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The aim of this study was to evaluate the consequence of the introduction of Clinical Pathways (CPs) and the inclusion of Likelihood Ratios (LRs) in test results instead of the reference intervals in the workload for the laboratory and in-patients.A controlled before (2003) and after (2004, 2005, and 2006) study compared the exams requested using CPs instead of single exams for three pathologies (pulmonary embolism, acute myocardial infarction, and bile-pancreatic pathologies) in order to evaluate if this procedure is followed in clinical care and if it provides useful and accurate investigation for clinical care. Data were collected from the laboratory computer archive system over 3 years (2004 - 2006).The total number of requests decreased between the "before" and "after" 2004 and 2005. We found an increase (30% to 40%) in the requests of CPs. The percentage for each of the considered CPs showed a significant increase for the pulmonary embolism (EP) and bile-pancreatic pathologies: during the semesters monitored, we found an 80% increase in the request of these CPs. The percentage of acute myocardial infarction (AMI) CPs did not show a difference between the semesters compared. We also found an improvement in the diagnostic effectiveness: the concordance between the emergency department (ED) and ward diagnosis for EP increased.We demonstrated that this procedure is followed in clinical care for the three pathologies studied and that the use of CPs and LRs provide useful tools in making a more appropriate diagnosis. We demonstrated also that clinical audit is very important for monitoring. Audit is integral to good clinical practice and, in fact, aims to influence activity on a local level and is useful in maintaining best practice.

The Emergency Department and the laboratory of our institution jointly developed simple Clinical Pathways for some important clinical conditions (pulmonary embolism, acute myocardial infarction, bile-pancreatic disease) and since May 2004 the positive and negative likelihood ratios have been added to the reports of the tests included in the clinical pathways. In the first semester 30% of clinicians adopted the new mode of tests requesting AMI, Pulmonary embolism and bile pancreatic clinical pathways, respectively, 24% 32% and 42%. According to a survey carried out in 2004 all the ED staff had knowledge of the project. A real partnership developed between the laboratory staff and Emergency Department physicians leading to the adoption of the Evidence Based Laboratory Medicine tools in the decision making process.