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Rational Use of Blood Calcium Determinations

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Rational Use of Blood Calcium Determinations DOI: 10.1590/1516-3180.2014.1324731 SHORT COMMUNICATION Rational use of blood calcium determinations Uso racional da dosagem de cálcio no sangue Mario Ferreira-JuniorI, Arnaldo LichtensteinI, Maria Mirtes SalesII, Leandro Utino TaniguchiIII, Francisco José Bueno de AguiarIV, Luiz Augusto Marcondes FonsecaV, Nairo Massakazu SumitaVI, Alberto José da Silva DuarteVII Central Laboratory Division, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, Brazil ABSTRACT IMD, PhD. Attending Physician, Department of Internal Medicine, General Practice and CONTEXT AND OBJECTIVE: This study was motivated by the recent excessive increase in requests Propaedeutics Service, Hospital das Clínicas, for blood calcium determinations and laboratory tests in general, in the Hospital das Clínicas complex Faculdade de Medicina, Universidade de São of Faculdade de Medicina, Universidade de São Paulo (HCFMUSP). Its aim was to suggest rules for the Paulo, São Paulo, Brazil. determination of total and ionized calcium in our intensive care units, emergency department, wards IIMD, PhD. Clinical Pathologist, Head of Flow and outpatient services, thus contributing towards improving the quality of medical care and achieving Cytometry Laboratory, Central Laboratory Division, more appropriate use of human and financial resources. Hospital das Clínicas, Faculdade de Medicina, DESIGN AND SETTING: Critical analysis on clinical and laboratory data and the pertinent scientific litera- Universidade de São Paulo, São Paulo, Brazil. ture, conducted by the study group for rational clinical laboratory use, which is part of the Central Labora- IIIMD, PhD. Intensive Care Physician, Discipline tory Division, HCFMUSP. of Emergency Medicine, Hospital das Clínicas, METHODS: The study group reviewed scientific publications, statistics and clinical and laboratory data Faculdade de Medicina, Universidade de São Paulo, concerning requests for total and ionized calcium determinations in the settings of intensive care units, and Hospital Sírio Libanês, São Paulo, Brazil. emergency department, wards and outpatient services. IVMD. Attending Physician and Supervisor of RESULTS: From this critical analysis, clinical decision flow diagrams aimed at providing guidance for order- the Clinical Emergencies Division, Hospital das ing these tests were constructed. Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil. CONCLUSIONS: Use of the proposed flow diagrams may help to limit the numbers of inappropriate re- quests for ionized and total calcium determinations, with consequent reductions in the number of tests, VMD, PhD. Attending Physician, Department of Internal Medicine, Clinical Immunology and risks to patients and unnecessary costs. Allergy Service, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São RESUMO Paulo, Brazil. CONTEXTO E OBJETIVO: Este trabalho foi motivado pelo recente aumento excessivo de solicitações de VIMD, PhD. Clinical Pathologist and Director dosagem de cálcio no sangue, assim como de exames laboratoriais em geral, no complexo do Hospital of Clinical Biochemistry Service, Central das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). Seu objetivo foi sugerir Laboratory Division, Hospital das Clínicas, regras para a determinação de cálcio total e iônico nas nossas unidades de terapia intensiva, pronto-so- Faculdade de Medicina, Universidade de São corro, enfermarias e ambulatórios e contribuir para a melhoria da qualidade da assistência médica, com Paulo, São Paulo, Brazil. utilização mais adequada dos recursos humanos e financeiros. VII MD, PhD. Full Professor, Department of TIPO DO ESTUDO E LOCAL: Análise crítica de dados clínicos, laboratoriais e da literatura médica perti- Pathology, Faculdade de Medicina, Universidade nente, realizada pelo grupo de estudos para o uso racional do laboratório clínico, vinculado à Divisão de de São Paulo, and Director of the Central Laboratório Central do HCFMUSP. Laboratory Division, Hospital das Clínicas, MÉTODOS: O grupo de estudos reviu publicações científicas, estatísticas e dados clínico-laboratoriais re- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil. lativos às solicitações de cálcio total e iônico nos ambientes das unidades de terapia intensiva, prontos- socorros, enfermarias e ambulatórios. KEY WORDS: RESULTADOS: A partir dessa análise crítica, foram construídos fluxogramas de decisão clínica que visam Clinical laboratory techniques. orientar a requisição desses testes. Blood chemical analysis. CONCLUSÕES: A utilização dos fluxogramas propostos pode ajudar a limitar a solicitação inadequada Calcium. das dosagens de cálcio total e iônico, com consequente redução