Objectives & Background Emergency Department (ED) staff order blood tests for diagnostic work-up and to facilitate prompt treatment. However, with the emerging use of Rapid Assessment and Treatment (RAT) models aiming to provide early assessment by doctors, inappropriate investigations can be requested as a consequence. Our objectives were to establish whether coagulation screens performed in our London ED were clinically appropriate, and to determine its subsequent financial implications.

Methods Retrospective analysis of blood investigations performed was done using the ED computer system (Ascribe Symphony, UK). The first cohort was a random selection of approximately one-third of ED attendances during a one-week period in July 2013. Inclusion criteria were only patients who were seen by ED clinicians; patients seen directly by other specialties were excluded. Clinical notes were reviewed for every patient who had coagulation screens requested. A recently revised ED ‘investigation matrix’ was used as a local departmental standard.

Up-to-date costs were obtained from the Pathology Department for common investigations (including a coagulation screen and D-Dimer for 2013/14). On the basis of initial results, implementations were introduced in the form of: staff teaching sessions, displaying of up-to-date cost figures, daily team read file and local posters highlighting the importance of cost prevention.

The re-audit (second cohort) was performed 9 months later in May 2014 for all consecutive patients investigated by ED clinicians in a one-week period. Patients were included and excluded on the basis of the same criteria, with the same ‘blood matrix’ as a standard.

Results 70% of patients in the first cohort had blood tests (n=137). 54% of these patients had coagulation screens (n=74), 66% of them not being clinically indicated (n=49). From our initial findings, we projected an estimated loss of>£90,000 per year.

52% patients in the second cohort had blood tests (n=370). 23% of these patients had coagulation screens (n=84), with 68% clinically inappropriate (n=57) based on our clinical criteria.

Conclusion Coagulation screens are sent in the majority of patients in the absence of clinical indications. A huge financial implication is associated with the investigations. A different approach is required in the ED to avoid inappropriate use of coagulation screens.