Managing the pre- and post-analytical phases of the total testing process

Application Effectiveness of a Pre-Analytical Quality Management Pathway Based on the Structure-Process-Outcome Model

Objective

This single-center, before-and-after study applied the structure-process-outcome (SPO) model to pre-analytical quality control to investigate its effect on laboratory testing quality, nursing practices, patient satisfaction, and clinician trust in test results.

Methods

A before-and-after design was conducted in a provincial Class A tertiary hospital. The control group (April-September 2022) and observation group (April-September 2023) each included all laboratory specimens and 550 clinical nurses (from the same wards). The SPO-guided pre-analytical quality management pathway involved forming a multidisciplinary team, establishing a grid management system, implementing a non-punitive reporting system, standardizing specimen collection, and developing a quality management information system. Groups were compared on non-compliant test sample rates, nurses' knowledge, beliefs, and behaviors, operational standardization, patient satisfaction, and clinical doctors' trust. Data were analyzed using t-tests (with effect sizes) and χ²-tests; confidence intervals and multiple-comparison corrections were also applied.

Results

The observation group showed significantly lower rates of non-compliance in sample type, collection container, volume, contaminated blood cultures, and coagulated samples (all p < 0.01, with 95% confidence intervals). Nurses' knowledge (Cohen's d = 0.44) and behaviors (Cohen's d = 1.56) improved significantly. Operational standardization (92.5 ± 3.2 vs 85.7 ± 4.1), patient satisfaction (93.8% vs 87.2%), and clinical doctors' trust (91.2% vs 84.5%) also increased significantly (p < 0.01).

Conclusion

The SPO-based pre-analytical quality management pathway significantly improved non-compliant sample rates, nurses' knowledge and behavior, operational standardization, patient satisfaction, and clinical trust in test results. This approach may serve as a reference for other institutions aiming to enhance pre-analytical quality management.

Competence of healthcare professionals performing electroencephalography test: A systematic review

Objective

To describe the EEG competence of healthcare professionals and how this competence has been measured in previous literature.

Methods

A systematic review following the preferred Reporting Items for Systematic Reviews and Meta-Analyses. A literature search was conducted in CINAHL, PubMed, Scopus, and Web of Science databases focusing on studies that empirically examined the EEG competence of healthcare professionals.

Results

A total of 28 studies were included. EEG competence consists of two main categories: knowledge and skills of EEG, and attitudes and values towards EEG. The EEG competence of healthcare professionals was assessed in three different settings: tests, simulations, and real life. The data collection methods were knowledge tests, self-assessments, and observations. The tools were developed by a researcher(s) for the single study and were not psychometrically tested.

Conclusion

EEG competence is a multidimensional concept that includes knowledge, skills, attitudes, and values that need to be considered when defining EEG competence and developing tools to measure it.

Significance

This systematic review provides information to the educators of healthcare professionals and healthcare organizations involved in developing comprehensive EEG training programs and assessments to foster professional development and ensure reliable diagnostic test results for patients.

From errors to excellence: the pre-analytical journey to improved quality in diagnostics. A scoping review

This scoping review focuses on the evolution of pre-analytical errors (PAEs) in medical laboratories, a critical area with significant implications for patient care, healthcare costs, hospital length of stay, and operational efficiency. The Covidence Review tool was used to formulate the keywords, and then a comprehensive literature search was performed using several databases, importing the search results directly into Covidence (n=379). Title, abstract screening, duplicate removal, and full-text screening were done. The retrieved studies (n=232) were scanned for eligibility (n=228) and included in the review (n=83), and the results were summarised in a PRISMA flow chart. The review highlights the role of healthcare professionals in preventing PAEs in specimen collection and processing, as well as analyses. The review also discusses the use and advancements of artificial intelligence (AI) and machine learning in reducing PAEs and identifies inadequacies in standard definitions, measurement units, and education strategies. It demonstrates the need for further research to ensure model validation, address the regulatory validation of Risk Probability Indexation (RPI) models and consider regulatory, safety, and privacy concerns. The review suggests that comprehensive studies on the effectiveness of AI and software platforms in real-world settings and their implementation in healthcare are lacking, presenting opportunities for further research to advance patient care and improve the management of PAEs.

