BMJ Qual Improv Report 6: doi:10.1136/bmjquality.u221651.w8161
  • BMJ Quality Improvement Programme

REDucing Unnecessary Coagulation Testing in the Emergency Department (REDUCED)

  1. Michelle Sholzberg
  1. Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
  1. Correspondence to Michael Fralick fralickm{at}
  • Received 5 December 2016
  • Revision requested 13 December 2016
  • Revised 31 December 2016
  • Published 2 May 2017


The PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time) were tests developed in the early 20th century for specific and unique indications. Despite this, they are often ordered together routinely. The objective of this study was to determine if a multimodal intervention could reduce PT/INR and aPTT testing in the emergency department (ED). This was a prospective multi-pronged quality improvement study at St. Michael's Hospital. The initiative involved stakeholder engagement, uncoupling of PT/INR and aPTT testing, teaching, and most importantly a revision to the ED order panels. After changes to order panels, weekly rates of PT/INR and aPTT testing per 100 ED patients decreased (17.2 vs 38.4, rate ratio=0.45 (95% CI 0.43-0.47), p<0.001; 16.6 vs 37.8, rate ratio=0.44 (95% CI 0.42-0.46), p<0.001, respectively). Rate of creatinine testing per 100 ED patients, our internal control, increased during the same period (54.0 vs 49.7, rate ratio=1.09 (95% CI 1.06-1.12); p<0.0001) while the weekly rate per 100 ED patients receiving blood transfusions slightly decreased (0.5 vs 0.7, rate ratio=0.66 (95% CI 0.49-0.87), p=0.0034). We found that a simple process change to order panels was associated with meaningful reductions in coagulation testing without obvious adverse effects.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: