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Creating value and improving patient safety – the role of the Lab Professional

Creating value and improving patient safety – the role of the Lab Professional. Dr Danielle B Freedman FiLM Feb 2011. Q1. What do users want from a lab service – Top10 aspects. What do users really want? Role of Laboratory interface Value of interpretative service

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Creating value and improving patient safety – the role of the Lab Professional

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  1. Creating value and improving patient safety – the role of the Lab Professional Dr Danielle B Freedman FiLM Feb 2011

  2. Q1 • What do users want from a lab service – • Top10 aspects

  3. What do users really want? Role of Laboratory interface • Value of interpretative service • ‘Demand management’ inappropriate testing/non testing • ‘24 hour cover’ Effective use of POCT Patient Safety

  4. The Problems Too many tests Different names Different units Different reference intervals Different alert limits Inconsistent guidelines

  5. What do our users want from Laboratory Medicine? Information to allow clinicians to make better decisions about patients Patient safety Clinical governance, accountability, accreditation Demand management. Investigations need to becheap, quick and correct. “New” tests Right investigation on the right patient at the right time Result needs to get to the right clinician at the right time using the right medium Right interpretation and right patient outcome

  6. What interests Practice Based Commissioners • Care Closer to Home eg Warfarin monitoring • Care pathways and pathology tests eg eGFR and Primary Care management of chronic kidney disease • Collection of specimens and electronic reporting of results • Need to establish clinical dialogue with laboratories • Development of Point of Care Testing • Patient safety J Crockett CEO, Wolverhampton City PCT 2008

  7. Consolidation • Diagnostics “nearer the home” • Diagnostics provided by ‘others’ ? Fragmentation of service

  8. Primary Care Clinical Advice Questionnaire S Beds 2009 Q. Did Clinical Advice on Interpretation aid in patient management? 110 respondents

  9. Comments: ‘Particularly useful in obtaining advice when testing for endocrine disorders’ ‘A1 Service’ ‘GP provider link is excellent’ ‘Knowing there is someone to ask can save inappropriate investigations & unnecessary referral’s’ ‘Dr Freedman very helpful & always return calls promptly’

  10. Are endocrine comments useful to GPs? IM Barlow Ann Clin Biochem 2008; 45: 88–90

  11. TFT comments affecting patient management Percentage feeling comments (very) frequently helping/influencing patient management IM Barlow Ann Clin Biochem 2009; 46: 85–86

  12. Objective evidence of the benefit of interpretative comments Provision of interpretative comments to GPs has led to: 22% reduction in inadequate thyroxine replacement in samples from hypothyroid patients ~500 more patients adequately treated after introducing comments Kilpatrick Ann Clin Biochem.2004:41:225-7

  13. Getting the most from your Pathology Lab’National Association of Primary Care Review April 2009Housley D & Freedman DB. ‘ Outpatient referral MRI Patient experience of an incorrect pathological diagnosis “Emphasis on laboratory role on interpretation … computer generated comments according to predetermined rules; comments on reports or by dialogue at bedside or by phone …” e.g.  PRL Reflex testing - Macroprolactin - Comment Avoids

  14. Survey of East of England GP Commissioning Groups

  15. Survey of East of England GP Commissioning Groups

  16. Conclusion • Pathology and laboratory services need to become more ‘dynamic’ and responsive to needs of patients, 1° care clinicians and commissions • Community pathology services should receive higher profile in commissioning and need dialogue PBC, PCTs and pathologists • Improve access to phlebotomy • Test ordering – education and training and feedback or behaviour, clinical guidelines • Accreditation – governance infrastructure • POCT • Patient Safety

  17. Q2 • What points in TTP have highest incidence of errors ?

  18. Patient Safety and Pathology Pre Analytical right test right patient right label ‘request form’ right sample right lab right conditions - temperature Analytical EQA Accrediation (CPA) Post Analytical right result right patient right clinican right communication right interpretation right Mx and further investigations

