What tests/labs should be ordered urgently and emergently in non-COVID-19 patients? 

Posted on April 20, 2020 by Raymond Cho, Dr. Launny Lowden

Summary

Labs for non-COVID-19 patients during the pandemic should include urgent bloodwork to inform treatment, therapeutic drug monitoring, INRs, GTT for gestational diabetes, pregnancy-related tests, standing orders for patients with chronic illness (if results will impact management) and oncology patients receiving active treatment. Please refer to the PHSA EOC document for details on lab services.

I.   GUIDELINES ON TESTING

      • PHSA Emergency Operations Centre (details on full, reduced and essential services) (1)
        • This SBAR details surge planning for laboratory services in an effort to ensure that priority tests for all patients continue.
        • It takes into consideration: possible shortages of staffing, reagents, ancillary support and a potential surge in testing for patients who postponed their medical visits during the pandemic.
        • The document outlines the laboratory test menus that will be performed based on the level of surge (i.e. full service, reduced service, essential service) within the categories of hematology, biochemistry, cytogenetics and medical microbiology (current as of 20 Apr 2020).
        • Although individual labs are at various stages, at a provincial level, laboratories are running at a reduced service level; as such physicians are asked to limit testing to those they deem as urgent.
      • Interior Health Laboratory Outpatient Clinic Operations Memo states that outpatient bloodwork should be limited to (2):
        • Urgent bloodwork to inform treatment
        • Therapeutic drug monitoring
        • International normalized ratios (INRs)
        • Glucose tolerance for gestational diabetes
        • Pregnancy related tests as per Perinatal Services BC guidelines
        • Standing orders for patients with chronic illness (if results will impact immediate management)
        • Testing for oncology patients receiving active treatment,
        • Alberta Guidelines for laboratory testing
        • Saskatchewan Health Authority (6)
        • American College of Radiology and Centre for Disease Control recommends rescheduling non-urgent imaging and fluoroscopy procedures which includes screening mammograms, lung cancer screening, non-urgent CT, ultrasound, X-rays, MRIs and other elective radiologic/radiologically guided exams and procedures (7).
    • Screening in BC including screening mammograms, FIT testing, HIV screening have been suspended for the time being (3).
  • Alberta Guidelines for laboratory testing
    • The CPSA posed questions to determine ‘urgency’,applicable to ordering tests (4):
      • Do patients feel the benefit of testing exceeds the risk of leaving their home?
      • Is the benefit to the individual patient worth the risk of having them leave their home? Special consideration must be given to high-risk patients.
      • Will the care provided prevent the need for a patient to access acute care in the foreseeable future?
      • Would a group of peers support the decision that testing is urgent?
    • The Alberta Health Service recommends cessation of routine laboratory testing, including standing orders, for stable community patients (as determined clinically). Patients who require labs required for immediate management will be served (5).
  • Saskatchewan Health Authority (6)
    • Saskatchewan has taken a more stringent approach, discontinuing routine testing and reducing labs to a defined limited test menu for STAT and URGENT requests only (standing orders exempted). 
  • American College of Radiology and Centre for Disease Control recommends rescheduling non-urgent imaging and fluoroscopy procedures which includes screening mammograms, lung cancer screening, non-urgent CT, ultrasound, X-rays, MRIs and other elective radiologic/radiologically guided exams and procedures (7).

II.   EXAMPLES OF INDIVIDUAL PRACTICE

  • A similar question was asked in the UBC CPD Webinar “Primary Care in the Time of COVID-19: Three Family Physicians Share Their Experiences” (8):
    • Dr. David Catterall, a family physician servicing Vancouver’s inner city, states that he defers non-essential bloodwork (i.e. HIV patients who have been stable for some time can defer HIV titres for a month, patients testing for HCV RNA are being pushed, etc.). Non-essential imaging is delayed as well. 
    • Dr. Jenn Baxter, a rural physician, states that regular/standing order tests (e.g. stable INRs) are being extended with discretion on how stable the patient is. Routine imaging (i.e. X-rays, CT scans, etc.) is being deferred but patients with new respiratory complaints are triaged and imaged as necessary. 
    • Dr. Alyssa Cantarutti, an urban family physician, briefly touched on thinking about which tests can be deferred. She minimizes tests that may not change management.

III.   CONCLUSION

  • The provincial guidelines for laboratory services above can be used to guide physician ordering of tests for non-COVID-19 patients during this pandemic.
  • Defining urgency with regards to testing can be difficult; however, physicians are generally being asked to order tests that can immediately affect the management of patients.

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Cupples J, Wilson D. Laboratory Services Surge Planning. Health Emergency Management BC | PHSA EOC SBAR. 2020 [cited 2020Apr20]. Available from:  https://drive.google.com/file/d/14LmpTpOe2qwLF2bp1m_Yfy_xhZI5hv4D/view
  2. Szczepanski I, Lowden L. Interior Health Laboratory Outpatient Clinic Operations – UPDATED. COVID-19 Information Update. 2020 [cited 2020Apr20]. Available from: https://drive.google.com/file/d/1pgKBi3ZPNVJGsJBAHlStPoabRppff7hD/view
  3. COVID-19 and Cancer Screening [Internet]. BC Cancer. 2020 [cited 2020Apr20].  Available from: http://www.bccancer.bc.ca/screening/health-professionals/covid-19-and-cancer-screening#Cervix
  4. Dick C. Defining “Urgent” During COVID-19 [Internet]. College of Physicians and Surgeons of Alberta. 2020 [cited 2020Apr8]. Available from: http://www.cpsa.ca/wp-content/uploads/2020/04/ATP-COVID-19-Urgent-Care.pdf
  5. Novel Coronavirus (COVID-19) – Frequently Asked Questions for Primary Care [Internet]. Alberta Health Services. 2020 [cited 2020Apr8]. Available from: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-primary-care-faq.pdf
  6. Howey L. Saskatchewan Laboratory Medicine Provincial Program Bulletin. Saskatchewan Health Authority. 2020 [cited 2020Apr20]. Available from: https://drive.google.com/file/d/1sC5fwFM91eperUyATIAja_Tt99oyUm2w/view
  7. COVID-19 Radiology-Specific Clinical Resources [Internet]. COVID-19 Radiology-Specific Clinical Resources | American College of Radiology. 2020 [cited 2020Apr8]. Available from: https://www.acr.org/Clinical-Resources/COVID-19-Radiology-Resources
  8. Baxter J, Cantarutti A, Catterall D. Primary Care in the Time of COVID-19: Three Family Physicians Share Their Experiences [Internet]. UBC CPD Medicine. UBC; 2020 [cited 2020Apr8]. Available from: https://video.med.ubc.ca/videos/cpd/2020-04-02-UBCCPD-Primary-Care-COVID19.mp4

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.