do número de exames, de riscos para os Practice management, medical. pacientes e de custos desnecessários. Decision making. PALAVRAS-CHAVE: Técnicas de laboratório clínico. Análise química do sangue. Cálcio. Administração da prática médica. Tomada de decisões. Sao Paulo Med J. 2014; 132(4):243-8 243 SHORT COMMUNICATION | Ferreira-Junior M, Lichtenstein A, Sales MM, Taniguchi LU, Aguiar FJB, Fonseca LAM, Sumita NM, Duarte AJS INTRODUCTION • When are total calcium determinations sufficient to make Over recent years, there has been a growing trend favoring medical decisions? extensive use of technology in medical practice, strongly sup- • Are there any situations in which ionized calcium determina- ported by both the lay and the scientific media, with the inten- tion must be avoided? tion of benefiting patients and society.1 As a side effect, excessive • Are there any situations in which calcium determinations and inappropriate use of laboratory tests is leading to neglect of must be repeated before 24 hours have elapsed? the logical primacy of clinical reasoning in diagnostic investi- gations and in follow-up,2 thereby increasing the chance of cog- OBJECTIVE nitive errors.3 Moreover, frequent collection of blood and other The aim of this study was to provide suggested rules for total biological materials for laboratory tests may lead to significant and ionized calcium determinations in our intensive care units, blood losses,4 thus also increasing the risk of infections5 and emergency department, wards and outpatient services thus con- false positive test results. In addition, this increases costs6 tributing towards improving the quality of medical care and and overburdens nursing and laboratory teams. achieving more appropriate use of human and financial resources. The growing demand for laboratory tests can be ascribed to They were formulated by our study group for rational labora- several factors, such as: tory test use, which is linked to the Central Laboratory Division • The worldwide increase in longevity and associated of HCFMUSP. This group has been working to establish guide- comorbidities;7,8 lines for rational ordering of costly or highly requested tests in • Overvaluation of laboratory tests at the expense of history- our institution, since 2010. taking and physical examination;3 • Influence of technology and of the lay and scientific media;1,9 METHODS • Ignorance of costs;7 HCFMUSP is a university hospital providing high-complexity • Defensive medicine;10 care in São Paulo, Brazil, with 933 beds, of which 142 are in inten- • High complexity cases;7 sive care units. Our monthly average in 2012 was around 15,000 • Insecurity or inexperience;7 consultations for the emergency department and 92,000 for the • Lack of institutional guidelines, thus allowing arbitrary outpatient services. choice of laboratory tests.6 Our study group was created to promote rational use of the clinical laboratory. It is formed by seven physicians belonging to For all of the above reasons, there has been a steady increase the staff of the hospital, and all of them have worked in the fields in test ordering and in the related costs at our hospital, like in of intensive care, internal medicine, outpatient care, emergency other institutions worldwide. This can be exemplified by blood medicine, clinical pathology or hospital administration for at calcium determinations. It should be stressed that in our insti- least 15 years. tution, there are no formal restrictions in relation to ordering of In order to draw up guidance algorithms for ordering any kind of test. ionized and total blood calcium determinations, this group In 2012, the Central Laboratory Division of Hospital das attended weekly meetings, over a six-month period, in order Clínicas, Faculdade de Medicina, Universidade de São Paulo to discuss and review theoretical matters and to study the data (HCFMUSP) recorded 233,955 total calcium determina- registers held by the Central Laboratory Division. The orders tions, which were performed at a direct cost of US$ 38,801.00 registered were examined with regard to the following: fre- (R$ 79,544.70). On the other hand, over the same period, our quency; direct and indirect costs; blood collection; storage and records show 297,539 ionized calcium determinations at a processing of biological material; analytical methods and inter- direct cost of US$ 404,767.00 (R$ 829,773.89). These data are ferences with their precision and accuracy; interpretation of worrisome from a medical and financial standpoint and raise results within different scenarios such as intensive care units, some serious questions: emergency departments, wards and outpatient settings; and the • Were all these ionized calcium determinations really reported medical management. Whenever
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