Local Initiatives

Choosing Wisely Manitoba is leading many quality improvement initiatives to introduce evidence-based changes and improvements to Manitoba’s health care system. Our goal is to improve appropriateness of care, patient and provider experience, health system efficiencies and sustainability by working with our healthcare stakeholders to build capacity for research stewardship and quality improvements projects that aim to reduce unnecessary tests, treatments and procedures in Manitoba.

How are we implementing Choosing Wisely Manitoba?

Thyroid Function Testing
Immune Globulin
Improving the Appropriate Use of MRI for Lower Back Pain
Red Blood Cell Utilization
Improving Preoperative Diagnostic Testing
Reducing Unnecessary Prostate-Specific Antigen (PSA) Testing
Discontinuation of Creatine Kinase for diagnosis of Acute Coronary Syndrome
Activated Partial Thromboplastic Time
ESR and CRP Testing
Just One
Tissues for Disposal
Appropriate Vitamin D Testing
Appropriate Use of FOBT

Thyroid Function Testing

The Shared Health laboratory, Section of Endocrinology and Metabolism and Pediatric Endocrinology have collaborated to develop a clinical guideline to streamline thyroid function testing in primary care; effectively automating the reflexing of free T4 and free T3 tests as appropriate within the testing process. The provincial clinical guideline will be supported by revised laboratory requisitions to reflect the reflex testing model and will include physician education and decision support embedded into requests. Dynacare laboratories are also being engaged to adopt similar policies.

Both Choosing Wisely Canada and Choosing Wisely USA have recommendations surrounding the testing of Free T4 and Free T3.

Canadian Society of Endocrinology and Metabolism – Don’t use Free T4 or T3 to screen for hypothyroidism or to monitor and adjust levothyroxine (T4) dose in patients with known primary hypothyroidism. T4 is converted into T3 at the cellular level in virtually all organs. Intracellular T3 levels regulate pituitary secretion and blood levels of TSH, as well as the effects of thyroid hormone in multiple organs. Therefore, in most people a normal TSH indicates either normal endogenous thyroid function or an adequate T4 replacement dose. TSH only becomes unreliable in patients with suspected or known pituitary or hypothalamic disease when TSH cannot respond physiologically to altered levels of T4 or T3.

American Society for Clinical Pathology – Don’t order multiple tests in the initial evaluation of a patient with suspected thyroid disease. Order thyroid-stimulating hormone (TSH), and if abnormal, follow up with additional evaluation or treatment depending on the findings. The TSH test can detect subclinical thyroid disease in patients without symptoms of thyroid dysfunction. A TSH value within the reference interval excludes the majority of cases of primary overt thyroid disease. If the TSH is abnormal, confirm the diagnosis with free thyroxine (T4).

Choosing Wisely Canada’s Understand the Gland Toolkit

Immune Globulin

Improving the Appropriate Use of MRI for Lower Back Pain

Red Blood Cell Utilization

Improving Preoperative Diagnostic Testing

In Manitoba, many patients presenting for low-risk surgery were receiving full preoperative assessments despite the fact that these assessments did not improve outcomes. In 2014 a multidisciplinary team was formed to restructure the way preoperative assessment is carried out in Manitoba. The goal was to ensure that all Manitobans receive the necessary and appropriate preoperative diagnostic testing for minor surgeries through the sustainable implementation of a standardized, evidence-informed clinical practice guideline.

This project started with an examination of the barriers and facilitators to guideline adoption and implementation including further analysis of audit results, stakeholder consultations and a literature review. The results of this work were then used to develop and implement a new Routine Preoperative Lab Test Guideline. A series of interventions were then developed aiming first to reduce unnecessary testing in cataract surgery and then to reduce unnecessary testing in other types of surgery.

The implementation of a revised Cataract Surgery History and Physical (H&P) Form emphasized that tests are not usually required for cataract surgery and eliminated cuing for unnecessary preoperative tests. At the same time a Red-Green project eliminated preoperative History and Physicals for ~60% of cataract surgery patients. Pre and post-implementation audits showed a 77.5% reduction in patients undergoing preoperative testing from pre to post-implementation.

