing within the general surgery department of a district general hospital against the NICE recommendations. Compliance, financial and clinical implications of performing inappropriate blood tests are discussed below.

Compliance

Since the dissemination of its guideline, NICE conducted a single nationwide follow-up survey in 2005; national compliance was regarded to be good (NICE 2005).

More recently there have been two published studies that have examined compliance.

Putnis et al 2008 measured compliance in terms of the percentage of inappropriate tests performed. The authors reported 31 of the 178 (17.4%) tests were performed against recommendations but 13 (7.3%) of them had valid documented reasons.

Krishnamurthy et al 2007 assessed 'full compliance' with the guidelines by examining the percentage of patients that had all their recommended tests performed as well as not having had any inappropriate tests. Of a total of 125 patients, 78 (62.4%) were classed as being non-compliant. Eleven (14.1%) patients did not have certain recommended tests performed and 67 (85.9%) patients had inappropriate tests performed (n=93). The total number of tests performed was not stated.

Both studies identified the coagulation screen as the most regularly inappropriately performed test, accounting for 13 of the 31 (41.2%) inappropriate tests in the Putnis study and 45 of the 93 (48.4%) inappropriate tests in the Krishnamurthy study.

In comparison, 85 of the 273 (31.1%) routine blood tests featured in this study were inappropriate, and had no documented clinical indication. Similar to the results of the other studies, coagulation screen was the inappropriate test performed most regularly (n=58; 65.9%).

Clinical implications

Anaesthetic, surgical and non-clinical complications and changes in management have been used as measures of the clinical impact of routine preoperative tests in numerous studies (SCTA 1991, Munro et al 1997, ASA 2002, Johnson & Mortimer 2002, Chung et al 2009, Bryson et al 2006, Sarayrah & Habaiben 2009). However, NICE has made no recommendations for the evaluation of clinical impact when auditing practice on a local level. To date, no published audit of the guideline has examined the clinical implications of performing inappropriate blood tests.

In this study five patients encountered complications. These included: an intra-abdominal collection and breast collection (n=2); blood transfusions for postoperative anaemia following intra-operative blood loss (n=2); and a return to theatre for uncontrolled bleeding (n=1). Blood tests that were performed in these patients were all recommended.

It was decided that the formation of postoperative collections (intra-abdominal and breast) could not have been predicted by any test, and so were not considered to have any association with the preoperative blood tests (performed in only one of the two patients, all recommended and normal).

The two patients that developed postoperative anaemia had recommended preoperative FBCs, the values of which were within the trust reference range (13.4g/[dL-.sup.1] and 14 g/[dL-.sup.1]). It would therefore not be possible to associate the results of the tests to the complications and changes in management that arose. Furthermore the estimated blood losses stated in the operative notes were high enough to cause the drop in Hb.

The patient that developed rectal bleeding following a haemorrhoidectomy had a preoperative coagulation screen that was both recommended and indicated; the patient was on warfarin for atrial fibrillation. It is debatable whether the preoperative INR value (1.4) could be classed as 'abnormal' given the patient's drug history. Furthermore, the INR was 1.2 (within operating parameters for the trust) on the day of the operation, following the substitution of warfarin with enoxaparin. It was therefore decided that there was no association between the rectal bleeding and the result of the preoperative coagulation screen, but rather a technical complication, as stated in the operative notes.

Possibly the more significant finding was that no complication or change in management could have been associated with the results of an inappropriate test; all 85 were normal. The results are consistent with the literature; routine testing of healthy individuals is of little, if any, clinical benefit (SCTA 1991, Munro et al 1997, ASA 2002, Johnson & Mortimer 2002, Bryson et al 2006, Chung et al 2009, Sarayrah & Habaiben 2009).

Cost implications

Up to an estimated [pounds sterling]17,000 per annum is spent on inappropriate preoperative blood test within our trust. This figure is based on the 7,578 operations in colorectal, vascular, breast, orthopaedic and urology operations performed in the trust per year. Based on the 5 million elective surgical procedures performed per year across the 167 NHS trusts in England and Wales, approximately [pounds sterling]11.2 million is being spent on inappropriate blood tests prior to elective surgery.

