, a CRP, a CMP, a TSH, a B12 and a folate?

Assoc. Professor Deborah Leach, Clinical Director Emergency Department, Box Hill Hospital

These days, there’s such sophisticated way of investigating illness that we have a lot of tests, pathology and imaging tests, at our fingertips and it’s really easy to order these things and people forget that we can live with clinical uncertainty. We don’t need the answer right now, all the time. The patient experience is very negatively impacted by unnecessary tests, so they spend longer in hospital, waiting for that test. There’s the knock-on effect of a false positive test, that needs investigations and extra time and extra anxiety spent on that unnecessary test.

Doctor Paul Buntine, Emergency Physician, Eastern Health

I think we do unnecessary tests for a number of reasons. I think we sometimes do it out of fear of missing something, which is often an unrealised fear. I think we sometimes do it because we’re scared we might look silly to somebody else. Somebody a bit more senior, perhaps. Sometimes we just do it out of habit. We just do it because that’s what people have done since the beginning of time. That’s what we were taught. We never really thought about whether that test was actually a useful test for that patient in this situation.

Dr Harriet Herbison, Medical Registrar, Eastern Health

I think a lot of junior doctors do order tests because they’re afraid of missing something. I also think there’s a lot of like not too sure what’s going on, so casting a bit of a wide net sometimes and, I think, if there were more guidelines, then people would feel like they were able to back themselves more with not ordering tests.

Tony O’Neill, Associate Director of Pathology, Eastern Health

Problems fall into two categories. The first is ensuring we have enough resources to provide the services that are required. While we’re a highly automated laboratory, there is much of what we do, especially in the pre-analytical phase, which requires manual input and, therefore, we need to have hands to be able to do that. When we are processing large volumes of work, those resources become stretched. From a financial point of view, everything we do in the laboratory costs. The reagents, the instruments we use, they all cost money and every test we do, cost money.

Dr Mineesh Datta, Radiologist & Clinical Director of Medical Imaging, Eastern Health

I think there’s no doubt that medical imaging plays a crucial role in assessment of patients but with every medical imaging test, there are inherent risks. For example, the issue of ionising radiation in CTs. Even for non-ionising radiation such as ultrasound or minimal radiation with plain films, we’re not infrequently come across abnormalities which are incidental to the patient’s presentation and these are treated as lesions and they’re often followed up for many years, causing the patient stress, causing the clinician stress and often to no result, they end up being benign and it results in a huge financial burden on society as a whole.

Screen title: Clinicians at Eastern Health have developed a program called NUTS to assist clinical decision-making and help reduce unnecessary testing.

Assoc. Professor Deborah Leach, Clinical Director Emergency Department, Box Hill Hospital

NUTS is the no unnecessary tests group that has been formed at Eastern Health. It is a clinician-led group with very strong support from Eastern Health Executive and Administration and we are really a very keen group of clinicians who are trying to reduce the number of unnecessary tests and look at this in a new and innovative way so that we can all collaborate together to look at pathways of care and educate and improve patient care.

Doctor Paul Buntine, Emergency Physician, Eastern Health

We’ve put a number of systems in place to reduce unnecessary testing, such as getting junior doctors to just talk to a senior doctor before they order a test. We’ve also created some clinical pathways to guide people in their testing. 

Screen title: A simple flowchart helps ED clinicians decide whether to send urine samples for formal laboratory testing.

Screen title: the number of these samples sent for testing has now reduced by 49%

Dr Harriet Herbison, Medical Registrar, Eastern Health

I think the NUTS system is really important to junior doctors. It does make them think more critically about what they’re doing and I think it also means that there’s more interaction between the consultants and the registrars and so there’s more bouncing of ideas.

Screen title: Asking junior doctors to check with a senior doctor before ordering simple pathology tests has resulted in a 35% reduction in these tests.

Nurse

You’re all good to go, have a good day.

Patient

Thank you.

Tony O’Neill, Associate Director of Pathology, Eastern Health

We have been very keen contributors to the NUTS program because it has given us an opportunity to connect with areas of the hospital and the health network that sometimes we have difficulty connecting with. It’s given us the ability to work side-by-side with the people who order tests to help them understand what sort of issues we face in the laboratory so that we can come up with a pathology service that delivers what they require when they require it. 

Associate Professor Colin Feekery, Executive Director & Chief Medical Officer, Eastern Health

There are many important things we do at Eastern Health but NUTS would be up there as one of the more important. Doctors really need to carefully consider why they are doing a test and why they are spending public money and why they are taking that resource away from other potential patients.

Assoc. Professor Deborah Leach, Clinical Director Emergency Department, Box Hill Hospital

We’ve seen really a groundswell of support for this project. I think people are looking for leadership in this area and people are looking for some guidance as to what is necessary to order. NUTS is vitally important to Eastern Health and, more importantly, it’s of vital importance to our patients.  

 
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'No Unnecessary Tests' (NUTs) aims to scale up a successful and proven project at Eastern Health's Box Hill Emergency Department with a focus on reducing unnecessary tests. A clinician-led approach has been utilised to identify key areas of potential over-ordering at other emergency department sites and selected inpatient settings. 

