Originally Posted 10-30-2022 14:13
For those of us fortunate enough to attend this year's laboratory conference at Good Samaritan Hospital's Hedde Hall or virtually, there was plenty of knowledge exchanged, camaraderie built and foundations for the future of clinical lab science in Indiana extended. The April chill may still have been in the air Friday, April 8 and Saturday, April 9 but the MLSs, educators, students, lab managers and experts received the conference information warmly.
ASCLS-IN' president, Biz Fisher first introduced George Fritsma, MS, the author of the Fritsma Factor blog and the opening speaker. Delving into his wonderfully named topic, "Clumsy Clinical Communication: Let's Blame the Lab", Mr. Fritsma asked and answered some reasons why lab communication can break down.
Is the order for "C protein" actually for Protein C or C-reactive protein? Yes. Is the order for vitamin D actually for total Vitamin D, D2, D3 or 1, 25 dihydroxycholecalciferol? Just please run the vitamin D.
With these examples, Mr. Fritsma illustrated how the various laboratories for which he consults improved their LIS direct clinicians to the correct lab test to rule out or confirm a disease and establish treatment and management.
He presented a study of primary care physicians (PCP) at one hospital when there was a perceived failure to utilize lab information properly. The frequencies were classified in a small percentage of hundreds of thousands of PCP orders a week. The top three most likely errors were
Incorrect interpretation 37%.
Inadequate follow up 45%.
Failure to refer 26%.
Fifty-four percent of these errors were caused by more than one factor.
By imbedding the use of algorithms panels, such as those of ASCP's "Choosing Wisely" and allowing the LISs choices to flag or redirect the ordering PCP to correct test ordering, they were able to greatly reduce preanalytical variables involved in securing the specimen, interpretation of the results and implementation of the care plan on the basis of the results.
Following this presentation, the attendees heard from Gurmuch Singh, MD, Ph.D, Brandy Gonsulus, DCLS and Christian Bramwell, MD on the subject of appropriate laboratory utilization. He relayed the findings of his study involving of Univ. of TX Medical Branch, Univ. of Kentucky Medical Center and August University Health on intervention and monitoring of hypercritical laboratory results.
He indicated that those ordering physicians' qualities that were most likely to provide a good outcome in the execution of lab orders and implementation of results were flexibility and competence. To encourage this, a system involving physicians, bachelor of nursing, pharmacy doctorates and quality assurance personnel formed a multidisciplinary team. The team employed quality improvement process to streamline lab communications. The resulting information allowed residents to be trained in resource utilization as part of rounding with physicians.
As an example of quality improvement at the individual test level, one facility performed a critical review of procalcitonin's (PCT) use in diagnosis and treatment. The conclusion was that it did not add value to the care. As a result, the lab discontinued PCT as an offering.
Additionally, examining their CPT-10 and ICD-9-CM coding selection and linked billing system allowed improvements to their revenue stream. Reviews of reference laboratory test timing and discretionary testing led to hard stops being implemented for some assays related to certain diagnoses.
When Augusta became a state-wide testing facility for COVID-19 testing, the PCR testing information platform Cepheid was used to accommodate the results of their utilization reviews.
The teams worked because they were given the freedom to innovate and fail without it jeopardizing the project or professional standing.
Dr. Gonsulus described her part of the utilization review project at Rutgers University's Doctorate of Clinical Laboratory Science program (DCLS), the first of its kind in the US. She described part of her responsibilities in her facility as oversight for CLSI standard implementation within the lab's policies and procedures.
The work with laboratory utilization for physicians and residents was tracked through Resident In-Service Examination (RISE) standardized scores related to clinical pathology. By communicating lab utilization, the study was able to point to an increase in these RISE scores, tied specifically to their communication review. Similar processes were implemented through teams involving nurses, physical therapists, respiratory therapists, nutritionists and hospital administration.
Dr. Gonsolus described the duties and training of a DCLS. Some of the responsibilities of a DCLS included: critical care rounding; care staff assistance with test selection and interpretation; post-laboratory work involving pharmacy in addressing patients' disease processes; epidemiological statistics; and laboratory-based research.
The training for the DCLS as Dr. Gonsolus described it involved two to four years' study time and lab background then a one-year in-person residency. After which, the DCLS could be employed as a technical consultant, lab director, QA director, liaison for revenue integrity and work with a facility's diagnostics management team.
Dr. Brummel, a family medicine resident, addressed the audience on his participation in pathology utilization. He described the roles of peer review, including patient safety and adverse event analysis and the role of the CLS/MLS in the utilization team.
After a break for lunch and a little socializing, attendees were treated to The Subtle Art of Organization, courtesy of Lesa Nelson, MLS. Her presentation was forged from experience at the bench, the managerial desk, facilitation of nursing and resident education programs and ongoing graduate studies.
She observed that assessing labs' organizational needs drives data tool selection for sharing information. The organizational need and individuals' communication style directs its user to LIS, QA, and business software. As organizing one's self to help organize a team is not a read skill for many in the lab, her presentation was a must-see to anyone wanting to improve their practical organization, personally or professionally.
Cindy Rogers's presentation addressed digital imaging in hematology; both the images and the style of delivery were colorful and engaging. Ms. Rogers' excitement at her presentations of cases studies that included AML staging, harlequin cells and Auer rods, to name a few, got participants remembering their training or experience.
At each slide, Ms. Rogers linked morphology and its meaning to diagnostics and treatment. If you know that vacuoles in nuclei suggest Burkitt's Lymphoma, Sezary cells denote cutaneous skin lymphoma, iron deficiency is linked to increased platelets through erythropoetin production, and that one can quantify actual parasites in malaria through instrumentation, then the hematology lab all but becomes an MLS' shiny toy.
Next came a discussion of sepsis and the laboratory in the form of Thomas Bane, Ph.D's discussion of its relationship to the emergency department (ED). The use of 23.5 hour observation status in ruling out sepsis was presented as a way to make sure that the ED/lb team perform sufficient testing of assays such as lactate and administration of antibiotic prophylaxis before releasing a patient.
As an aside, his presentation also explored the utility of breaking apart manufacturer claims and finding conflicting studies to get a broader picture of disease process versus effective lab testing. The example given was the utility of positioning mean distribution width (MDW) immediately under the WBC in a patient report to facilitate quick diagnosis of sepsis.
With all this continuing education at our disposal, I think it's safe to say we would be delighted to see more educational partnerships between the Indiana and Kentucky chapters and their generous sponsoring agencies in the future.
Eugene (Geno) Leser
Technical Support Specialist
Roche Diagnostics Corp.