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Report of Pre-analytical Processes
at Toronto East General Hospital
(Submission for CLMA Pre-analytical Excellence Award)
Marilyn Spagnoli, MLT, ART, BTech, MHS
Director, Laboratory Services
Toronto East General Hospital
February 27, 2012
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INTRODUCTION
Toronto East General Hospital (TEGH) is a 515-bed, urban, full service
community teaching hospital comprised of acute care, rehabilitation, complex continuing
care, and mental health beds, as well as ambulatory, emergency, diagnostic and
laboratory services. On an annual basis, TEGH has over 60,000 emergency visits, over
20,000 acute care admissions, delivers approximately 3500 babies, and serves the needs
of over 220,000 patients within its ambulatory care programs.
The department of Laboratory Medicine embraces the hospital’s vision to be the
leader in quality and value. A quality management system serves to articulate all
policies/processes/procedures while maintaining records of quality activities. Our
success in laboratory pre-analytical processes exemplifies our commitment to the
hospital’s mission and deep-seated accountability framework and success factors: patient
focus, ensure value, encourage people, collaborative spirit and inspire innovation.
Laboratory processes (pre-analytical, analytical and post-analytical) are patient focused
as we strive for safety, quality, and timeliness. The efficiencies created ensure value and
appropriate use of resources. We appreciate our people and have made the investment in
training, communication and healthy, safe workplace. Our excellence is a result of
extensive collaboration within and between departments and with our vendor partners.
Technology has enabled significant innovation; however, creativity, training and
communication have a major role. This report presents an integrated approach, with a
combination of preanalytical processes, to improve patient safety and ensure high quality
laboratory results.
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PRE-ANALYTICAL PROCESSES:
Electronic Order Entry
Laboratory orders are placed on the nursing units using the hospital information
system (HIS). Specimen labels are generated via the laboratory information system (LIS)
based on the orders placed in the HIS as translated to the LIS by an orders interface. The
specimen tube types and volumes required are set in the LIS and the appropriate labels
are then generated accordingly. Building the orders interface required extensive
collaboration between laboratory staff, information technology services and patient care
areas to ensure appropriate order entry processes were in place before processes were
converted to electronic formats. The concept of order sets was created to provide an
intuitive ease of ordering for the end user while managing utilization of laboratory tests.
Electronic laboratory order entry has been in place for over a decade, where nursing or
clerical staff would input physician’s orders. Such electronic order entry processes
served to build a sound foundation for the computerized provider order entry (CPOE).
In 2010, CPOE was implemented hospital wide. Laboratory resources were
integrally involved in the planning and implementation of the project. Order sets were
standardized in consultation with laboratory leaders to strengthen appropriate utilization.
Planning and implementation of this project included physician participation,
redundant/downtime plans, extensive training, extensive change management and
physician adoption strategies. CPOE has improved clarity in physician’s orders,
utilization and standardized care. Improved efficiencies have resulted in more
appropriate use of resources and improved timeliness of laboratory results. This initiative
is an enabler of patient safety, increasing the quality of patient care through standardized
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order sets that support best practices. The system supports availability of active clinical
decision support and reminders. Work flow is improved through streamlined care
processes and reduced turnaround times for patient investigations and therapies.
Improved communication between clinicians and the system strengthens training of
locums or trainees for adoption of best practices. CPOE also provides the opportunity for
remote access to order entry. Overall, CPOE supports data driven clinical and
management decision making.
Patient identification
Patient identification mishaps are the greatest source of error for laboratories. At
TEGH, patients are uniquely identified using a hospital identifier on an armband. The
hospital has a policy that emphasizes positive patient identification using at least two
client identifiers prior to the provision of any service or procedure. Patient identification
is sought proactively versus retrospectively; wherever possible, the patient is involved in
the identification process. For personal information such as the patient’s name or date of
birth, the patient is asked to state the information in its entirety, rather than asking for a
passive agreement. Acceptable patient identifiers include the patient’s name (first, middle
and surname), date of birth, hospital number and/or the patient’s health card number.
Positive patient identification protocols are imparted during clinical orientation sessions
for new employees and are regularly communicated by nursing practice leaders to ensure
adherence to the policy.
Recent improvements in the health card validation process have also strengthened
patient identification efforts. Staff are now able to validate the patient’s health card
number through the HIS. If there are discrepancies between the information provided by
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the Ministry of Health and information in the HIS, a window appears displaying both sets
of information. Staff reviews both lists to identify the mismatch and then copy the
Ministry information into the HIS. Information compared includes: patient name(s),
gender and date of birth.