Building on what we learned through the cataract project, on July 11, 2016, five revised documents were implemented to help reduce cues that prompt unnecessary testing for all other types of surgery. The revised documents were implemented in eight surgical sites across Winnipeg.

Four Documents:

Our primary outcome, to reduce preoperative diagnostic testing by 25%, was evaluated through retrospective chart reviews of two random samples of surgical patients during typical weeks in the WRHA. The results demonstrated a significant (p<0.0001) 35% reduction in preoperative diagnostic testing.

In order to review adherence to the guidelines and to support implementation by providing feedback and supporting materials, we have conducted approximately 10 audits of surgeons in each of the 8 surgical sites in Winnipeg (excluding cataract and pediatrics). The results revealed that the majority of surgeries were compliant with the guidelines (60%) but that there is a large range in the number of unnecessary tests ordered between surgical specialties from 24% of tests ordered are unnecessary to 72% are unnecessary. Based on these results our next step is to provide feedback to individual surgeons including supporting materials to increase adherence to the guidelines.

See a Summary of the Evaluation Results

For a copy of the full evaluation please contact us at admin@choosingwiselymanitoba.ca.

Reducing Unnecessary Prostate-Specific Antigen (PSA) Testing

Discontinuation of Creatine Kinase for diagnosis of Acute Coronary Syndrome

Discontinuation of the use of creatine kinase (CK) for the diagnosis of acute coronary syndrome (ACS)

Background Information:

Creatine kinase (CK) has been a traditional biomarker for identifying patients with acute myocardial infarction (AMI). High-sensitivity cardiac troponin (hsTnT), however, has been shown to be significantly more sensitive and specific in identifying myocardial ischemia and has become the preferred biomarker for myocardial necrosis among consensus recommendations.¹ For example the 2018 American Heart Association consensus guidelines on the universal definition of myocardial infarction recommend high sensitivity troponin assays for the diagnosis of ACS due to their superior sensitivity and specificity for myocardial injury; other biomarkers, such as CK, are not recommended.⁷

This has called into question the clinical utility and cost effectiveness of CK in the work-up of chest pain in the emergency department (ED).^2-5

A study conducted by researchers in the University of Manitoba Departments of Internal Medicine, Section of Cardiology and Emergency Medicine⁶, aimed to clarify whether CK provided any added diagnostic value over hsTnT alone. A retrospective review of all adult patients (36,251) presenting to St. Boniface Hospital Emergency Department in 2017 was conducted. Patients presenting with cardiac complaints who had non-diagnostic hsTnT and positive CK were identified, and their charts reviewed to determine whether a diagnosis of AMI was made, and whether they experienced subsequent cardiovascular morbidity or mortality. The results revealed that CK provided no diagnostic benefit over hsTnT alone in >99.9% of cases.

Based on the results of this, and other studies^3,5that demonstrate that routine CK testing does not provide a significant benefit to patient care and therefore represents an unnecessary system cost, the goal of this resource stewardship project will be to eliminate routine CK testing for the diagnosis of AMI in emergency departments across the WRHA.

In July 2020, the project was rolled out across Manitoba.

Clinical Practice Change:
Discontinuation of the use of creatine kinase for the diagnosis of acute coronary syndrome (ACS) Clinical Practice Change

References:

Jaffe AS. New standard for the diagnosis of acute myocardial infarction. Cordial Rev 2001; 9(6): 318-22.
Volz KA, Horowitz GL, McGillicuddy DC, Grossman SA, Sanchez LD.Should creatine kinase-MB index be eliminated in patients with indeterminate troponins in the ED? Am J Emerg Med 2012; 30(8): 1574-6.
Volz KA, McGillicuddy DC,Horowitz GL, Sanchez LD. Creatine kinase-MB does not add additional benefit to a negative troponin in the evaluation of chest pain. Am J Emerg Med 2012; 30(1): 188-90.
Saenger AK, Jaffe AS. Requiem for a heavyweight: the demise of creatine kinase-MB. Circulation 2008; 118(21): 2200-6.
Le RD, Kosowsky JM,Landman AB,Bixho I, Melanson SE, Tanasijevic MJ. Clinical and financial impact of removing creatine kinase-MB from the routine testing menu in the emergency setting.Am J Emerg Med 2015; 33(1):72-5.
Wiens EJ, Arbour J, Thompson K, Seifer C. Routine creatine kinase testing does not provide clinical utility in the emergency department for diagnosis of acute coronary syndromes. BMC Emerg Med. 2019;19:37. doi: 10.1186/s12873-019-0251-4.
Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D, White H: the Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). Circulation. 2018;138:e000–e000.

