The Rational Investigations Project was an evidence-based initiative that aimed to reduce unnecessary pathology testing through enhanced clinical decision-making.
The project was a continuation of successful pioneering Choosing Wisely projects and is the flagship initiative of the NSW Sustainable ED Program. The pilot enabled important conversations about pathology tests where evidence shows they may provide no benefit and, in some cases, lead to harm – challenging the notion that ‘more is always better’ when it comes to healthcare.
Developed in the Coffs Harbour Emergency Department (ED) in 2022, in partnership with NSW Health Pathology Atlas of Variation team, and supported by the Climate Risk and Net Zero Unit, the integrated project empowered clinicians with education, decision-support tools and cost awareness leading to reductions in low value testing and enhancing patient care. By aligning clinical practice with principles of high value, low waste care, the project increased efficiencies, savings and reduced emissions. The initiative is not about doing fewer tests, but doing the right tests.
In the first 12 months, the ED pilot demonstrated over $500,000 in hospital savings, a 21% reduction in ED blood gas testing and a 1.7% hospital-wide decrease in pathology testing against a 6% statewide average growth. There was an estimated 1.5 tonne reduction in carbon emissions, with zero adverse outcomes identified. The pilot has evolved into the Choosing Wisely inspired statewide program with NSW Health Pathology and cross-system stakeholders.
Addressing low value healthcare
Up to 30% of healthcare is deemed to be low value, with an estimated 10% harmful. It has been estimated that 12-44% of pathology tests are unnecessary or not clinically needed. Across NSW, the number of pathology tests undertaken increased by an average of 6% in 2024.
Over-ordering of pathology tests:
- contributes to patient harm through false positives and overdiagnosis
- delays safe discharge
- impairs workflows
- strains budgets
- increases staff workloads.
Pathology testing also contributes to healthcare’s high environmental footprint. In the 2020-21 financial year, Australia spent $3.9 billion on Medicare subsidised pathology services. Despite multiple ad hoc healthcare initiatives, no whole-of-health strategic approach had been identified previously. The Rational Investigations Project emerged in response to the need for a collaborative systems approach.
Led by Mid North Coast Local Health District (MNCLHD) clinicians and informed by Choosing Wisely, the Sensible Test Ordering Project and Evolve principles, the project reframes reduction not as rationing, but as patient-centred best practice and good medicine. Coffs Harbour ED was selected as part of the Ministry of Health’s Net Zero Leads program. The success of this pilot has informed the development of a broader statewide Choosing Wisely inspired program, which will roll out across multiple districts with the backing of NSW Health Pathology and partner agencies. This represents a significant step towards a sustainable, safer and value-based healthcare system.
Extensive staff consultation and education
The project was launched by the clinical lead (NSW ED Net Zero Lead) and data lead (NSW Health Pathology Atlas of Variation), supported by ED leaders, project nurses, champions, the Climate Risk and Net Zero Unit, MNCLHD teams and over 70 collaborators statewide. Extensive staff consultation, perspectives and behavioural science integration were pivotal factors.
The project team undertook the pilot in 3 phases:
- Phase 1 – ED clinical staff engagement: Core activities for ED clinical staff included staff meetings, teaching sessions, one-to-one support and multi-media engagement. Clinical engagement included ICU staff and other medical specialties outside of ED to ensure that the reduction of pathology testing in ED did not lead to an increase in testing in services outside of ED. Education package included project summaries, clinical practice guidelines, cost cues and educational posters.
- Phase 2 – Hospital teams’ engagement: Engagement with hospital teams including meetings with medical leads and teams.
- Phase 3 – Pilot expansion: Additional funding enabled expansion across two hospitals’ EDs and ICUs, with an initial team of 6 project nurses.
Implementation included in-person clinical handovers, and multi-media engagement included posters, emails, and communication groups to reinforce the change. Project challenges included data access and complexity, systems issues, limited resourcing and stakeholder support. Despite this, strong clinician engagement occurred due to patient focus, multiple co-benefits and implementation team resilience. The project’s success depended on funded part-time medical and project nursing leads, local champions and the collaborative leadership of the NSW Health Pathology team.
A high-impact, multi-benefit ED project
Decrease in hospital-wide pathology testing
Results demonstrated over $500,000 in hospital savings, a 21% reduction in ED blood gas testing and 1.7% hospital-wide decrease in pathology testing against 6% statewide average growth. There was an estimated 1.5 tonne carbon emissions reduction. Zero adverse patient outcomes were identified.
Dedicated funding and clinical lead roles are essential
The project’s system-wide success relied on sustainable healthcare clinician lead roles with strong executive support and sufficient resourcing. Temporary project nurse funding in 2024 enabled rapid expansion across 2 EDs and ICUs.
The Rational Investigations Project is a contagious catalyst
The project has sparked engagement internationally. Staff provided high levels of positive feedback. The initiative has been a catalyst for action across traditional siloes—functioning as a “domino project” that drives collective mindset change. The work has laid the foundation for rational medication, radiology and other high-value care initiatives implemented by district sustainable healthcare medical and nursing teams.