BRCA Mutation Testing in Men with Metastatic Castration-Resistant Prostate Cancer: Practical Guidance for Australian Clinical Practice

Some patients with metastatic castration-resistant prostate cancer (mCRPC) possess germline or acquired defects in the DNA damage repair (DDR) genes BRCA1 and BRCA2. Tumors with BRCA mutations exhibit sensitivity to poly-ADP ribose polymerase inhibitors (PARPi) such as olaparib and rucaparib. As a result, molecular diagnostic testing to identify patients with BRCA mutations eligible for the PARPi therapy has become an integral component of managing patients with mCRPC. There are practical challenges in the current molecular testing pathway in Australia that can compromise testing success. Testing success is often contingent on quality of tissue handling and laboratory processing techniques to minimize DNA degradation and suboptimal sequencing data quality. Greater adoption of best testing practices in Australia can be facilitated with education and greater awareness of expert recommendations. Here, we provide expert recommendations on how to optimize BRCA molecular diagnostic testing in patients with mCRPC. Optimization and standardization of molecular diagnostic testing will support health care providers and institutes in establishing more efficient testing pathways, enabling access to targeted therapies such as PARPi, and improving patient outcomes.

From the Operating Theater to the Pathology Laboratory: Failure Mode, Effects, and Criticality Analysis of the Biological Samples Transfer

Introduction: The frozen section intra-operative consultation is a pathology procedure that provides real-time evaluations of tissue samples during surgery, enabling quick and informed decisions. In the pre-analytical phase, errors related to sample collection, transport, and identification are common, and tools like failure mode, effects, and criticality analysis help identify and prevent risks. This study aims to enhance patient safety and diagnostic quality by analyzing risks and optimizing sample management. Materials and Methods: The failure mode, effects, and criticality analysis was conducted by a multidisciplinary team to analyze the workflow of frozen section sample handling from collection in the operating theater to acceptance at the pathology lab. Six steps were identified, each assigned tasks and responsibilities, with risks assessed through the risk priority number, calculated from severity, occurrence, and detectability. Severity was classified based on the WHO framework, ranging from "No Harm" to "Death", to prioritize risks effectively. Results: The study identified 12 failure modes across 11 sub-processes, prioritized by risk. Key failures included missing patient identification, incorrect sample retrieval, missing labels, misdirected samples, and samples sent to the wrong lab. Discussion: Pre-analytical errors in pathology pose risks to diagnosis and patient care, with most errors occurring in this phase. A multidisciplinary team identified key issues, such as sample mislabeling and delays due to staff unavailability, and implemented corrective actions, including improved signage, staff re-training, and sample tracking systems. Monitoring and regular checks ensured ongoing adherence to protocols and reduced the risks of misidentification, transport delays, and procedural errors. Conclusions: The frozen section intra-operative consultation is vital in surgical pathology, with the pre-analytical phase posing significant risks due to potential errors in sample handling and labeling. Failure mode, effects, and criticality analysis has proven effective in identifying and prioritizing these failures, despite resource demands, by allowing corrective actions that enhance patient safety and healthcare quality.

The Italian external quality assessment program for Cystic Fibrosis sweat chloride test: CFTR modulators and the impact of a new sweat test report form

Background

The advent of CFTR modulators highlighted that the sweat test (ST) for CF can be used also as an outcome measure for the basic defect of CFTR. Despite the technological advances, ST still remains operator-dependent and its execution should be strongly paired with guidelines. In 2022, due to the advent of CFTR modulators, the Italian CF Society introduced a specific ST report. The aim of the present paper is to discuss the impact of this new report in the 2022-23 round of the Italian External Quality Assessment program for ST (I-EQA-SCT).

Methods

The scheme of the I-EQA-SCT is prospective, enrolment is voluntary, the payment of a fee is required and results are shared through a web-facility. Assessment covers analysis, interpretation, and reporting of results. In the 2022-23 round, 2 out of the 3 mock clinical information referred to patients who started modulators.

