A strategy for optimizing staffing to improve the timeliness of inpatient phlebotomy collections.

Arch Pathol Lab Med. 2011 Dec;135(12):1576-80

Authors: Morrison AP, Tanasijevic MJ, Torrence-Hill JN, Goonan EM, Gustafson ML, Melanson SE

Abstract
CONTEXT: The timely availability of inpatient test results is a key to physician satisfaction with the clinical laboratory, and in an institution with a phlebotomy service may depend on the timeliness of blood collections. In response to safety reports filed for delayed phlebotomy collections, we applied Lean principles to the inpatient phlebotomy service at our institution. Our goal was to improve service without using additional resources by optimizing our staffing model.
OBJECTIVE: To evaluate the effect of a new phlebotomy staffing model on the timeliness of inpatient phlebotomy collections.
DESIGN: We compared the median time of morning blood collections and average number of safety reports filed for delayed phlebotomy collections during a 6-month preimplementation period and 5-month postimplementation period.
RESULTS: The median time of morning collections was 17 minutes earlier after implementation (7:42 am preimplementation; interquartile range, 6:27-8:48 am; versus 7:25 am postimplementation; interquartile range, 6:20-8:26 am). The frequency of safety reports filed for delayed collections decreased 80% from 10.6 per 30 days to 2.2 per 30 days.
CONCLUSION: Reallocating staff to match the pattern of demand for phlebotomy collections throughout the day represents a strategy for improving the performance of an inpatient phlebotomy service.

PMID: 22129187 [PubMed - indexed for MEDLINE]

Antiphospholipid antibody syndrome.

Arch Pathol Lab Med. 2011 Sep;135(9):1092-6

Authors: Sangle NA, Smock KJ

Abstract
Antiphospholipid antibodies are directed against phospholipid-protein complexes and include lupus anticoagulant, anticardiolipin antibodies, and anti-beta-2 glycoprotein I antibodies. Antiphospholipid antibody syndrome is a common cause of acquired thrombophilia and is characterized by venous or arterial thromboembolism or pregnancy morbidity and the presence of antiphospholipid antibodies. Antibodies should be demonstrable on at least 2 occasions separated by 12 weeks. Heterogeneity of the autoantibodies and absence of gold standard assays makes interpretation of laboratory results a challenge for both laboratorians and clinicians. This review discusses the key laboratory and clinical aspects of antiphospholipid antibody syndrome. Particular focus is given to lupus anticoagulant detection, in view of recently updated laboratory guidelines.

PMID: 21877992 [PubMed - in process]

Does routine repeat testing of critical values offer any advantage over single testing?

Arch Pathol Lab Med. 2011 Apr;135(4):440-4

Authors: Toll AD, Liu JM, Gulati G, Behling EM, Kocher WD

Abstract Context.-Before being communicated to the caregiver, critical laboratory values are verified by repeat testing to ensure their accuracy and to avoid reporting false or erroneous results. Objective.-To determine whether 2 testing runs offered any advantage over a single testing run in ensuring accuracy or in avoiding the reporting of false or erroneous results. Design.-Within the hematology laboratory, 5 tests were selected: hemoglobin level, white blood cell count, platelet count, prothrombin time, and activated partial thromboplastin time. A minimum of 500 consecutive critical laboratory test values were collected retrospectively for each test category. The absolute value and the percentage of change between the 2 testing runs for each critical value were calculated and averaged for each test category and then compared with our laboratory's preset, acceptable tolerance limits for reruns. Results.-The mean results obtained for the absolute value and the percentage of change between the testing runs were 0.08 g/dL (1.4%) for hemoglobin levels, 50 cells/µL (10.2%) for white blood cell counts, 1500 cells/µL (9.9%) for platelet counts, 0.7 seconds (1.4%) for prothrombin time, and 5.1 seconds (4.4%) for activated partial thromboplastin time (all within our laboratory's acceptable tolerance limits for reruns). The percentage of specimens with an absolute value or a mean percentage of change outside our laboratory's acceptable tolerance limits for reruns ranged between 0% and 2.2% among the test categories. No false or erroneous results were identified between the 2 testing runs in any category. Conclusions.-Routine, repeat testing of critical hemoglobin level, platelet count, white blood cell count, prothrombin time, and activated partial thromboplastin time results did not offer any advantage over a single run.