In 2016, Eastern Health produced a short video to be shown at a Healthcare forum in Sweden about their campaign called NUTS. This video provides some further information about the 2016 campaign. 

Ambulance officer

I’m going to pop some oxygen on, ok?

Doctor

Can I get you to order a , a CRP, a CMP, a TSH, a B12 and a folate?

Assoc. Professor Deborah Leach, Clinical Director Emergency Department, Box Hill Hospital

These days, there’s such sophisticated way of investigating illness that we have a lot of tests, pathology and imaging tests, at our fingertips and it’s really easy to order these things and people forget that we can live with clinical uncertainty. We don’t need the answer right now, all the time. The patient experience is very negatively impacted by unnecessary tests, so they spend longer in hospital, waiting for that test. There’s the knock-on effect of a false positive test, that needs investigations and extra time and extra anxiety spent on that unnecessary test.

Doctor Paul Buntine, Emergency Physician, Eastern Health

I think we do unnecessary tests for a number of reasons. I think we sometimes do it out of fear of missing something, which is often an unrealised fear. I think we sometimes do it because we’re scared we might look silly to somebody else. Somebody a bit more senior, perhaps. Sometimes we just do it out of habit. We just do it because that’s what people have done since the beginning of time. That’s what we were taught. We never really thought about whether that test was actually a useful test for that patient in this situation.

Dr Harriet Herbison, Medical Registrar, Eastern Health

I think a lot of junior doctors do order tests because they’re afraid of missing something. I also think there’s a lot of like not too sure what’s going on, so casting a bit of a wide net sometimes and, I think, if there were more guidelines, then people would feel like they were able to back themselves more with not ordering tests.

Tony O’Neill, Associate Director of Pathology, Eastern Health

Problems fall into two categories. The first is ensuring we have enough resources to provide the services that are required. While we’re a highly automated laboratory, there is much of what we do, especially in the pre-analytical phase, which requires manual input and, therefore, we need to have hands to be able to do that. When we are processing large volumes of work, those resources become stretched. From a financial point of view, everything we do in the laboratory costs. The reagents, the instruments we use, they all cost money and every test we do, cost money.

Dr Mineesh Datta, Radiologist & Clinical Director of Medical Imaging, Eastern Health

I think there’s no doubt that medical imaging plays a crucial role in assessment of patients but with every medical imaging test, there are inherent risks. For example, the issue of ionising radiation in CTs. Even for non-ionising radiation such as ultrasound or minimal radiation with plain films, we’re not infrequently come across abnormalities which are incidental to the patient’s presentation and these are treated as lesions and they’re often followed up for many years, causing the patient stress, causing the clinician stress and often to no result, they end up being benign and it results in a huge financial burden on society as a whole.

Screen title: Clinicians at Eastern Health have developed a program called NUTS to assist clinical decision-making and help reduce unnecessary testing.

Assoc. Professor Deborah Leach, Clinical Director Emergency Department, Box Hill Hospital

NUTS is the no unnecessary tests group that has been formed at Eastern Health. It is a clinician-led group with very strong support from Eastern Health Executive and Administration and we are really a very keen group of clinicians who are trying to reduce the number of unnecessary tests and look at this in a new and innovative way so that we can all collaborate together to look at pathways of care and educate and improve patient care.

Doctor Paul Buntine, Emergency Physician, Eastern Health

We’ve put a number of systems in place to reduce unnecessary testing, such as getting junior doctors to just talk to a senior doctor before they order a test. We’ve also created some clinical pathways to guide people in their testing. 

Screen title: A simple flowchart helps ED clinicians decide whether to send urine samples for formal laboratory testing.

Screen title: the number of these samples sent for testing has now reduced by 49%

Dr Harriet Herbison, Medical Registrar, Eastern Health

I think the NUTS system is really important to junior doctors. It does make them think more critically about what they’re doing and I think it also means that there’s more interaction between the consultants and the registrars and so there’s more bouncing of ideas.

Screen title: Asking junior doctors to check with a senior doctor before ordering simple pathology tests has resulted in a 35% reduction in these tests.

Nurse

You’re all good to go, have a good day.

Patient

Thank you.

Tony O’Neill, Associate Director of Pathology, Eastern Health

We have been very keen contributors to the NUTS program because it has given us an opportunity to connect with areas of the hospital and the health network that sometimes we have difficulty connecting with. It’s given us the ability to work side-by-side with the people who order tests to help them understand what sort of issues we face in the laboratory so that we can come up with a pathology service that delivers what they require when they require it. 

Associate Professor Colin Feekery, Executive Director & Chief Medical Officer, Eastern Health

There are many important things we do at Eastern Health but NUTS would be up there as one of the more important. Doctors really need to carefully consider why they are doing a test and why they are spending public money and why they are taking that resource away from other potential patients.

Assoc. Professor Deborah Leach, Clinical Director Emergency Department, Box Hill Hospital

We’ve seen really a groundswell of support for this project. I think people are looking for leadership in this area and people are looking for some guidance as to what is necessary to order. NUTS is vitally important to Eastern Health and, more importantly, it’s of vital importance to our patients.