Results

Fourteen laboratories completed the 2022-23 I-EQA-SCT round. Three of them failed in the interpretation of results from these two mock cases and/or used a wrong report not consistent with the more recent Italian Sweat Test Recommendations.

Conclusions

The overall results obtained from the laboratories involved in the I-EQA-SCT program clearly showed that the laboratories' qualitative and quantitative performance improved significantly. Results emerged from this round highlighted an issue in the report form used for monitoring patients on CFTR modulator therapy thus stressing the importance of these programs in improving both the performance of lab services and ameliorating the sweat test recommendations.

Laboratory reflex testing strategy for the early identification of primary care patients with multiple myeloma

OBJECTIVES

Our objective was to shorten the screen for multiple myeloma (MM), through reflex testing.

DESIGN AND METHODS

The clinical laboratory in the public University Hospital of San Juan (Alicante, Spain), serves 234,551 inhabitants. Through an intervention agreed with general practitioners, the Laboratory Information System (LIS) automatically registered serum immunoglobulins (Ig) when serum total proteins (STP) > 80 g/L for the first time in primary care patients. When concomitantly one Ig presented a value above and one below its reference interval, the LIS automatically registered a serum protein electrophoresis (SPEP). When a monoclonal peak in SPEP, immunofixation electrophoresis (IFE) for the typification of monoclonal bands (MB) was performed. If MB were present, a comment in the report explained the intervention. The number of additionally registered Ig, SPEP, IFE, and new diagnosis of MM were counted. The number of days elapsed from the report of elevated STP result to the final MM diagnosis was also counted as median and interquartile range (IQR), and compared to a pre intervention period.

RESULTS

2071 cases of hyperproteinemia were identified, and had 91 a monoclonal peak, confirmed by IFE. In 35 patients it was a new finding, and 9 were diagnosed with MM, 3 Waldestrom macroglobulinemia, 2 lymphoplasmacytic lymphoma and 21 monoclonal gammopathy of undetermined significance. The number of days elapsed from hyperproteinemia to diagnosis was lower in the intervention period (21.5 vs 119.4) (P < 0.01). As our results show, in addition to shortening the time to diagnosis, an increased rate of detection of plasma cell disorders was observed when using our algorithm.

CONCLUSIONS

The above laboratory interventions agreed with clinicians, making use of laboratory technology resulted in early identification of MM.

Inter-patient heterogeneity in the hepatic ischemia-reperfusion injury transcriptome: Implications for research and diagnostics

Cellular responses induced by surgical procedure or ischemia-reperfusion injury (IRI) may severely alter transcriptome profiles and complicate molecular diagnostics. To investigate this effect, we characterized such pre-analytical effects in 143 non-malignant liver samples obtained from 30 patients at different time points of ischemia during surgery from two individual cohorts treated either with the Pringle manoeuvre or total vascular exclusion. Transcriptomics profiles were analyzed by Affymetrix microarrays and expression of selected mRNAs was validated by RT-PCR. We found 179 mutually deregulated genes which point to elevated cytokine signaling with NFκB as a dominant pathway in ischemia responses. In contrast to ischemia, reperfusion induced pro-apoptotic and pro-inflammatory cascades involving TNF, NFκB and MAPK pathways. FOS and JUN were down-regulated in steatosis compared to their up-regulation in normal livers. Surprisingly, molecular signatures of underlying primary and secondary cancers were present in non-tumor tissue. The reported inter-patient variability might reflect differences in individual stress responses and impact of underlying disease conditions. Furthermore, we provide a set of 230 pre-analytically highly robust genes identified from histologically normal livers (<2% covariation across both cohorts) that might serve as reference genes and could be particularly suited for future diagnostic applications.