Improving adherence to guidelines

Despite the innumerable studies that have shown the practice of routine testing is inefficient, the adoption of guidelines remains problematical (Pasternak 2004, Bryson et al 2006, Krishnamurthy et al 2007). The results of this study support this. Understanding the possible reasons why clinicians continue to order tests without reason is needed in order to improve practice. These issues must be addressed if any strategies implemented are to be successful (Macpherson 1993).

Various reasons have been proposed to explain the poor compliance with preoperative blood testing (Kumar & Srivastava 2011, Power & Thackray 1999). These include the following:

1. Fear. This may range from the fear of cancellation or postponement of surgery, to the fear of litigation from not carrying out tests that may have influenced an adverse event (Power & Thackray 1999, Barazzoni et al 2002, Garcia-Miguel et al 2003Smetama & Macpherson 2003).

2. Working behaviours and the influence of others. Many junior doctors perform blood tests believing that their seniors would want them. Doctors are also influenced by the experiences of their predecessors and seniors and therefore working behaviours are passed on to them (Johnson & Mortimer 2002). A vicious cycle may emerge and it then becomes difficult to change working behaviour (Bryson 2005). There is also reluctance to challenge decisions made by a member of another discipline, such as between an anaesthetist and a surgeon (Johnson & Mortimer 2002).

3. Local policies. Although The Hillingdon Hospital has none in place, other trusts may have local policies already in place for staff to follow (MacPherson et al 2005).

In this study, the lack of awareness of the guidelines is also a possible explanation. The junior surgeons and preassessment nurses perform the majority of routine preoperative tests at The Hillingdon Hospital NHS Trust, but prior to this audit were not educated about the guidelines as part of their induction or formal teaching programme. Furthermore there were no posters, printed or electronic copies of the guidelines available on the intranet at the time of data collection. Since the findings of this study, small pocket sized versions of the guidelines and large posters have been printed and distributed to the junior doctors, preassessment nurses and around the preassessment clinics. The posters and portable guidelines incorporated the top 15 most common procedures for each specialty, making it easier for doctors and nurses to use.

To improve compliance within the trust, all members that are responsible for ordering preoperative blood tests must be included in any implementation strategies (Kumar & Srivastava 2011). These include the anaesthetists, surgeons and preoperative nurses within this trust. Furthermore the continuing education of senior staff members as well as juniors is needed (Ferrando et al 2005). Juniors especially can change rotations many times per year and so this would have to be taken into account.

The implementation strategies chosen must take into account local resources, finances, time and needs (NICE 2003). Whichever methods are chosen, it is important that the dogma that routine testing can be cost effective, improve outcome and reduce medico-legal liability must be dispelled (Kumar & Srivastava 2011), as well as taking steps to ensure that guidelines are available in places where preoperative investigations are ordered (NICE 2003). Both are needed if a significant improvement in practice is to be achieved.

Limitations of our study

As a consequence of retrospective data collection it was difficult to ascertain the accuracy of record-keeping. Potential absent documentation of preoperative history and examination findings, complications, changes in management, and indications for tests not recommended by the guidelines would have affected the quality of data obtained. An emphasis on clear and detailed documentation was made within the educational talks within our trust intervention strategies.

NICE has suggested that the evidence behind the guidelines is 'weak' (grade IV evidence, Oxford Centre for Evidence-based Medicine Levels of Evidence) and cannot be enforced. Adaptation of the guidelines to local circumstances or the incorporation of recommendations into existing local guidelines is also encouraged (NICE 2003). Guidelines consisting of higher grade evidence may exist elsewhere. However, in The Hillingdon Hospital no guidance on preoperative testing existed at the time of this audit. Therefore the implementation of NICE recommendations could only improve on current practice. This may be the case with other trusts as well.

Although the sample size in this study was comparable to other published audits (Putnis et al 2008, Krishnamurthy et al 2007) a larger cohort would have given a more accurate incidence of adverse outcomes and changes in management which resulted from an inappropriate blood test. For example, Turnbull and Buck (1985) performed a prospective study of 1010 patients, analysing 5003 blood tests, to notice a change in anaesthetic management in 17 patients. However, despite cohort size most studies, including Turnbull and Buck, suggest a low incidence of complications and changes in management, and this is comparable to the results of this study (SCTA 1991, Allison & Bromley 1996, Munro et al 1997, ASA 2002, Johnson & Mortimer 2002, Smetana & Macpherson 2003, Ferrando et al 2005, Bryson et al 2006, Chung et al 2009Sarayrah & Habaiben 2009).

