From the Guidelines
Laboratory testing for older patients in nursing homes should be ordered at least every 30 days for the first 90 days after admission and then at least once every 60 days, as per federal guidelines 1. When it comes to ordering labs for older patients in nursing homes, it's essential to strike a balance between diagnostic vigilance and minimizing burden.
- The goal is to focus on tests that will meaningfully impact treatment decisions and quality of life for these vulnerable patients.
- A baseline comprehensive metabolic panel, complete blood count, thyroid function tests, vitamin B12, and vitamin D levels upon admission can be useful, followed by individualized testing schedules based on each patient's medical conditions and medication regimens.
- For patients with specific conditions, such as diabetes, more frequent testing may be necessary, such as HbA1c testing quarterly 1.
- Acute changes in condition warrant targeted testing, and unnecessary routine testing should be avoided as it can lead to false positives, unnecessary interventions, patient discomfort, and increased costs.
- It's also important to consider the principles outlined in the Choosing Wisely initiative, which recommends ordering diagnostic tests in response to specific clinical questions rather than at regular intervals 1.
From the Research
Laboratory Testing in Nursing Homes
- The frequency of ordering labs on older patients in nursing homes is not strictly defined, but studies suggest that it should be individualized based on the patient's condition, life expectancy, and quality of life 2.
- A study found that pharmacists in a skilled-nursing facility recommended laboratory tests, and physicians accepted 87.9% of these recommendations 3.
- The most common tests recommended were SMA-6, serum concentrations of various drugs, and anticoagulation studies 3.
- Another study suggested that physicians should take a leadership role in developing clinically useful, cost-effective testing strategies for nursing homes 4.
Factors Influencing Laboratory Testing
- The decision to order laboratory tests should consider the patient's advanced dementia, life expectancy, and quality of life 2.
- Routine laboratory testing protocols in nursing homes vary widely, and there is a need for standardized, cost-effective testing strategies 4.
- The management of patients with diabetes and chronic kidney disease requires individualized glycemic goals, consideration of macrovascular and microvascular complications, and life expectancy 5, 6.
Test Ordering Practices
- A study found that 37 out of 53 physicians polled felt that ordering Troponin I in a patient with advanced dementia hindered patient care, and they would not have ordered the test 2.
- Pharmacists' recommendations for laboratory tests were often based on routine monitoring, suspected drug toxicity or interactions, and the need for information to determine whether drug therapy should continue 3.