The Nature, Causes, and Clinical Impact of Errors in the Clinical Laboratory Testing Process Leading to Diagnostic Error: A Voluntary Incident Report Analysis

OBJECTIVES

Diagnostic errors, that is, missed, delayed, or wrong diagnoses, are a common type of medical errors and preventable iatrogenic harm. Errors in the laboratory testing process can lead to diagnostic errors. This retrospective analysis of voluntary incident reports aimed to investigate the nature, causes, and clinical impact of errors, including diagnostic errors, in the clinical laboratory testing process.

METHODS

We used a sample of 600 voluntary incident reports concerning diagnostic testing selected from all incident reports filed at the University Medical Center Utrecht in 2017-2018. From these incident reports, we included all reports concerning the clinical laboratory testing process. For these incidents, we determined the following: nature: in which phase of the testing process the error occurred; cause: human, technical, organizational; and clinical impact: the type and severity of the harm to the patient, including diagnostic error.

RESULTS

Three hundred twenty-seven reports were included in the analysis. In 77.1%, the error occurred in the preanalytical phase, 13.5% in the analytical phase and 8.0% in the postanalytical phase (1.5% undetermined). Human factors were the most frequent cause (58.7%). Severe clinical impact occurred relatively more often in the analytical and postanalytical phase, 32% and 28%, respectively, compared with the preanalytical phase (40%). In 195 cases (60%), there was a potential diagnostic error as consequence, mainly a potential delay in the diagnostic process (50.5%).

CONCLUSIONS

Errors in the laboratory testing process often lead to potential diagnostic errors. Although prone to incomplete information on causes and clinical impact, voluntary incident reports are a valuable source for research on diagnostic error related to errors in the clinical laboratory testing process.

An approach to genetic testing in patients with metastatic castration-resistant prostate cancer in Singapore

Introduction

There has been a rapid evolution in the treatment strategies for metastatic castration-resistant prostate cancer (mCRPC) following the identification of targetable mutations, making genetic testing essential for patient selection. Although several international guidelines recommend genetic testing for patients with mCRPC, there is a lack of locally endorsed clinical practice guidelines in Singapore.

Method

A multidisciplinary specialist panel with representation from medical and radiation oncology, urology, pathology, interventional radiology, and medical genetics discussed the challenges associated with patient selection, genetic counselling and sample processing in mCRPC.

Results

A clinical model for incorporating genetic testing into routine clinical practice in Singapore was formulated. Tumour testing with an assay that is able to detect both somatic and germline mutations should be utilised. The panel also recommended the "mainstreaming" approach for genetic counselling in which pre-test counselling is conducted by the managing clinician and post-test discussion with a genetic counsellor, to alleviate the bottlenecks at genetic counselling stage in Singapore. The need for training of clinicians to provide pre-test genetic counselling and educating the laboratory personnel for appropriate sample processing that facilitates downstream genetic testing was recognised. Molecular tumour boards and multidisciplinary discussions are recommended to guide therapeutic decisions in mCRPC. The panel also highlighted the issue of reimbursement for genetic testing to reduce patient-borne costs and increase the reach of genetic testing among this patient population.

Conclusion

This article aims to provide strategic and implementable recommendations to overcome the challenges in genetic testing for patients with mCRPC in Singapore.

Towards an FDA-cleared basophil activation test

Food allergy is a global health problem affecting up to 10% of the world population. Accurate diagnosis of food allergies, however, is still a major challenge in medical offices and for patients seeking alternative avenues of diagnosis. A flawless test to confirm or rule out a food allergy does not exist. The lack of optimum testing methods to establish precise clinical correlations remains a major obstacle to effective treatment. Certain IgE measurement methods, including component testing, have received FDA clearance, but they have been used primarily as an analytical tool and not to establish clinical correlations. Most allergy tests are still carried out within the laboratory, and skin tests outside a laboratory setting that are used for food allergy diagnosis rely on non-standardized allergens, according to the FDA definition. Epitope mapping and basophil activation test (BAT) have recently been proposed as a means of establishing better clinical correlations. Yet neither have received FDA clearance for widespread distribution. Of the two methods, the BAT has the advantage of being a functional assay. Over the past few years, several large private practice groups in the United States, have developed BAT as a clinical assay and have started using it in patient care. Given this clinical experience, the vast number of papers published on BAT (more than 1,400 as of 2022) and the trend toward increasing FDA regulation, it is essential to understand the roadmap for regulatory clearance of this assay.

