How the Clinical Laboratory Enhances Patient Care

1. How the Clinical Laboratory Enhances Patient Care kscls Fred V. Plapp, MD PhD Medical Director Saint Luke’s Regional Laboratories kcclma Patchwork of Knowledge

2. 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

3. 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

4. Viral MeningitisTraditional Diagnosis 4 – 10 Days

5. Viral MeningitisReal Time PCR Diagnosis 1 million viral copies in 30 minutes instead of 10 days

6. New Meningitis Algorithm

7. 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

8. 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 $$$$$

9. Rapid ID of CoNSLab & Pharmacy Cost Savings Cost per patient included antibiotics & laboratory tests

10. 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 Rapid ID of CoNSDownstream Cost Savings kscls kcclma Patchwork of Knowledge

11. 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

12. Reining in the Outlier

13. Open Heart SurgeryTransfusion 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

14. Average Number of UnitsTransfused per OHS Case

15. 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

16. 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

17. 70 Order SetsImpact on Test Utilization

18. Inpatient Tests per Discharge

19. 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

20. 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

21. 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

22. Glucose Meter ID Errors

23. Test Utilization Ideaswww.clinlabnavigator.com