Future considerations

The NICE guidelines have recommendations for urine testing, sickle cell screening, ECG and chest radiographs. Auditing compliance of these investigations and investigating the financial and clinical implications may also prove to be beneficial to the patient and to the NHS as a whole.

Summary

1. Trust compliance with NICE guidelines is poor. Far too many inappropriate tests are being performed with no clinical justification (31%).

2. Adherence to guidelines is therefore required, and if significant change is to arise it must occur across all general surgery departments across the UK.

3. Steps must be taken to ensure both the availability of the guidelines, and the education of all medical staff involved with the ordering of routine preoperative blood tests, for there to be considerable improvement. Educational talks, posters, and small pocket-sized guidelines as part of the intervention strategies can help raise awareness.

4. A re-audit, which is underway at the Hillingdon Hospital NHS Trust, is not only necessary to assess a change in compliance but also to help adapt the guidelines according to local needs.

Conclusion

Besides compliance, the aims of this audit were to assess the financial and clinical implications of performing inappropriate blood tests prior to elective surgery against NICE recommendations. Recognising poor compliance alone would not deter those responsible for ordering and performing blood tests from the practice of 'routine screening' healthy individuals. The assessment of the clinical and financial implications of performing inappropriate tests was also thought to be necessary to change working behaviour The influence of senior figures such as consultants, and dispelling the fear of litigation (from a complication where the absence of test may later be thought to be have been important) were also thought to be important factors. Our experience at a district general hospital supports the findings of innumerable studies and that of the NICE recommendations: routine testing of healthy individuals prior to elective surgery does not impact upon clinical management or correlate with adverse outcome, and represents a potential source of considerable financial saving for the NHS. We would encourage all NHS trusts to assess their practice of performing routine blood tests prior to elective surgery, and to implement strategies to improve compliance accordingly.

References

Allison JG, Bromley HR 1996 Unnecessary preoperative investigations evaluation and cost analysis American Journal of Surgery 62 686-9

American Society of Anesthesiologists 2002 Practice advisory for preanesthesia evaluation: A report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology 96 (2) 485-9

Audit Commission 2003 Operating theatres: Review of national findings Available from: www.audit-commission.gov.uk/nationalstudies/health/other/pages/operatingtheatres.aspx (Accessed July 2012)

Barazzoni F, Grilli R, Amicosante AM et al 2002 Impact of end use involvement in implementing guidelines on routine preoperative tests International Journal for Quality in Health Care 8 1-7

British United Provident Association 2006 Schedules of procedures Available from: www.bupa.com.mt/members%20area/~/media/Bupa%20Malta%20Files/2011/BUPA%20Schedule%20of%20Procedures%202007.ashx [Accessed July 2012]

Bryson GL 2005 Has preoperative testing become a habit? Canadian Journal of Anesthesia 52 557-61

Bryson GL, Wyand S, Bragg PR 2006 Preoperative testing is inconsistent with published guidelines and rarely changes management Canadian Journal of Anesthesia 53 236-41

Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT 2009 Elimination of testing in ambulatory surgery Anesthesia & Analgesia 108 467-75

Eiicho I 2005 Role of preoperative laboratory tests in preoperative assessment The Journal of Japan Society for Clinical Anesthesia 25 582-7

Ferrando A, Ivaldi C, Buttiglieri A et al 2005 Guidelines for preoperative assessment: Impact on clinical practices and costs International Journal for Quality in Health Care 17 323-9

Garcia-Miguel FJ, Serrano-Aguilar PG, Lopez-Bastida J 2003 Preoperative assessment Lancet 362 1749-57

Health and Social Care Information Centre 2011 Hospital episode statistics, main procedures and interventions 2009-2010 Available from: www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=204 [Accessed July 2012]

Johnson RK, Mortimer AJ 2002 Routine preoperative blood testing: is it necessary? Anaesthesia 57 (9) 914-7

Krishnamurthy A, Dutta D, Phillips J, Methal N 2007 Are we still performing too many blood tests? Quality & Safety in Health Care 16 (5) 400