Practical considerations for laboratories: Implementing a holistic quality management system

A laboratory quality management system (LQMS) is an essential element for the effective operation of research, clinical, testing, or production/manufacturing laboratories. As technology continues to rapidly advance and new challenges arise, laboratories worldwide have responded with innovation and process changes to meet the continued demand. It is critical for laboratories to maintain a robust LQMS that accommodates laboratory activities (e.g., basic and applied research; regulatory, clinical, or proficiency testing), records management, and a path for continuous improvement to ensure that results and data are reliable, accurate, timely, and reproducible. A robust, suitable LQMS provides a framework to address gaps and risks throughout the laboratory path of workflow that could potentially lead to a critical error, thus compromising the integrity and credibility of the institution. While there are many LQMS frameworks (e.g., a model such as a consensus standard, guideline, or regulation) that may apply, ensuring that the appropriate framework is adopted based on the type of work performed and that key implementation steps are taken is important for the long-term success of the LQMS and for the advancement of science. Ultimately, it ensures accurate results, efficient operations, and increased credibility, enabling protection of public health and safety. Herein, we explore LQMS framework options for each identified laboratory category and discuss prerequisite considerations for implementation. An analysis of frameworks' principles and conformity requirements demonstrates the extent to which they address basic components of effective laboratory operations and guides optimal implementation to yield a holistic, sustainable framework that addresses the laboratory's needs and the type of work being performed.

Evaluation of preanalytical and postanalytical phases in clinical biochemistry laboratory according to IFCC laboratory errors and patient safety specifications

Introduction

The aim of the study was to determine the current state of laboratory's extra-analytical phase performance by calculating preanalytical and postanalytical phase quality indicators (QIs) and sigma values and to compare obtained data according to desired quality specifications and sigma values reported by The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Working Group - Laboratory errors and Patient Safety.

Materials and methods

Preanalytical and postanalytical phase data were obtained through laboratory information system. Rejected samples in preanalytical phase were grouped according to reasons for rejection and frequencies were calculated both monthly and for 2019. Sigma values were calculated according to "short term sigma" table.

Results

The number of rejected samples in laboratory was 643 out of 191,831 in 2019. Total preanalytical phase rejection frequency was 0.22%. According to the reasons for rejection, QIs and sigma values were: "Samples with excessive transportation time": 0.0036 and 5.47; "Samples collected in wrong container" 0.02 and 5.11. In December, QIs and sigma values were: "Samples with excessive transportation time": 0.01 and 5.34; "Samples collected in wrong container": 0.03 and 4.98. The postanalytical QIs and sigma values were: "Reports delivered outside the specified time": 0.34 and 4.21; "Turn around time of potassium": 56 minute and 3.84, respectively. There were no errors in "Critical values of inpatients and outpatients notified after a consensually agreed time".

Conclusions

Extra-analytical phase was evaluated by comparing it with the latest quality specifications and sigma values which will contribute to improving the quality of laboratory medicine.

Analysis of preanalytical errors in a clinical chemistry laboratory: A 2-year study

Patient safety and medical diagnosis of patients are mainly influenced by laboratory results. The present study aimed to evaluate the errors in the preanalytical phase of testing in a Clinical Chemistry diagnostic laboratory. A review was conducted at the Clinical Chemistry Laboratory of a hospital in Saudi Arabia from January 2019 to December 2020. Using the laboratory information system, the data of all canceled tests and requests were retrieved and evaluated for preanalytical errors. A total of 55,345 laboratory test requests and samples from different departments were evaluated for preanalytical errors. An overall rate of 12.1% (6705) was determined as preanalytical errors. The occurrence of these errors was found to be highest in the emergency department (21%). The leading preanalytical errors were nonreceived samples (3.7%) and hemolysis (3.5%). The annual preanalytical errors revealed an increasing rate in outpatient and inpatient departments, while a decreasing rate was observed in the emergency department. An increased rate of errors was also noted for the 2-year study period from 11.3% to 12.9%. The preanalytical phase has a significant impact on the quality of laboratory results. The rate of error in the study was high and the leading causes were nonreceived samples and hemolysis. An increased occurrence of hemolyzed samples in the outpatient department was noted. Enhanced educational efforts emphasizing specimen quality issues and training in sample collection among hospital staff must be carried out.

