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September 2021

Think twice before ordering blood tests 

New guidance aims to reduce 'unnecessary' blood testing in primary care by urging clinicians to 'Think twice, check twice, order once' and to avoid a surge in demand as testing resumes by tackling the backlog over 8 weeks

Routine blood tests can now be resumed following a national shortage of blood sample tubes caused most blood tests in general practice to be cancelled.

NHS England and NHS Improvement (NHSEI) says that 9 million tubes have been procured from US stocks, and they have been approved for use by the MHRA under an exceptional use authorisation.

However, NHSEI warns the situation is not completely resolved and it is vital to optimise the use of blood tubes and to ensure that testing does not exceed levels recorded in June and July this year.

NHSEI has published best practice guidance for blood testing, which says clinicians should ‘think twice, check twice and order once’ before ordering a blood test. ‘This is also a clear opportunity for the NHS to optimise the use of blood tests not only for now but also for the future.’

The guidance states ‘there is significant unwarranted variation in blood test requesting across primary care. Appropriate blood test planning and requesting reduces demand on phlebotomy and laboratory resources and reduces avoidable costs (of unnecessary testing) to the NHS.’

Practice are urged to consider if the test is essential for management and adheres to clinical guidance.

  • FBC, LFTs and TFTs are rarely required for most routine reviews
  • Coagulation tests are rarely required as a routine test in primary care: INR should be measured using point of care testing (POCT) if available, and lab confirmation is not required
  • D-dimer testing should only be done in patients where DVT is likely. POCT should be considered if not referring to same day emergency care
  • Inflammatory markers (CRP and ESR) should only be requested if there is a clinical indication and the result will change management. In the absence of rheumatology advice or specific indication, CRP is preferable to ESR. Where ESR is required, in most cases it can be tested on the same EDTA sample as FBC, so an additional sample tube is not required
  • Before requesting blood tests check if the patient is due another test and whether the tests can be combined, e.g. if a patient is due a CKD review and there is concern about LFTs, ensure both tests are done together using a single tube for all biochemistry tests.
  • Refer to national guidance on minimum retesting intervals to determine the frequency of blood tests

While testing could resume from 17 September, practices are being asked to avoid a surge in demand for tubes over and above the quantities needed before the shortages hit, and work through any backlog of tests over a period of at least 8 weeks, prioritising as necessary, to spread the demand for tubes. Meanwhile, hospitals are required to reduce the number of tests they carry out by at least 25% compared with June and July.

The letter follows an earlier instruction to limit tests in general practice to only the absolutely essential until mid-September, with NHSEI warning the shortage would get worse over the next few weeks and last for a ‘significant period’.

The shortages seem to have arisen because the NHS relies on a single supplier, Becton Dickinson, for blood sampling tubes. According to a report in The Guardian, the company blames increased demand for its products, transportation challenges that have affected all industries, and increased demand for raw materials and components.

A Department of Health and Social Care spokesperson said: ‘We have secured tens of millions of additional blood tubes, including importing additional supplies from the EU and the US, which will be available to the NHS soon, and there continues to be stock in place to ensure clinically urgent testing continues.’

However, NHSEI has warned that it will take time for the products to be ‘imported and delivered in volume’.

Practice Nurse 2021;51(7): online only