1. An Audit of Nutritional Trace Element Requesting Within York Teaching Hospitals
Roger Bramley

2. Background
Measurement of trace elements (zinc, copper and selenium) is useful to monitor situations where nutritional deficiencies can occur.
Limited indications for isolated zinc measurement.
At York there are two options for requesting:
Zinc only requests (processed in-house)
Full profile requests (copper, zinc and selenium requests processed externally as a combined panel)

3. Aims/Standards Aims: Standards:
To investigate the reasons for and frequency of trace element requesting with the aim of reducing inappropriate testing.
Standards:
Appropriate frequency of request (taken from British Obesity and Metabolic Surgery Society (BOMSS) guidelines and NICE CG32).
All samples should have a clear indication for request provided.

4. Methods
Data were gathered from the pathology LIMS and electronic patient record.
Initial data gathering was performed between 1st January to 31st March 2017.
Re-audits of data after implementation of changes:
01/09/17 – 30/11/17 (3 months post changes)
01/02/18 – 30/04/18 (8 months post changes)

5. Results 1: Location of Requests
Zinc Only Requests
Full Profile Requests
Zinc only (Jan-Mar 2017)
Full profile (Jan-Mar 2017) GP
325 74 IP 37
Inpatient 54 OP 82
Outpatient
110
Mental Health 61
Total
505
238

6. Results 2: Reasons for Requests
Figure 1: Reasons for ordering of zinc-only or trace element panels at York Teaching Hospitals Trust.
Full Profile Requests
Zinc Only Requests

7. Results 3: Retest Frequency (Bariatric Surgery)
Median retest interval was 6 months.
BOMSS recommends annual testing (unless symptoms of deficiency develop).

8. Findings Significantly more zinc only requests from GPs.
Many zinc only requests are for potentially inappropriate reasons.
Bariatric surgery monitoring of trace elements is too frequent.

9. Interventions 1: Isolated Zinc Requesting
Discouraging requests:
Electronic requesting prompt.
Information sheets sent to GPs.
Coded comment added to GP requests to highlight that test is rarely useful.
Test is still available if required

10. Interventions 2: Adherence to Guidelines
No long term TPN (NICE CG32 not relevant)
Stricter implementation of BOMSS guidelines coordinated by bariatric dietitian and changes to sample labelling in clinics.
Set of labels designed to be used at each clinic appointment over the year.
Significant cost reduction in moving to best practice guidelines.

11. Interventions 3: Minimum Retest Intervals
Implemented for both zinc only and full profile requests after discussion with users:
3 months for full profile requests
1 month for zinc only requests
Electronic requesting pop-up box discourages if retested too soon.
Any tests breaching limits reaching LIMS are blocked are held on a list for review by a clinical scientist/chemical pathologist.

12. Outcomes - Zinc RequestingGP
Non-GP
Total Requests
% Reduction in Requests
Pre
325
180
505
N/A
3m post
228
134
362
28.2
8m post
136
114
250 (242)
50.4 (52.0)
A further 8 of the 250 samples breached re-testing intervals and were cancelled.
>50% reduction in zinc requests over a 3 month period.
Varies by location:
58.2% decrease in GP
36.3% decrease in non-GP

13. Outcomes - Full Profile Requesting
Total no. samples processed
No. requests cancelled
Median duration between bariatric patient samples
Pre
238
6 months
3m post
242
8 months
8m post
245 23
9 months
No significant difference in the number of tests performed but no increase.
Median retest interval increasing for bariatric surgery patients.
Shift from zinc only to full profile?

14. Conclusions
Engage with users (e.g. bariatric dietician) to ensure appropriate frequency of testing.
Use order comms and LIMS to help enforce MRI and review requests that breach MRI to ensure processing of "appropriate repeats".
Education of GP users combined with electronic requesting prompts can be an effective way of ensuring more appropriate testing.