Quality Control in Digital Pathology: Automatic Fragment Detection and Counting

Manual assessment of fragments during the pro-cessing of pathology specimens is critical to ensure that the material available for slide analysis matches that captured during grossing without losing valuable material during this process. However, this step is still performed manually, resulting in lost time and delays in making the complete case available for evaluation by the pathologist. To overcome this limitation, we developed an autonomous system that can detect and count the number of fragments contained on each slide. We applied and compared two different methods: conventional machine learning methods and deep convolutional network methods. For conventional machine learning methods, we tested a two-stage approach with a supervised classifier followed by unsupervised hierarchical clustering. In addition, Fast R-CNN and YOLOv5, two state-of-the-art deep learning models for detection, were used and compared. All experiments were performed on a dataset comprising 1276 images of colorec-tal biopsy and polypectomy specimens manually labeled for fragment/set detection. The best results were obtained with the YOLOv5 architecture with a map@0.5 of 0.977 for fragment/set detection.

Considerations for the selection of tests for SARS-CoV-2 molecular diagnostics

During the course of 2020, the outbreak of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS‐CoV‐2) spread rapidly across the world. Clinical diagnostic testing for SARS-Cov-2 infection has relied on the real‐time Reverse Transcriptase Polymerase Chain Reaction and is considered the gold standard assay. Commercial vendors and laboratories quickly mobilised to develop diagnostic tests to detect the novel coronavirus, which was fundamentally important in the pandemic response. These SARS-Cov-2 assays were developed in line with the Food Drug Administration-Emergency Use Authorization guidance. Although new tests are continuously being developed, information about SARS-CoV-2 diagnostic molecular test accuracy has been limited and at times controversial. Therefore, the analytical and clinical performance of SARS-CoV-2 test kits should be carefully considered by the appropriate regulatory authorities and evaluated by independent laboratory validation. This would provide improved end-user confidence in selecting the most reliable and accurate diagnostic test. Moreover, it is unclear whether some of these rapidly developed tests have been subjected to rigorous quality control and assurance required under good manufacturing practice. Variable target gene regions selected for currently available tests, potential mutation in target gene regions, non-standardized pre-analytic phase, a lack of manufacturer independent validation data all create difficulties in selecting tests appropriate for different countries and laboratories. Here we provide information on test criteria which are important in the assessment and selection of SARS-CoV-2 molecular diagnostic tests and outline the potential issues associated with a proportion of the tests on the market.

Analytical and Post Analytical Phase of an ISO 15189:2012 Certified Cytopathology Laboratory-A Five Year Institutional Experience

Objective

Analytical and post analytical phase are integral part of total quality management system and include steps from submission of slides till reports are dispatched. The present study was conducted to analyze the analytical and post analytical phase of the ISO15189:2012 certified cytopathology laboratory. It was also intended to study the various errors which were encountered and steps taken to reduce these discrepancies.

Methods

The study included all documents of quality program from 1 November 2014 till 31 Oct 2019 in medical institute situated in north Himalayan region of India. All the data was recorded and analyzed for analytical and post analytical phase.

Results

The number of samples received in cytopathology lab was 21,566 with total quality errors of 5.19%. Out of these pre-analytical errors were 55%, analytical 10.5% and post analytical errors constituted 34.4%. The maximum errors detected were due to typographical errors followed by delayed turnaround time. Cyto-histopathological discordance was 10.5% in non-gynecological cases and 2.2% in gynecological cases.

