The effect of a gold coin fine on C-reactive protein test ordering in a tertiary referral emergency department

An education campaign on CRP testing was conducted at the Nepean Hospital ED to coincide with Jeans for Genes Day on 2 August 2013. This day was characterised by an informal atmosphere, including much wearing of jeans, various morning and afternoon teas, and gold coin donations. “No CRP Day” was run simultaneously with Jeans for Genes Day at the Nepean Hospital ED. Education was commenced running up to the day, with email discussions about the utility and potential indications of CRP testing. Also discussed was the cost of CRP testing to the ED, what we could spend the money on otherwise, and how CRP tests were affecting our NEAT performance.

A CRP jar was used, akin to a swear jar in that anyone ordering a CRP test had to put a gold coin in the jar as penance. This money was slated to be donated to the Children’s Medical Research Institute as part of Jeans for Genes Day. Education continued, centring on the CRP jar, with the jar being shaken loudly in front of anyone ordering a CRP test. The jar was left in the ED for the remainder of the month as visual reminder of the campaign.

A retrospective audit of CRP ordering was performed. The date of the intervention was defined as 2 August 2013, the control period was 1–31 July 2013 and the study period was 2–31 August 2013. The number of CRP tests ordered by medical staff working in the ED was collected for each period. A comparison of independent proportions was performed using VassarStats (http://vassarstats.net).

There were 5219 presentations in the control period and 5497 in the study period. In the control period, 1290 CRP tests were ordered, that is in 24.7% of presentations. In the study period, 394 CRPs tests were ordered, that is in 7.2% of presentations. This represented an absolute reduction in the rate of CRP test ordering of 17.6% (95% CI, 16.2%–18.9%; P < 0.001).

After No CRP Day, there was a significant reduction in the number of CRP tests ordered in the Nepean Hospital ED, beyond what was expected when the study was designed. It is possible that medical staff in the ED knew that CRP testing is not useful in the work-up for most patients and that they needed “permission” not to order CRP tests. Once they had this permission, they were very happy not to order CRP tests, thus producing the massive fall in ordering.

A significant finding of this study was the proportion of presentations for which CRP tests were performed as part of the clinical work-up before the intervention: almost one-quarter of ED presentations. It is possible that there had been little thought behind pathology test ordering during the control period, akin to a scattergun approach. This is despite many clinical pathways being available for use in the ED, none of them advising the use of CRP testing.

Post-hoc discussions with medical students suggested that, in medical school, the CRP test was not taught as being an important part of a clinical work-up. Similar post-hoc discussions with senior, post-fellowship medical staff suggested that the CRP test was not widely regarded as an important test, with a few exceptions relative to craft group. It seemed then that the main group “championing” the use of CRP testing was the registrar and trainee cohort of medical staff. Medical graduates, as interns, became exposed to the use of the CRP test as a standard test for the work-up of patients in their medical practice, saw CRP testing as an entrenched part of practice, and transitioned into registrars teaching the concept of CRP testing as standard practice to future cohorts of medical graduates. Then it seems that once registrars completed their training and became specialists, the need for CRP testing became less important. Thus, like a virus requiring an endemic host population, it seems that the idea of CRP testing as an important part of a standard work-up is endemic to the hospital registrar population.

A limitation of this study is that only numbers of CRP tests ordered were examined, not the effects on patient outcomes or length of stay. Also, the study did not assess whether CRP testing was indicated in each patient for whom it was ordered, so it is not possible to comment on the appropriateness of individual CRP tests. Hence there is no reason to advocate that CRP tests should never be ordered for patients who present to an ED.

The number of CRP tests ordered after the intervention seemed to still be high compared with the number of CRP tests claimed to be ordered by ED medical staff (zero!). This might be because CRPs were “added on”, by inpatient teams, to pathology tests ordered by ED staff while patients were still in the ED or after patients were transferred to a ward. There was no way to control for this phenomenon in the study.

Very little money was generated for Jeans for Genes Day beyond what was raised by nursing staff at morning and afternoon teas, and a lot less than the expected $394. This was probably more related to the propriety of the test orderers rather than a failure of the concept of the CRP jar.