  19. “patients who are acutely ill are often cared for by most junior medical staff who have least knowledge and experience”

  20. BMA News, 2 June 2007 (letter) T-bone stake “…It reminded me of the occasion when a FY2 rang while I was on call to inform me that he had seen a patient with a broken forearm – but did not know the anatomical name for the bone. At a guess it started with the letter “T”, he said. I dashed to the patient’s side to clarify that the patient had actually injured what I was envisaging and was in no danger. The FY2 had never sat a formal anatomy exam, nor had he undergone formal dissection/pro-section lessons at medical school…”

  21. “How confident are you in requesting laboratory tests?”

  22. “How confident are you on interpreting laboratory tests?”

  23. Labs Are Vital™ Media Monitoring and Successful Results

  24. What points in the process have the highest incidence of errors? Bar coding? Specimen collection? Specimen Analysis? Results reporting? NO Laposata 2008

  25. What points in the process have the highest incidence of errors? Test selection by clinicians? Interpretation of test results by clinicians? YES Laposata,2008

  26. Types and relative frequency of errors in the different phases of the TTP Phase of the TTP Relative Frequency (%) Pre-pre-analytic 46 – 68.2 25 - 45.5 Post-post-analytic Plebani M Ann Clin Biochem 2010, 47: 101-110

  27. Post-post analytical errors: frequency of incorrect interpretation of diagnostic tests in different clinical settings Setting Primary Internal Emergency care medicine department Incorrect interpretation of diagnostic tests: estimate (%) 37 38 37 Plebani M , Ann Clin Biochem 2010 : 47 101-110

  28. Safe care measures “avoiding injuries to patients from the care that is intended to help them” Commonwealth Fund, 2010

  29. “No point in requesting a test if no-one looks at the results and/or acts on the result…” Kilpatrick and Holding BMJ 01 Delay Accident and Acute Medical emergency department admissions ward (n=3228) (n=1836) Within 1 hour 794 (25)% 412 (22)% 1-3 hours 491 (15)% 341 (19)% Over 3 hours 500 (15)% 553 (30)% Never 1443 (45)% 529 (29)% Of 1443 A & E results – 43 (3%) could have led to an immediate change in management

  30. Audit of Emergency Department at the Luton & Dunstable Hospital: Results reported and reviewed for a 24 hour period Results not reviewed within one hour 50% [of which 89% were outside reference interval] Not within 2 hours 26% Not within 3 hours 14% Not at all 10% 17 Feb 2010

  31. Disconnect between Lab Alerts & Follow UpSingh et al. Am J Med 2010: 123:238-244 Out Patient results May – Dec 2008 Hb Aic ≥ 15% positive hepatitis C antibody PSA ≥ 15 ng / ml TSH ≥ 15 MU / l 10.2% of alerts unacknowledged ‘Multidisciplinary interventions involving human – computer interaction and highly reliable tracking systems to monitor test result notification outcomes are needed to alleviate patient safety concerns’

  32. Frequency of failure to inform patient of clinically significant outpatient test results Failure to inform outpatients of significant abnormal test results 1 in 14 tests e.g. Cholesterol = 8.3mmol/ L Potassium = 2.6 mmol / L Casalino et al Arch Int Med: 2009 169.1123-9

  33. Critical Value Reporting ISO EN15189 :2007 … “ immediate notification of a critical value is a special requisite” CPA (UK) Ltd … “ critical value reporting is essential to ensure Quality of diagnostic laboratory services” Joint Commission NPSG 2010 ... “report critical results on a timely basis”

  34. A Way Forward: Critical Value Reporting Need for consensus critical values list Surveys for comparing and improving existing policies regarding critical values should be promoted at an INTERNATIONAL LEVEL Piva, Sciacovelli, Plebani & Laposata Clin Chem Lab Med 2010: 48:461-8

