IntroductionThe Choosing Wisely guidelines advise against ordering routine blood tests for hospitalised patients unless they change management. Unnecessary testing can lead to adverse effects (eg, iatrogenic anaemia, poor sleep quality, risk for infections and increased cost of care).MethodsAn 8-week quality initiative aimed at reducing unnecessary blood tests was implemented in three internal medicine resident inpatient services. The initiative included a 30 min educational session, reminders prior to rotation and midrotation and posters in work areas that displayed lab pricing and urged judicious testing. Residents were encouraged to justify the purpose of ordering tests in their daily progress notes. Attending physicians were made aware of the initiative. Preintervention and postintervention time points were used to compare key metrics. A >10% decrease between time periods was used as an evaluation criterion.ResultsThere were 293 patient records reviewed in the preintervention period and 419 in the postintervention period. The two groups were similar in terms of age and gender. Median blood test count (complete blood count/basic metabolic profile/comprehensive metabolic profile) decreased from 4 to 2 tests per patient per day (50 % decrease) after the intervention. The median length of hospital stay decreased from 4.9 to 3.9 days (21% decrease). A decreased percentage of people requiring transfusions was also noted (2016: 6.1%, 2017: 2.9%).ConclusionThe frequency of unnecessary routine blood tests ordered in the hospital can be decreased by educating resident physicians, making them cost conscious and aware of the indications for ordering routine labs. Frequent reminders are needed to sustain the educational benefit.

Background: Leukoaraiosis has been shown to impact functional outcomes after acute ischemic stroke. However, its association with domain specific recovery after ischemic stroke is uncertain. We sought to determine whether preexisting leukoaraiosis is associated with short term motor and cognitive recovery after stroke. Methods: We retrospectively studied ischemic stroke patients admitted to acute inpatient rehabilitation (AIR) between January 2013 and September 2015. Patient baseline characteristics, infarct volume, prestroke modified Rankin Scale, stroke cause, rehabilitation length of stay, and Functional Independence Measure (FIM) scores were recorded. Leukoaraiosis severity was graded on brain MRI using the Fazekas scale. Multiple linear regression was used to determine factors independently associated with the total, cognitive, and motor FIM scores at AIR discharge, respectively. Results: Of 1,600 ischemic stroke patients screened, 109 patients were included in the final analysis. After adjustment, the initial NIHSS (β −0.541, CI −0.993-−0.888; p=0.020) and preexisting leukoaraiosis severity (β −1.448, CI −2.861-−0.034; p=0.045) independently predicted the total FIM score. Domain specific analysis showed that infarct volume (β −0.012, CI −0.019-−0.005; p=0.002) and leukoaraiosis severity (β −0.822, CI −1.223-−0.410; p=0.0001) independently predicted FIM cognitive scores at discharge from AIR. Leukoaraiosis did not predict FIM motor score (p=0.17).

Background: White matter hyperintensities (WMH) have been shown to impact functional outcomes after ischemic stroke. However, their role in cognitive recovery after ischemic stroke is unclear. Therefore, it is important to evaluate if WMH can predict the degree of cognitive recovery after inpatient rehabilitation. Methods: We retrospectively studied 162 patients admitted to inpatient rehabilitation after an acute ischemic stroke. We reviewed patient demographics, presence of co-morbidities, infarct volume, pre-admission Modified Rankin Scale, TOAST criteria, acute interventions for their stroke, rehabilitation length of stay, and Functional Independence Measure (FIM) scores (motor and cognitive) at admission and discharge from rehab. WMH were graded according to the Fazekas scale on the basis of visual assessment in both periventricular and subcortical areas. Results: 162 patient charts reviewed, 53 were excluded due to primary intracerebral hemorrhage and insufficient imaging. 109 patients were included in the final analysis. Multiple linear regression analysis revealed that, when adjusted for infarct volume, NIHSS stroke scale and age; severity of WMH as graded on Fazekas scale independently predicted Functional Independence Measure (FIM) cognitive scores at discharge (p < 0.0084). WMH severity did not predict Functional Independence (FIM) motor scores. Conclusions: In this retrospective analysis, we found that severity of WMH hyperintensities as graded by Fazekas scale is an independent predictor of cognitive FIM scores after inpatient rehabilitation for acute ischemic stroke.