PMID: 21466359 [PubMed - in process]

International normalized ratio versus plasma levels of coagulation factors in patients on vitamin k antagonist therapy.

Arch Pathol Lab Med. 2011 Apr;135(4):490-4

Authors: Gulati G, Hevelow M, George M, Behling E, Siegel J

Abstract Context.-The key question when managing patients on warfarin therapy who present with life-threatening bleeding is how to use the international normalized ratio (INR) to best direct corrective therapy. The corollary question for the clinical laboratory is at what level will the INR reflect a critical value that requires notifying the clinician. Objective.-To determine the levels of vitamin K-dependent factors over a range of INR values. Design.-Evaluation of the vitamin K-dependent coagulation factor levels on plasma remnants from patients in whom a prothrombin time and INR was ordered to monitor warfarin therapy. There were a total of 83 specimens evaluated with an INR range from 1.0 to 8.26. Results.-The mean activity levels of all 4 factors remained near or above 50% when the INR was less than 1.5. The average factor X level was 23% when the INR range was 1.6 to 2.5, but levels of factors II, VII, and IX did not drop below the hemostatic range until the INR was greater than 2.5. At an INR of 3.6 or more, the activity levels of all 4 factors were less than 30% in more than 90% of the specimens. Conclusion.-Levels of factors II, VII, IX, and X declined with increasing INR but not at the same rate and not to the same level at a given INR. However, most of the values were below the hemostatic value once the INR was 3.6 or more, the level that was also considered critical for physician notification.

PMID: 21466367 [PubMed - in process]

The use of computerized provider order entry to improve the effectiveness and efficiency of coagulation testing.

Arch Pathol Lab Med. 2011 Apr;135(4):495-8

Authors: Georgiou A, Lang S, Rosenfeld D, Westbrook JI

Abstract Effective pathology services require timely communication of patient-related information between the laboratory and clinicians. The aim of this study was to measure the effect of a computerized provider order entry (CPOE) system on the frequency with which clinicians notify the Hematology Laboratory of details on heparin or warfarin treatments when ordering activated partial thromboplastin time (aPTT) or the prothrombin time (PT) and international normalized ratio (INR). Although information about the total number of patients on warfarin or heparin was unavailable, it was possible to ascertain that the percentage of abnormal results for each year ranged from 39% in 2005 to 45%, 40%, and 38% in the years 2006 to 2008. The proportion of order requests that reported whether patients were on warfarin or heparin increased from 3% of the aPTT tests (253 of 8307) and 1.9% of the PT and INR requests (161 of 8433) in August through September 2005 (before the CPOE was implemented) to 3.9% (393 of 9990; P < .001) and 2.6% (282 of 10814; P ?=? .009), respectively, in August through September 2008 (after CPOE implementation). During that period (2005-2008), the median turnaround time for the laboratory decreased from 28 to 21 minutes for the PT and INR test results (P < .001) and from 34 to 23 minutes for the aPTT test results (P < .001). The results show that CPOE and decision-support systems can enhance laboratory efficiency and improve its contribution to effective patient care.

PMID: 21466368 [PubMed - in process]

Pseudohyponatremia revisited: a modern-day pitfall.

Arch Pathol Lab Med. 2011 Apr;135(4):516-9

Authors: Fortgens P, Pillay TS

Abstract Factitiously low sodium estimations are a hazard in most modern clinical laboratories. Most modern high-throughput analyzers use indirect ion-selective electrodes to estimate electrolyte concentrations in serum samples. This analysis is preceded by a dilution step of the sample. If the water concentration is altered by the presence of increased lipid or protein, the dilution step and the subsequent calculation of concentration by the analyzer results in a falsely low sodium value. This places patients at risk, particularly if the factitious result is acted upon by the physician. In this short review, we highlight this problem and review the methodology and situations where this artifact can occur and discuss strategies to circumvent this problem. When factitious results are suspected, whole blood sodium can be assessed using a direct ion-selective electrode, by measurement of osmolality, or by calculation of the serum water fraction and applying a correction to the reported value.

