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An Audit of Nutritional Trace Element Requesting Within York Teaching Hospitals

This audit investigates the reasons for and frequency of trace element requesting in York Teaching Hospitals, with the aim of reducing inappropriate testing. Findings and interventions are discussed to improve requesting practices.

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An Audit of Nutritional Trace Element Requesting Within York Teaching Hospitals

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  1. An Audit of Nutritional Trace Element Requesting Within York Teaching Hospitals Roger Bramley

  2. Background • Measurement of trace elements (zinc, copper and selenium) is useful to monitor situations where nutritional deficiencies can occur. • Limited indications for isolated zinc measurement. • At York there are two options for requesting: • Zinc only requests (processed in-house) • Full profile requests (copper, zinc and selenium requests processed externally as a combined panel)

  3. Aims/Standards • Aims: • To investigate the reasons for and frequency of trace element requesting with the aim of reducing inappropriate testing. • Standards: • Appropriate frequency of request (taken from British Obesity and Metabolic Surgery Society (BOMSS) guidelines and NICE CG32). • All samples should have a clear indication for request provided.

  4. Methods • Data were gathered from the pathology LIMS and electronic patient record. • Initial data gathering was performed between 1st January to 31st March 2017. • Re-audits of data after implementation of changes: • 01/09/17 – 30/11/17 (3 months post changes) • 01/02/18 – 30/04/18 (8 months post changes)

  5. Results1: Location of Requests Zinc Only Requests Full Profile Requests

  6. Results2: Reasons for Requests Zinc Only Requests Full Profile Requests Figure 1: Reasons for ordering of zinc-only or trace element panels at York Teaching Hospitals Trust.

  7. Results3: Retest Frequency (Bariatric Surgery) • Median retest interval was 6 months. • BOMSS recommends annual testing (unless symptoms of deficiency develop).

  8. Findings • Significantly more zinc only requests from GPs. • Many zinc only requests are for potentially inappropriate reasons. • Bariatric surgery monitoring of trace elements is too frequent.

  9. Interventions1: Isolated Zinc Requesting • Discouraging requests: • Electronic requesting prompt. • Information sheets sent to GPs. • Coded comment added to GP requests to highlight that test is rarely useful. Test is still available if required

  10. Interventions2: Adherence to Guidelines • No long term TPN (NICE CG32 not relevant) • Stricter implementation of BOMSS guidelines coordinated by bariatric dietitian and changes to sample labelling in clinics. • Set of labels designed to be used at each clinic appointment over the year. • Significant cost reduction in moving to best practice guidelines.

  11. Interventions 3: Minimum Retest Intervals • Implemented for both zinc only and full profile requests after discussion with users: • 3 months for full profile requests • 1 month for zinc only requests • Electronic requesting pop-up box discourages if retested too soon. • Any tests breaching limits reaching LIMS are blocked are held on a list for review by a clinical scientist/chemical pathologist.

  12. Outcomes - Zinc Requesting • A further 8 of the 250 samples breached re-testing intervals and were cancelled. • >50% reduction in zinc requests over a 3 month period. • Varies by location: • 58.2% decrease in GP • 36.3% decrease in non-GP

  13. Outcomes - Full Profile Requesting • No significant difference in the number of tests performed but no increase. • Median retest interval increasing for bariatric surgery patients. • Shift from zinc only to full profile?

  14. Conclusions • Engage with users (e.g. bariatric dietician) to ensure appropriate frequency of testing. • Use order comms and LIMS to help enforce MRI and review requests that breach MRI to ensure processing of "appropriate repeats". • Education of GP users combined with electronic requesting prompts can be an effective way of ensuring more appropriate testing.

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