Specimen Collection
In order to achieve the highest quality of laboratory results, specimens must be
submitted correctly. Specimen rejections are often due to inappropriate submission or
incorrect specimens.
The hospital employs a dedicated phlebotomy team collection model for routine
in-patient and out-patients. However, a nurse collection model exists in Emergency and
in critical care areas. Education on specimen collection and general laboratory
information is provided to clinical staff as part of orientation and on an ongoing basis to
reinforce compliance. An on-line specimen collection manual and specimen dictionary is
readily available through the hospital intranet. These documents reflect the most current
versions as they are directly linked to the laboratory’s quality management document
control system.
Labels for specimen collection indicate the required specimen tube type for the
requested test and the multiple tube/containers required. Barcode technology is used on
the label to enable a fully automated laboratory system.
Recently, a Lab Roadshow was used to demonstrate the specimen collection
containers and their appropriate application (see Appendix A). The ‘Lab Roadshow’
visited all nursing areas to make for a short presentation. Additional sessions were
available on request and targeted sessions were also arranged for areas that were trending
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higher numbers of specimen rejections. Laminated posters were also created to depict
appropriate specimen collection containers which were posted in clean utility rooms for
ongoing reference. A reduction in the number of specimen rejection was observed
following these interventions (see Appendix B).
When specimen submissions are incorrect, an electronic incident reporting system
facilitates easily accessible reporting. The hospital supports a ‘just culture’ of patient
safety and encourages reporting of all incident and adverse events. Incident reporting
pertaining to laboratory testing is categorized as pre-analytical, analytical and post-
analytical. Incident reports are referred to risk management and back to the departments
involved to identify root causes, trends, patterns and corrective action plans where
required.
Transport
The importance of timely transport to the laboratory cannot be understated. A
pneumatic tube system links several key areas such as Emergency, critical care areas and
oncology, with the receiving area of the laboratory. The tube system is maintained and
monitored regularly to ensure specimen integrity. A portering system is used for other
areas and for those specimens not able to be transported by the tube. An electronic tele-
tracking system is used to ensure appropriate prioritization and accountability for
transport.
Technology: Preanalytical Laboratory Automation
In 2011, the Roche Modular Pre-analytical Automation (MPA) was fully
implemented to receive, centrifuge, aliquot and sort all laboratory specimens. Despite
only the chemistry analyzers being fully integrated, all core lab blood work is received
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and processed using the automation. Specimens are sorted by a technician on designated
racks and then directly loaded onto the instrument. The technology is fully interfaced
with the HIS, LIS and the connected analyzers. Specimen receipt in the lab is
acknowledged in the patient record via the interface. Decapping, centrifuging, and
aliquotting are automated, on-line as defined in the interface according to test
requirements. A laboratory technician is responsible for overseeing the pre-analytical
technology and addressing any errors/alarms as they occur. The automation requires
minimal maintenance; however, a certain comfort level is required for acceptance.
Extensive training and support for all staff was provided by the vendor prior to
implementation. Training included both didactic and hands-on education. The uptake by
the lab technician group was exceptional as this group had limited exposure and
experience with such advanced technology.
The MPA has allowed continuous processing, eliminating the need for interrupted
loading of stat specimens. It has also limited the use of batch testing thus reducing
manual intervention of storage and retrieval. The automation has significantly increased
the speed at which patient samples are processed in the sample receiving area.
Diminished reliance on technical staff for manual tasks has allowed technologists to
concentrate on more specialized tasks. This fully automated platform has allowed the
laboratory to absorb increased volumes without increasing staff. It is ergonomically
sound, thus eliminating many of the staff health and safety risks associated with manual
sample handling. The system also keeps the primary tubes “pristine” to ensure that
samples are not contaminated, thereby reducing potential sampling errors. In addition to
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the pre-analytical advantages, the system automatically archives samples for ease of
retrieval.