PMID: 21466372 [PubMed - in process]

Neurocysticercosis.

Arch Pathol Lab Med. 2010 Oct;134(10):1560-3

Authors: Moskowitz J, Mendelsohn G

Neurocysticercosis is a significant public health issue within the United States. Although cysticercosis was once thought to have been eradicated in the United States, the number of documented cases is rising and immigrants from endemic areas are at the highest risk for acquiring and developing this disease. The clinical presentation of neurocysticercosis is variable and vague neurologic symptoms or sudden unexplained death in individuals with risk factors may be the only available information warranting a consideration of neurocysticercosis. Radiologic and laboratory findings can help guide medical and surgical interventions, while histologic confirmation establishes a more definitive diagnosis. Encysted larvae can be found throughout the central nervous system and undergo progressive stages of decay. Degenerating vesicles elicit an inflammatory response, involving surrounding structures, and cause the major clinical symptomatology.

PMID: 20923314 [PubMed - indexed for MEDLINE]

Drug-induced thrombocytopenia.

Arch Pathol Lab Med. 2009 Feb;133(2):309-14

Authors: Kenney B, Stack G

Drug-induced thrombocytopenia was first described in the 19th century, yet our understanding of its pathogenesis continues to evolve. The list of drugs implicated in drug-induced thrombocytopenia is extensive and growing. Many, if not most, of these medications induce thrombocytopenia by immune mechanisms. Because the degree of thrombocytopenia can put patients at risk for serious bleeding, a prompt diagnosis is key to clinical management. The laboratory approach to diagnosing drug-induced thrombocytopenia is 2-pronged. First, nondrug causes of thrombocytopenia must be ruled out. Second, testing for drug-dependent platelet antibodies, available at specialized reference laboratories, often can identify the offending medication, although usually not in time for initial clinical management. Once a medication is suspected of causing thrombocytopenia, it must be discontinued promptly, and the patient should be monitored closely. Thrombocytopenia generally resolves quickly after offending medication withdrawal, and the prognosis of drug-induced thrombocytopenia is then excellent.

PMID: 19195976 [PubMed - indexed for MEDLINE]

Notification of critical results: a College of American Pathologists Q-Probes study of 121 institutions.

Arch Pathol Lab Med. 2008 Dec;132(12):1862-7

Authors: Valenstein PN, Wagar EA, Stankovic AK, Walsh MK, Schneider F

CONTEXT: Hospital accreditors are placing increased emphasis on the timeliness with which critical laboratory results are reported to caregivers. OBJECTIVE: To measure the speed of critical result notification at a group of laboratories, identify factors associated with faster reporting, and place findings in the context of the time required to transport and test specimens and to correct critical abnormalities. DESIGN: Contemporaneous review of 3545 inpatient and emergency department critical result notifications in 121 laboratories enrolled in the College of American Pathologists Q-Probes program. RESULTS: The median laboratory required a median of 5 minutes for staff to notify someone about a critical result once testing was complete. Laboratories affiliated with smaller institutions (P = .01), rural laboratories (P = .001), and sites that called results before releasing them from the laboratory computer (P = .02) were able to notify caregivers more quickly. There was variation among institutions in the time it took to notify caregivers (interquartile range, 1.5-8 minutes). At the median facility, notification took place 56.5 minutes after the specimen had been collected. CONCLUSIONS: The time required to notify caregivers of a critical laboratory result is a small proportion of the time taken to collect and test specimens or the time that has been reported for caregivers to correct abnormalities. Although failure to notify caregivers of critical results may represent an important patient safety vulnerability, the timeliness of laboratory notification is a minor contributor to total test turnaround time at most institutions.

PMID: 19061281 [PubMed - indexed for MEDLINE]

Reduction of blood loss from laboratory testing in hospitalized adult patients using small-volume (pediatric) tubes.