Kumar A, Srivastava U 2011 Role of routine laboratory investigations in preoperative evaluation Journal of Anaesthesiology & Clinical Pharmacology 27 174-9

Lopez-Argumedo M, Asua J 1999 Preoperative evaluation in elective surgery INAHTA Synthesis Report. Osteba, Vitoria-Gasteiz. Dept of Health, Basque Government Basque Office for Health Technology Assessment

Macpherson DS 1993 Preoperative laboratory testing: Should any test be routine before surgery Medical Clinics of North America 77 289-308

MacPherson RD, Reeve SA, Stewart TV et al 2005 Effective strategy to guide pathology test ordering in surgical patient Australia & New Zealand Journal of Surgery 75 138-43

Munro J, Booth A, Nicholl J 1997 Routine preoperative testing: a systematic review of the evidence Health Technology Assessment 1 (12) 1-62

National Institute for Health and Clinical Excellence 2003 Preoperative tests: The use of routine preoperative tests for elective surgery. Appendix 1: Results of a systematic review of the literature for routine preoperative testing; Appendix 5: Economics of routine preoperative testing Available from: http://www.nice.org.uk/Guidance/CG3 [Accessed May 2012]

National Institute for Health and Clinical Excellence 2005 A survey measuring the impact of NICE guidelines. 3: Preoperative tests London, NICE

Pasternak LR 2004 Preoperative laboratory testing: General issues and considerations Anesthesiology Clinics 22 13-25

Power LM, Thackray NM 1999 Reduction of preoperative investigations with the introduction of an anaesthetist led preoperative assessment clinic Anaesthesia and Intensive Care 27 481-8

Putnis S, Nanuck J, Heath D 2008 An audit of preoperative blood tests Journal of Perioperative Practice 18 (2) 56-9

Ranasinghe P, Perera YS, Abayadeera A 2010 Preoperative investigations in elective surgery: Practices and costs at the national hospital of Sri Lanka Sri Lankan Journal of Anaesthesiology 18 29-35

Roizen MF, Lichtor JL 2003 Preoperative assessment and premedication for adults In: Healy TEJ, Knight PR (eds) Wylie and Churchill Davidson's A practice of Anesthesia 7th ed 415-25

Sarayrah MA, Habaiben E 2009 Preoperative blood testing in pediatric age group: Is it necessary? Middle East Journal of Family Medicine 53 7-9

Smetana GW, Macpherson DS 2003 The case against preoperative laboratory testing Medical Clinics of North America 87 7-40

Swedish Council on Technology Assessment in Health Care 1991 Preoperative routines International Journal of Technology Assessment in Health Care 7 (1) 95-100

Turnbull JM, Buck C 1987 The value of preoperative screening investigations in otherwise healthy individuals Archives of Internal Medicine 147 (6) 1101-5

Velanovich V 1996 Collective review: Preoperative laboratory evaluation Journal of the American College of Surgeons 183 79-87

Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk.

Access is also available to non-members who pay a small fee for each article download.

by Gokulan K Phoenix, Tamara Elliott, James K Chan, Saroj K Das

Correspondence address: Dr Gokulan K Phoenix, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH. Email: gokulan.phoenix@nhs.net

About the authors

Gokulan K Phoenix

MBBS, MSc

Core Surgical Trainee Yr 1, Chelsea & Westminster Hospital, London

Tamara Elliott

MBBS, BSc

FY2 Doctor, Charing Cross Hospital, London

James K Chan

MB BChir, MA, MRCS

Plastic Surgery ST3, Clinical Research Fellow, Oxford Deanery, Oxford University

Saroj K Das

MS, FRCS

Consultant Surgeon, The Hillingdon Hospitals NHS Foundation Trust, London

No competing interests declared

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication May 2012.
ASA Grade 2: adults with comorbidity from cardiovascular disease

                             Age  (years)

Test          [greater than  [greater than    [greater
              or equal to]   or equal to]   thanor equal
                  16 to          40 to        to] 60 to
                 < 40            < 60          < 80

Chest X-ray   Consider this  Consider this  Consider this
              test (see      test (see      test (see
              page 2)        page 2)        page 2)

ECG           Yes            Yes            Yes
              Test           Test           Test
              recommended    recommended    recommended

