how the clinical laboratory enhances patient care
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How the Clinical Laboratory Enhances Patient Care. kscls. Fred V. Plapp, MD PhD Medical Director Saint Luke ’ s Regional Laboratories. kcclma. Patchwork of Knowledge. Diagnosis of Meningitis Expediting Patient Care. Infection of tissues surrounding the brain & spinal cord - PowerPoint PPT PresentationTRANSCRIPT
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How the Clinical How the Clinical Laboratory Enhances Laboratory Enhances
Patient CarePatient Care
Fred V. Plapp, MD PhDMedical Director
Saint Luke’s Regional Laboratories
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Diagnosis of MeningitisDiagnosis of MeningitisExpediting Patient CareExpediting Patient Care
Infection of tissues surrounding the brain & spinal cord
Bacterial or viral◦ Mostly viral
Viral usually mildBacterial is life-
threatening
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Diagnosis of MeningitisDiagnosis of MeningitisTraditional PracticeTraditional Practice
Patient presents to Emergency Room Lumbar puncture to collect CSF
◦Bacterial cultures require 3 days◦Viral cultures require 10 days
Patient admitted to hospitalTreated with IV antibiotics until likely
that bacterial culture will be negativeDischarged with outpatient antibiotics
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Viral MeningitisViral Meningitis Traditional DiagnosisTraditional Diagnosis
4 – 10 Days
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Viral MeningitisViral MeningitisReal Time PCR DiagnosisReal Time PCR Diagnosis
1 million viral copies in 30 minutes instead of 10 days
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New Meningitis AlgorithmNew Meningitis Algorithm
D ischarge
EnterovirusD etected
Adm it to H ospita l
EnterovirusN ot D etected
R T PC R w hile patient is in ER
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Meningitis OutcomesMeningitis OutcomesDownstream Cost SavingsDownstream 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 CoNSRapid ID of CoNSImproved Antibiotic Improved Antibiotic
StewardshipStewardshipPeptide 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 CoNSRapid ID of CoNSLab & Pharmacy Cost SavingsLab & 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 CoNSRapid ID of CoNSDownstream Cost SavingsDownstream Cost Savings
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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Recombinant rFVIIa UsageRecombinant rFVIIa UsageLaboratory as a WatchdogLaboratory 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 OutlierReining 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 SurgeryOpen Heart Surgery Transfusion ReviewTransfusion Review
OHS transfused ~one third of componentsClinical 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
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Ave
rag
e #
Un
its p
er P
atie
nt
RBC FFP Platelets
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Benefits of Decreased Benefits of Decreased TransfusionTransfusion$260,000 cost savings in blood
products per yearTransfusion reaction risks decreasedBlood Bank workload decreasedNursing time for transfusion
decreased
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Order SetsOrder SetsEnsuring Appropriate TestingEnsuring Appropriate Testing
Nurses & physicians write order setsClinical Pathologists review lab tests
◦Additions, deletions, substitutionsSuggestions returned to authorsOrder sets publishedTest utilization monitored before &
after
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70 Order Sets70 Order SetsImpact on Test UtilizationImpact 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 Inpatient Tests per DischargeDischarge
010
2030
4050
60
1Q94 1Q95 1Q96 1Q97 1Q98 1Q99 2Q00 1Q01 1Q02 1Q03 1Q04
75th percentile
25th percentile
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Specimen in Lab PolicySpecimen in Lab PolicyDecreasing WastageDecreasing 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 PolicySpecimen in Lab PolicySLH OutcomesSLH Outcomes
11,244 requests for tests on SIL
$51,726 savings in labor & supplies
Avoided 11,244 venipuncturesConserved 71,428 mL of blood
◦Equivalent to 140 units of RBCs
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POC Blood Glucose POC Blood Glucose TestingTesting
Improving Patient SafetyImproving Patient SafetyManual 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 ErrorsGlucose Meter ID Errors
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Err
or
Ra
te %
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Test Utilization IdeasTest Utilization Ideas www.clinlabnavigator.com