Arch Pathol Lab Med. 2008 Dec;132(12):1916-9

Authors: Sanchez-Giron F, Alvarez-Mora F

CONTEXT: Blood loss from laboratory testing (BLLT) can be significant in hospitalized patients. It is a common practice to draw full large-volume tubes of blood from adults. OBJECTIVE: To determine whether BLLT occurred when a small-volume (pediatric) blood collection tube (SVT) was substituted for each large-volume blood collection tube and to note whether an adequate sample still was obtained. DESIGN: During 2 consecutive weeks, hospital test requisitions were reviewed to collect patient demographics, tests requested, and number and type of tubes obtained. The amount of blood collected and BLLT per patient were calculated. Reduced sample requirements were calculated, and phlebotomists and ward nurses were required to use SVTs. After 2 weeks of familiarization, data were collected as previously described. Laboratory technicians logged problems related to the use of SVTs. RESULTS: Baseline: 227 patients had 664 requisitions, and median BLLT per patient was 13.5 mL (interquartile range [IQR], 7.6-27.3 mL). In critical care patients, the median was 19.9 mL (IQR, 12.0-35.8 mL), and maximum BLLT was 159.8 mL. Intervention phase: 246 patients had 696 requisitions, median BLLT was 3.7 mL (IQR, 1.2-6.3 mL; P < .001). In critical care patients, the median was 5.1 mL (IQR, 2.3-10.9 mL), and maximum BLLT was 61.8 mL (P < .001). All tests requested could be performed using SVTs, and no additional blood collections were required. Use of SVTs reduced overall BLLT per patient by 73% and by 74% in critical care patients. CONCLUSIONS: By decreasing the size of the blood collection tube for adults, we were able to markedly reduce BLLT without noting any insufficient specimen volumes.

PMID: 19061290 [PubMed - indexed for MEDLINE]

Primary central nervous system lymphoma.

Arch Pathol Lab Med. 2008 Nov;132(11):1830-4

Authors: Bhagavathi S, Wilson JD

Primary central nervous system lymphoma (PCNSL) is an uncommon extranodal non-Hodgkin lymphoma. Its incidence has increased during the last 3 decades and has been reported in both immunocompromised and immunocompetent patients. Immunocompromised patients are affected at a younger age compared with immunocompetent patients. It presents with raised intracranial pressure and focal neurologic and neuropsychiatric symptoms. The lesions are typically solitary. The majority of the lesions are located in the periventricular area, whereas in a few cases they are located in the supratentorial area. Diffuse large B-cell lymphomas constitute most PCNSLs, whereas T-cell, low-grade, anaplastic, and Hodgkin lymphomas are rarely encountered. The morphology of PCNSL shows a characteristic angiocentric pattern and is positive for B-cell markers by immunohistochemistry. The differential diagnosis of PCNSL includes central nervous system gliomas, metastatic tumors, demyelinating disorders, subacute infarcts, and space-occupying lesions due to an infectious etiology. The understanding of the molecular mechanisms involved in the pathogenesis of PCNSL and the identification of molecular biomarkers have lagged behind that of systemic nodal lymphomas. Primary central nervous system lymphomas are treated with combined radiotherapies and chemotherapies. The prognosis for PCNSL is worse than for other extranodal lymphomas.

PMID: 18976024 [PubMed - indexed for MEDLINE]

"Give us this day our daily bread"--evolving concepts in celiac sprue.

Arch Pathol Lab Med. 2008 Oct;132(10):1594-9

Authors: Upton MP

CONTEXT: Celiac sprue affects genetically susceptible individuals, who develop small intestinal injury and malabsorption following dietary exposure to gluten. The histologic features are nonspecific but characteristic. OBJECTIVES: To outline the histologic features of celiac sprue and the necessary clinical context to permit a diagnosis of celiac sprue, to assist the pathologist to identify artifactual biopsy changes that may mimic sprue, to define the differential diagnosis for conditions with a similar histology, and to review historic investigations of this disease. DATA SOURCES: Sources include the historic experiments and clinical work of members of the Gastroenterology Division of the Department of Medicine and experiences with gastrointestinal pathology consultation material at the University of Washington, Seattle, with reference to selected peer-reviewed articles. CONCLUSIONS: Confirmation of a diagnosis of celiac sprue is 2-fold: first, biopsy evidence of a characteristic, but nonspecific, pattern of injury including villous blunting or flattening, surface enterocyte damage, and increased intraepithelial lymphocytes; and second, dramatic clinical response to a gluten-free diet. Complete gluten removal from the diet is effective treatment for patients with symptoms of malabsorption; however, lifelong adherence to the diet is expensive, socially limiting, and nearly impossible on a contemporary diet with manufactured foodstuffs. Therefore, pathologists should avoid overdiagnosis of celiac disease based on minimal, nonspecific histologic changes.