Conclusion

Analytical and post analytical phase analysis is essential to minimize the errors and improve the quality of cytopathology lab. Cyto-histopathological correlation is valuable for continuous data tracking in the cytopathology with analytical errors analysis. Maintenance of external, internal quality program, turnaround time with documentation, continuous training and communication with clinician is fundamental for quality improvement in any cytopathology lab. Acknowledgement of nonconformance with root cause analysis and sincere efforts to minimize them is the basic key for successful quality management.

Economic Evaluation of Total Laboratory Automation in the Clinical Laboratory of a Tertiary Care Hospital

Background

Total laboratory automation (TLA) is an innovation in laboratory technology; however, the high up-front costs restrict its widespread adoption. To examine whether the capital investment for TLA is worthwhile, we analyzed its clinical- and cost-effectiveness for the expected payback period.

Methods

Clinical chemistry tests and immunoassays performed in the clinical laboratory of a tertiary care hospital were divided into a post-TLA group, including 1,182,419 tests performed during December 2019, and a pre-TLA group, including 1,151,501 tests performed during December 2018. Laboratory information system data were used to measure clinical effectiveness, and depreciation data were used to calculate TLA costs.

Results

Laboratory performance improved after TLA adoption in all four key performance indicators mean turn-around time (TAT), representing the timeliness of result reporting, decreased by 6.1%; the 99th percentile of TAT, representing the outlier rate, decreased by 13.3%; the TAT CV, representing predictability, decreased by 70.0%; and weighted tube touch moment (wTTM), representing staff safety, improved by 77.6%. Based on these effectiveness results, economic evaluation was performed using two approaches. First, the incremental cost-effectiveness ratio and wTTM were used as the most cost-effective performance indicators. Second, the expected payback period was calculated. Considering only staff cost reduction, it was anticipated that 4.75 yrs would be needed to payback the initial investment.

Conclusions

TLA can significantly enhance laboratory performance, has a relatively quick payback period, and can reduce total hospital expenses in the long term. Therefore, the capital investment for TLA adoption is considered to be worthwhile.

Genetic testing for homologous recombination repair (HRR) in metastatic castration-resistant prostate cancer (mCRPC): challenges and solutions

Patients with metastatic castration-resistant prostate cancer (mCRPC) have an average survival of only 13 months. Identification of novel predictive and actionable biomarkers in the homologous recombination repair (HRR) pathway in up to a quarter of patients with mCRPC has led to the approval of targeted therapies like poly-ADP ribose polymerase inhibitors (PARPi), with the potential to improve survival outcomes. The approval of PARPi has led to guideline bodies such as the National Comprehensive Cancer Network (NCCN) to actively recommend germline and or somatic HRR gene panel testing to identify patients who will benefit from PARPi. However, there are several challenges as genetic testing is still at an early stage especially in low- and middle-income countries, with cost and availability being major impediments. In addition, there are issues such as choice of optimal tissue for genetic testing, archival, storage, retrieval of tissue blocks, interpretation and classification of variants in the HRR pathway, and the need for pretest and post-test genetic counseling. This review provides insights into the HRR gene mutations prevalent in mCRPC and the challenges for a more widespread gene testing to identify actionable germline pathogenic variants and somatic mutations in the HRR pathway, and proposes a clinical algorithm to enhance the efficiency of the gene testing process.

Prevention of extra-analytical phase errors by non-analytical automation in clinical laboratory

During previous decades, significant improvements in laboratory errors have become a substantial part of reducing preventable diagnostic errors. In clinical laboratory practice, the errors in the testing process are primarily associated with extra-analytical phase error sources, influencing the test result quality profoundly. Thus, the management of these critical error sources makes their effects preventable thanks to automation and computer sciences. The implementation of non-analytical automated systems requires a risk management strategy based on laboratory’s workflow and bottlenecks. Then, the improvements can be measured and evaluated by the usage of quality indicators (QI). Consequently, the total quality of laboratory diagnostics and higher patient safety is closely dependent on this type of automation. This review will help laboratory professionals, managers, and directors improve the total testing processes (TTP). The automation technologies have added a serious impact on the proficiency of laboratory medicine. Several instrumentations have now partially or entirely automated many manual tasks to improve standardization, organization, efficiency, and TTP quality. The implementation of non-analytical automation has made them manageable. As a result, non-analytical automation within and outside the clinical laboratory will necessarily lessen the error sources’ effect on the total test process, enhancing the quality of the test results.

