How the Clinical Laboratory Enhances Patient Care

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How the Clinical Laboratory Enhances Patient Care
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kcclma
Patchwork of Knowledge

• Fred V. Plapp, MD PhD
• Medical Director
• Saint Lukes Regional Laboratories

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Diagnosis of MeningitisExpediting Patient Care

• Infection of tissues surrounding the brain
  spinal cord
• Bacterial or viral
• Mostly viral
• Viral usually mild
• Bacterial is life-threatening

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Diagnosis of MeningitisTraditional Practice

• Patient presents to Emergency Room
• Lumbar puncture to collect CSF
• Bacterial cultures require 3 days
• Viral cultures require 10 days
• Patient admitted to hospital
• Treated with IV antibiotics until likely that
  bacterial culture will be negative
• Discharged with outpatient antibiotics

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Viral Meningitis Traditional Diagnosis
4 10 Days
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Viral MeningitisReal Time PCR Diagnosis
1 million viral copies in 30 minutes instead of
10 days
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New Meningitis Algorithm
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Meningitis OutcomesDownstream Cost Savings

• Traditional Approach
• Average LOS is 2.8 days
• Average hospital charge is 14,050
• IV antibiotics during admission
• Outpatient antibiotics for 10 14 days
• SLH Molecular Approach
• Avoid admission if Enterovirus detected
• Avoid unnecessary antibiotics

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Rapid ID of CoNSImproved Antibiotic Stewardship

• Peptide Nucleic Acid FISH
• Non-amplified fluorescent molecular probe
• Recognizes species specific RNA
• Distinguishes Coagulase Negative Staph from Staph
  aureus
• Advantages
• Timely accurate same day results
• Minimal equipment requirement
• Other probes for Gram-negatives yeast
• Disadvantages
• Expensive cost per test
• Must batch test due to

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Rapid ID of CoNSLab Pharmacy Cost Savings
Time to ID Antibiotic Dose per Patient Cost per Patient
Culture Alone 132 hours 5.8 72.02
Culture PNA 38 hours 2.8 14.28
Cost per patient included antibiotics
laboratory tests
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Rapid ID of CoNSDownstream Cost Savings
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• SLHS performed 23,652 blood cultures in 2009
• 452 contaminants (1.9)
• 350 were CoNS
• Each contaminant adds 5000 to cost of hospital
  stay
• Rapid ID of CoNS saves 1.75M per year by
  preventing ? LOS

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Patchwork of Knowledge
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Recombinant rFVIIa UsageLaboratory as a Watchdog

• Recombinant Factor VIIa (Novoseven)
• Binds directly to tissue factor activates FX
• FDA approved for hemophilia with acquired
  inhibitor
• Off label use for acute bleeding ?
• Very expensive ( 1 per ug)
• Short half-life of 2-3 hours
• Possible thromboembolic events

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Reining in the Outlier
Surgeon 1Q09 1Q10
1 5450 0
2 0 0
3 0 0
4 0 12,220
5 98,690 16,000
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Open Heart Surgery Transfusion Review

• OHS transfused one third of components
• Clinical Pathologist analyzed blood usage each
  year
• Surgeon specific usage
• Reviewed with CTS team
• Evaluated risk factors, meds,practice variations
• Published transfusion guidelines risks
• Presented to surgeons, Department Chair, Chief
  Medical Officer

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Average Number of Units Transfused per OHS Case
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Benefits of Decreased Transfusion

• 260,000 cost savings in blood products per year
• Transfusion reaction risks decreased
• Blood Bank workload decreased
• Nursing time for transfusion decreased

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Order SetsEnsuring Appropriate Testing

• Nurses physicians write order sets
• Clinical Pathologists review lab tests
• Additions, deletions, substitutions
• Suggestions returned to authors
• Order sets published
• Test utilization monitored before after

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70 Order SetsImpact on Test Utilization
Year Cases/Yr Tests/Cs Test/Yr
1992 8823 50.3 443,797
1996 9630 44.3 426,609
Diff 807 -6 -17,188
Diff 9 -12 -4
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Inpatient Tests per Discharge
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Specimen in Lab PolicyDecreasing Wastage

• Worked with Blood Management Team to reduce
  iatrogenic blood loss
• SIL Policy implemented
• Stored blood specimens for 1 week
• Publicized in Lab Letter Nursing publications
• Avoided redrawing patients for add-on testing

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Specimen in Lab PolicySLH Outcomes

• 11,244 requests for tests on SIL
• 51,726 savings in labor supplies
• Avoided 11,244 venipunctures
• Conserved 71,428 mL of blood
• Equivalent to 140 units of RBCs

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POC Blood Glucose TestingImproving Patient Safety

• Manual Patient ID entry
• 12,000 tests per month
• 9.7 average error rate
• 450 unidentified results per month
• PI project to reduce errors
• Accu-Chek Inform RALS Plus
• Barcoded armbands handheld devices

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Glucose Meter ID Errors
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Test Utilization Ideas www.clinlabnavigator.com