Full blood    Yes            Yes            Yes
count         Test           Test           Test
              recommended    recommended    recommended

Hacmostasis   Consider this  Consider this  Consider this
              test (see      test (see      test (see
              page 2)        page 2)        page 2)

Renal         Yes            Yes            Yes
function      Test           Test           Test
              recommended    recommended    recommended

Random        No             No             No
glucose       Test not       Test not       Test not

Urine         Consider this  Consider this  Consider this
analysis      test (see      test (see      test (see
              page 2)        page 2)        page 2)

Blood gases   Consider this  Consider this  Consider this
              test (see      test (see      test (see
              page 2)        page 2)        page 2)

Lung          No             No             No
function      Test not       Test not       Test not

              Age  (years)

Test         [greater than
              or equal to]
                    80

Chest X-ray   Consider this
              test (see
              page 2)

ECG           Yes
              Test
              recommended

Full blood    Yes
count         Test
              recommended

Hacmostasis   Consider this
              test (see
              page 2)

Renal         Yes
function      Test
              recommended

Random        No
glucose       Test not

Urine         Consider this
analysis      test (see
              page 2)

Blood gases   Consider this
              test (see
              page 2)

Lung          No
function      Test not

ASA Grade 3: adults with comorbidity from cardiovascular disease

                           Age (years)

Test          [greater than  [greater than    [greater
              or equal to]   or equal to]   thanor equal
                  16 to          40 to        to] 60 to
                 < 40            < 60          < 80

Chest X-ray   Consider this  Consider this  Yes
              test (see      test (see      Test
              page 2)        page 2)        recommended

ECG           Yes            Yes            Yes
              Test           Test           Test
              recommended    recommended    recommended

Full blood    Yes            Yes            Yes
count         Test           Test           Test
              recommended    recommended    recommended

Hacmostasis   Consider this  Consider this  Consider this
              test (see      test (see      test (see
              page 2)        page 2)        page 2)

Renal         Yes            Yes            Yes
function      Test           Test           Test
              recommended    recommended    recommended

Random        No             No             No
glucose       Test not       Test not       Test not

Urine         Consider this  Consider this  Consider this
analysis      test (see      test (see      test (see
              page 2)        page 2)        page 2)

Blood gases   Consider this  Consider this  Consider this
              test (see      test (see      test (see
              page 2)        page 2)        page 2)

Lung          No             No             No
function      Test not       Test not       Test not

              Age  (years)

Test         [greater than
              or equal to]
                    80

Chest X-ray   Yes
              Test
              recommended

ECG           Yes
              Test
              recommended

Full blood    Yes
count         Test
              recommended

Hacmostasis   Consider this
              test (see
              page 2)

Renal         Yes
function      Test
              recommended

Random        No
glucose       Test not

Urine         Consider this
analysis      test (see
              page 2)

Blood gases   Consider this
              test (see
              page 2)

Lung          No
function      Test not


Grade of surgery          Example

Grade 1 (Minor)          Excision of skin lesion

Grade 2 (Intermediate)   Primary repair of inguinal hernia

Grade 3 (Major)          Thyroidectomy

Grade 4 (Complex         Anterior resection of rectum
major/major+)

Table 1 Grades of surgery with examples (from NICE guidelines)


Test         Total      Appropriate     Inappropriate
                     normal  abnormal  normal  abnormal

Full blood      92       67        14      11         0
count
(FBC)

Urea &          92       70         7      15         0
electrolytes
(U&Es)

Coagulation     88       29         1      58         0
Screen

Random           1        0         0       1         0
Glucose

Total          273      166        22      85         0

Table 2 Total number of each blood test performed,
appropriateness according to national guidelines and
whether complications and/or change in management occurred.


Test      Amount ([pounds      Estimated projection p.a ([pounds
          sterling]) spent     sterling]) based on 7,578 elective,
          on inappropriate     general surgery operations p.a.
          tests                (inc. colorectal, vascular,
                                breast, urology and orthopaedics)

FBC                 21.34                                   1456.80

U&Es                   24                                   1638.48

Clotting              203                                  13858.86

Glucose              1.60                                       109

Total              249.94                                  17063.14

Table 3 Cost breakdown for each inappropriate blood test performed
and estimated amount that can be potentially saved per year by the
trust.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.