PMID: 18834217 [PubMed - indexed for MEDLINE]

Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.

Arch Pathol Lab Med. 2008 Oct;132(10):1617-22

Authors: Wagar EA, Stankovic AK, Raab S, Nakhleh RE, Walsh MK

CONTEXT: Accurate specimen identification is critical for quality patient care. Improperly identified specimens can result in delayed diagnosis, additional laboratory testing, treatment of the wrong patient for the wrong disease, and severe transfusion reactions. Specimen identification errors have been reported to occur at rates of 0.1% to 5%. OBJECTIVE: To determine the frequency of labeling errors in a multi-institutional survey. DESIGN: Labeling errors were categorized as: (1) mislabeled, (2) unlabeled, (3) partially labeled, (4) incompletely labeled, and (5) illegible label. Blood specimens for routine or stat chemistry, hematology, and coagulation testing were included. Labeling error rates were calculated for each participant and tested for associations with institutional demographic and practice variable information. RESULTS: More than 3.3 million specimen labels were reviewed by 147 laboratories. Labeling errors were identified at a rate of 0.92 per 1000 labels. Two variables were statistically associated with lower labeling error rates: (1) laboratories with current, ongoing quality monitors for specimen identification (P = .008) and (2) institutions with 24/7 phlebotomy services for inpatients (P = .02). Most institutions had written policies for specimen labeling at the bedside or in outpatient phlebotomy areas (96% and 98%, respectively). Allowance of relabeling of blood specimens by primary collecting personnel was reported by 42% of institutions. CONCLUSIONS: Laboratories actively engaged in ongoing specimen labeling quality monitors had fewer specimen labeling errors. Also, 24/7 phlebotomy services were associated with lower specimen error rates. Establishing quality metrics for specimen labeling and deploying 24/7 phlebotomy operations may contribute to improving the accuracy of specimen labeling for the clinical laboratory.

PMID: 18834220 [PubMed - indexed for MEDLINE]

Nontuberculous mycobacterial infections.

Arch Pathol Lab Med. 2008 Aug;132(8):1333-41

Authors: Jarzembowski JA, Young MB

CONTEXT: Nontuberculous mycobacteria include numerous acid-fast bacilli species, many of which have only recently been recognized as pathogenic. The diagnosis of mycobacterial disease is based on a combination of clinical features, microbiologic data, radiographic findings, and histopathologic studies. OBJECTIVE: To provide an overview of the clinical and pathologic aspects of nontuberculous mycobacteria infection, including diagnostic laboratory methods, classification, epidemiology, clinical presentation, and treatment. DATA SOURCES: Review of the pertinent literature and published methodologies. CONCLUSIONS: Nontuberculous mycobacteria include numerous acid-fast bacilli species, many of which are potentially pathogenic, and are classified according to the Runyon system based on growth rates and pigment production. Their slow growth hinders cultures, which require special medium and prolonged incubation. Although such methods are still used, newer nucleic acid-based technologies (polymerase chain reaction and hybridization assays) can rapidly detect and speciate some mycobacteria--most notably, distinguishing Mycobacterium tuberculosis from other species. Infections caused by these organisms can present as a variety of clinical syndromes, not only in immunocompromised patients but also in immunocompetent hosts. Most common among these are chronic pulmonary infections, superficial lymphadenitis, soft tissue and osteoarticular infections, and disseminated disease. Treatment of nontuberculous mycobacterial infections is difficult, requiring extended courses of multidrug therapy with or without adjunctive surgical intervention.

PMID: 18684037 [PubMed - indexed for MEDLINE]