  35. Q3 • Top 10 Quality Indicators, in general terms

  36. “What is Quality in Pathology”12/13th Oct 2010 • www.rcpath.org/resources/pdf/rcpath_quality_meeting_draft_13.pdf • RCPath response to Ian Barnes letter “Reconfiguration of NHSPathology Services “ July 2010

  37. Q4 • Egs of Pre and Post analytical input has made a difference to patient outcome • ( excluding cell path/morphology/antibiotic sensitivity)

  38. Role of Laboratory Interface Clinical Vignette 48 year old male GP routine bloods Grossly lipaemic – triglyceride = 130 mmol/l (<1.9) DBF D/W GP – known alcoholic ? Risk of pancreatitis (from etoh and trigs) Commence ciprofibrate 100 mg od Cease etoh Suggest referral ASAP to hepatologist Avoidance of acute admission and potential morbidity

  39. Clinical Vignette 56 year old Chinese male (poor historian) Previous A&E attendance with 1/52 headache – given some medicine Since then generally unwell – sweating, ? Weight loss GP requested TFT – fT4 = 6 pmol/l, TSH = 1.23 mU/l TSH inappropriate for fT4 – lab add other Ix Sodium = 128 mmol/l Other U&E NAD Cortisol (08:30am) = 108 nmol/l Prolactin 167 mU/l Testosterone = 2.9 nmol/L LH = 1.9 U/l, FSH = 2.8U/l Hydrocortisone cover advised, followed by replacement of other axes – Urgent Chemical Pathology OPD arranged with GP. Infarcted pituitary adenoma confirmed. Avoidance of acute admission and potential morbidity.

  40. Clinical Vignette • Patient presents to GP with bruising and nose bleeds • Platelet count <20 • Consultant haematologist speaks to GP to start Prednisolone immediately at 7pm on Friday • - prevent inpatient admission and potential morbidity • Microbiologist authorising reports 2 children with MRSA from swabs collected for ?otitis externa • Both patients from same surgery seen 2 hours apart • Discussion with GP revealed insufficient attention to cleaning ear pieces and issues around hand hygiene

  41. “Before ordering a test, decide what you will do if it is either positive or negative, and if both answers are the same, then don’t do the test!” Reference ranges Factors influencing the result Interpretation Further investigations ‘Delivery’ of results

  42. Clinical Vignette 28 year old male GPrequests routine investigations at 6pm Friday night, processed in lab at 7pm: Sodium = 116 mmol/l (136 – 148) Potassium = 1.9 mmol/l (3.8 – 5.0) Urea <0.3 mmol/l Creatinine = 81 mol/l Only clinical details available ‘alcoholic’ ? Beer potomania Emergency admission arranged by DBF via GP

  43. 45 year old femaleCholesterol 8.2mmol/L despite being on Simvastatin 40mgGP phoned Clinical Biochemistry Diagnosis: Primary biliary cirrhosis Cost to Purchasers? Cost to patient? Value to the whole health economy? Comment: • Excludesecondary causes of hypercholesterolaemia • Liver tests demonstrated ALP = 350 IU/L [25 – 120] • Prior to starting Statin ALP = 340 IU/L • Further investigations: Antimitochondrial antibodies , U/S Liver, Liver biopsy

  44. Cost to the health economy Outpatients: New : £200 F/U : £100 Admission Acute: £1150 + Market forces 16% Luton 30% + London HDU :£1000/ day + Market forces ITU :£2000 / day + Market forces

  45. Q5 • IT supporting the clinical role of the lab

  46. For use in Consultant led hepatology or gastroenterology clinics only. Requests from other sources will be reviewed and may be rejected. Multi-disciplinary investigation strategies agreed between users and diagnostic departments save clinician time and reduce variation.

  47. Ordering by clinical condition with defined options for primary care reduce inappropriate tests and reduce variation in practice.

  48. Tests linked to diagnostic algorithms at time of order promote appropriate investigations, ensure adequate investigation and improve compliance with care pathways.

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