Advanced Search

Long-Term Care Survey Alert

Quality of Care:

Medical Expert Shares Views on Lab Testing in Nursing Facilities

Published on Wed Nov 09, 2011

Know when to do a digitalis level as soon as possible.

Repeating certain lab tests is reasonable to do -- "but probably not at the frequency they are repeated in many cases," says Naushira Pandya, MD, CMD, associate professor and chair with the Department of Geriatrics at NSU College of Osteopathic Medicine in Ft. Lauderdale, Fla.

Example: "You need to know the electrolytes for hypertensive patients on multiple medications, such as ACE inhibitors and diuretics," she says. "But even the [American Heart Association] won't tell you how often. In those cases, I think every three months you should check kidney function and electrolytes," she advises.

"And if someone is on a statin or antipsychotic that might affect liver function," she recommends testing liver function every six months.

Pandya provides these additional testing suggestions:

  • A1c: "If someone is diabetic, it's reasonable to do A1c every six months, but if the diabetes is not well-controlled -- or the person's therapy has changed many times -- it's reasonable to do A1c every three months," says Pandya.
  • Complete Blood Count. "You should do a CBC annually," Pandya suggests. "But if you know the patient is anemic or has sudden fatigue or a gastric ulcer or gastritis -- or an unexplained drop in hemoglobin -- then you would follow up on that with lab testing. It depends on the clinical situation. If someone wasn't anemic last year but this year they are, we will do relevant iron studies or B-12 or look for GI blood loss. You can't dictate that type of testing in a protocol fashion."

Watch for this: "Doing repeat lab testing can make a patient anemic," Pandya warns. She reports being asked to do consultations on patients to find out why they are anemic. And "I find out that when the person came into the hospital, they weren't anemic. They got sick and they had a lot of blood drawn for tests."

Cholesterol. Pandya notes that "some physicians test a patient's cholesterol every two to three months." But she doesn't think that's required "unless you are changing the statin dose. I think you can check cholesterol [initially] every six months and, if it's stable, every year."

Drug levels. "You also want to check drug levels of patients on seizure medications," says Pandya. She thinks it's reasonable to do that testing every couple of months. "It's reasonable to check digitalis levels every six months," she adds, but you should do a "dig level as soon as possible, if a patient has bradycardia, arrhythmias, or unexplained confusion."

INR Testing 'Very, Very Important,' Stresses Expert

INRs for patients on Coumadin (warfarin) are "very, very important," says Pandya. "Most Coumadin clinics and cardiology offices do them every month," she points out, noting that she believes "we do way too many in long-term care." For example, Pandya says she knows of some nursing facilities that do INRs every Monday, Wednesday, and Friday. "Then the physicians on call might not know what has been done, so they change the dose, and the patient never has a time when he or she reaches a steady state," which takes about a week to reach, she adds.

"If a patient on Coumadin has stable, therapeutic INR levels, I do a level every two weeks. Some people are hard to control; so in those cases, I do them every week."

What if a patient starts a medication that interacts with Coumadin? "You need to do INRs more frequently," says Pandya. "For example, a quinolone antibiotic can increase INR within two days, and you can have someone overcoagulated."

Editor's note: For Pandya's recommendations for doing creatinine testing in nursing facilities, see an upcoming Long-Term Care Survey Alert.

Other Articles in this issue of

Long-Term Care Survey Alert

View All