EVIDENCE
Traditionally, turnaround times for laboratory results have served as the principle
performance indicator. In looking for other meaningful measures we adopted a strategy-
in-a-page process. Multiple stakeholders worked collectively through the process to reach
the ultimate goal of consistently providing timely high-quality lab results. The primary
gap was consistency and predictability in our turnaround time. Contributing factors were
identified under three categories: equipment/technology, people, and processes. Tactics
for improvement included: improved communication, expanding use of the MPA,
training, and minimizing downtimes. Metrics for the tactics were identified and captured
as lead metrics. Lead metrics, associated more closely with inputs, measure the tactics
used to achieve our goal. Lag metrics measure the end result or outputs, which we
determined to be the test result turnaround times (see Appendix C). Average turnaround
times and predictability generally exceed benchmarks. Upon further investigation for
continuous improvement, delays were found to be predominantly due to instrument
downtimes, barcode reader malfunctions and/or staffing transition times.
Metrics are reported daily at the departmental huddle each morning. Huddles
provide an effective venue for communicating issues and problems as well as positive
corroboration for successes. Continuous improvement is the main goal. Metrics are
reviewed on a regular basis and changed as goals are achieved and other opportunities for
improvement are identified. The laboratory huddle is well attended by staff and with
exceptional enthusiasm. Ideas are solicited and welcomed for additional process
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improvements. Such departmental huddles are held throughout the hospital and staff are
encouraged to visit other unit’s huddles to engage in system wide collaboration.
Members from the hospital executive team regularly visit the laboratory huddle imparting
acknowledgment and support.
Improvement plans are prepared collectively and shared with all staff to empower
and engage staff in their respective areas. Laboratory staff feel valued when they
understand the organization’s commitment to improving pre-analytical processes.
Laboratory accomplishments are clearly demonstrated by the metrics and staff feels a
sense of pride. Laboratory technicians are empowered to function at a higher level while
within their scope of practice. In a recent staff satisfaction survey, results indicated a high
level of employee commitment and overall satisfaction. Effective change management,
communication and training for implementing significant technology changes have all
contributed to these results.
CONCLUSION
Understanding the importance of pre-analytical processes and collaboration across
the organization has led to ongoing improvements. The organization continues to adopt a
comprehensive approach to ensure the highest quality laboratory results with the
implementation of best practices and technology. Future work is planned to use barcode
technology for positive patient identification and specimen collection to further enhance
patient safety. The organizational culture of continuous improvement enables patient
safety and quality improvement initiatives. Support from senior management has allowed
the laboratory to excel and raise its profile as an essential contributor to patient care and
safety.
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APPENDIX A- ‘LAB ROAD SHOW’
The “Lab Road Show” cart is used to provide ‘show and tell’ about specimen collection. The cart
displays an assortment of specimen containers and is used to communicate specimen collection
information. The communication was conducted initially by a laboratory manager together with a
lab technician and later only by lab technicians. The cart was also used to distribute laminated
posters of the collection which were posted in clean utility rooms for ongoing reference.
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APPENDIX B- SPECIMEN REJECTIONS
Specimen rejections have decreased. Initiatives such as the ‘Lab Road Show’ and other
targeted education sessions have contributed. Ongoing communication and education is
required to sustain and further reduce rejections. *Data does not include rejections for Pathology,
Blood Bank and Coagulation Labs.
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APPENDIX C – TURNAROUND TIME METRICS
Figure 1. Average turnaround time for complete blood cell counts (CBC) for 2011 (time of receipt in lab to time verified)
The target for predictability is that 85% of stat CBC tests are verified within the target average TAT (45 min form Jan –Apr;
30 min. from May-Dec). Commencing March 2011, CBC tests were received using the MPA and manually transferred to
CBC analyzer. Based on successes, the target was reduced from 45 min. to 30 min. in May.
Figure 2. Predictability of turnaround time for CBCs for 2011 (time of receipt to time verified)
The target for predictability is 85% of stat CBC tests are verified within the target average TAT (45 min form Jan –Apr; 30
min. from May-Dec). The predictability dropped slightly when the target was reduced to 30 min. in May.
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Figure 3. Average turnaround time for Electrolytes (Na, K, Cl, CO2) for 2011 (time of receipt to time verified)
The target for average TAT of electrolytes is 45 min.
Routine chemistry testing was integrated on the MPA in Nov 2010. Average TAT was consistently at or below the 45
minute target. The average TAT dropped further once all core lab specimen were received using the MPA due to
standardized processing.
Figure 4. Predictability of turnaround time for Electrolytes (Na, K, Cl, CO2) for 2011 (time of receipt to time
verified)
The target for predictability is 75% of stat electrolytes tests are verified within the target average TAT of 45 min.
Predictability was trending close to target and exceeded the target once standardized processing came in effect.