Project Poster:

Activated Partial Thromboplastic Time

ESR and CRP Testing

Just One

Just One is an awareness campaign intended to educate and remind clinicians of best practices and guidelines around red blood cell infusions and their -potential harms.*

A clinical practice guideline was distributed to all Manitoba clinicians in the late 2018 to educate clinicians on appropriateness criteria for blood transfusions in stable, non-bleeding patients. The key messages were

Just one unit of blood should be ordered for stable patients with no clinical bleeding.
Re-assess the patient before requesting each unit of blood. Indications for a receiving additional units are:
- Active blood loss
- Ongoing symptoms of anemia

These are evidence-based recommendations made by the Canadian Society for Transfusion Medicine and Choosing Wisely Canada.

The materials included possible Patient impacts and system improvements including:

Patient Impact:

Each unit of blood administered has the potential to cause adverse reactions. These can range from as minor as a rash or fever to more severe reactions such as acute respiratory distress or even death. The reactions to a transfusion may happen immediately or it may be delayed as the body responds to the donors red cells via the patient’s immune system. In addition, every unit of blood transfused may increase the likelihood of the patient developing antibodies to donor red cells resulting in challenges in finding compatible units if/when the patient requires further transfusions.

System Improvements:

Reduction in the number of transfused red cells can reduce the significant pressure on Canada’s blood supply, ensuring availability for patients who require lifesaving units. System improvements can also be seen by reducing workload on Transfusion Medicine departments and Canadian Blood Services to collect, process, distribute and issue these products.

Choosing Wisely Manitoba, in partnership with Shared Health, has developed posters and postcards that relay safe transfusion practice regarding single unit transfusion orders. The postcard will be attached to each red cell unit as it is issued from the blood bank.

Posters and postcards were distributed across the province to hospital areas that commonly transfuse red blood cells. Postcards were attached to the units of blood for approximately one month whenever more than one unit was ordered.

View the Just One campaign poster here

*(May not apply to outpatient transfusions for oncology patients.)

Tissues for Disposal

Human tissues removed during a biopsy or surgical procedure are typically sent to a pathology laboratory for diagnostic examination and testing. Under the framework of Choosing Wisely Manitoba, and with the support of Orthopedic Surgeon and Clinical Champion, Dr. Eric Bohm, Shared Health conducted a retrospective review of approximately 300 orthopedic surgery cases (representing one surgeon’s annual caseload) to correlate pathology findings with the original diagnostic imaging report. As evidence and experts had suggested, the results of the review supported the case that pathology testing on tissues removed from the body during orthopedic procedures do not provide additional clinical data making the original diagnostic imaging report clinically sufficient. With no value added to patient care, these tissues are now recommended for exemption from requiring pathological review and instead recommended for immediate disposal.

New standard operating procedures to eliminate testing from elective hip and knee replacement surgeries were developed and implemented at Concordia Hospital, Grace Hospital and Boundary Trails Health Centre. Now fully implemented at all provincial orthopedic surgery sites, the disposal of these tissues is freeing pathologists’ for other important work.

On average pathology testing was reduced from 204 tests per month to 13 tests per month (April – December, 2017). That represented a 93% reduction in pathology testing following the implementation of the new standard operating procedures. Collaboration with surgeons has led to the development of processes to facilitate immediate disposal and improve workflow and efficiencies.

Reduction in pathology testing following the implementation of the new standard operating procedures.

Related clinical practice changes can be found here:

Appropriate Vitamin D Testing

Appropriate Use of FOBT