Determining the Optimal Storage Time and Temperature for Performing Platelet Function Assays and Global Hemostasis Assays

Platelet function assays and global haemostasis assays are essential in diagnosing bleeding tendencies, with light transmission aggregometry (LTA) as golden standard. The Multiple Electrode Aggregation (Multiplate), platelet function assay (PFA) and rotational thromboelastometry (ROTEM) are mostly used as whole-blood screening tests. Currently, patients have to travel to specialized laboratories to undergo these tests, since specific expertise is required. Pre-analytical variables, like storage time and temperature during transport, are still considered to be the most vulnerable part of the process and may lead to discrepancies in the test results. We aim to give a first impression on the stability of blood samples from healthy volunteers during storage and investigate the effect of storage time (1, 3, 6 and 24 hours) and temperature (4°C, room temperature and 37°C) on the Multiplate, PFA, ROTEM and LTA test results. Our data indicated that, for the PFA, whole blood can be stored for 3 hours at room temperature. Whole blood used for the Multiplate and ROTEM can be stored for 6 hours of storage. For LTA, PRP and whole blood were stable up to 3 hours at 4°C or room temperature and 6 hours at room temperature, respectively.

Brazilian laboratory indicators benchmarking program: three-year experience on pre-analytical quality indicators

OBJECTIVES

In the laboratory medicine segment, benchmarking is the process in which institutions seek to compare with the macro environment (performance comparison and best practices with different laboratories) and improve their results based on quality indicators. The literature has highlighted the vulnerability of the pre-analytical phase in terms of risks and failures and the use of interlaboratory comparison as an opportunity to define a strategic performance benchmark aligned with the laboratory medicine sector, which has been a promising strategy to ensure continuous improvement, identifying within the pre-analytical process the critical activities to guarantee patient safety. In this context, this paper aims to present the three-year experience (2016-2018) of the Benchmarking Program and Laboratory Indicators - in Portuguese, Programa de Benchmarking e Indicadores Laboratoriais (PBIL) - with emphasis on pre-analytical indicators and their comparison against literature references and other programs of benchmarking in the area of laboratory medicine. PBIL is organized by the Brazilian Society of Clinical Pathology/Laboratory Medicine (SBPC/ML) in conjunction with Controllab and coordinated by a Brazilian group with representatives from different countries.

METHODS

The data presented in this paper involving the performance results of 180 laboratories with active participation. Results are presented in percentage (%, boxplot graphical in quartiles) and Sigma metric, recognized as the metric that best indicates the magnitude of failures in a process. The Pareto Chart was used to facilitate ordering and to identify the main errors in the pre-analytical phase. The Radar Chart was made available in this work for the purpose of comparing the results obtained in Sigma by the PBIL and IFCC Working Group Laboratory Errors and Patient Safety (WG LEPS).

RESULTS

In the study period, just over 80% of the pre-analytical failures are related to Blood culture contamination (hospital-based and non-hospital-based laboratories), Recollect and Non-registered exams, with failure rates of 2.70, 1.05 and 0.63%, respectively. The performance of the PBIL program participants was in line with the literature references, and allowed to identify benchmarks in the laboratory medicine market, target of PBIL, with best practices were observed for some indicators.

CONCLUSIONS

The results of the program demonstrate the importance of an ongoing program comparative performance-monitoring program for setting more robust goals and consequently reducing laboratory process failures. Even with these promising premises and results, the contextualized analysis of the program indicators, point to a still significant number of failures in our market, with possibilities for improvement in order aiming to ensure more robust and effective processes.

Effects of circadian variation, lifestyle and environment on hematological parameters: A narrative review

The complete blood count (CBC) is the most widely prescribed laboratory test. It plays a key role in screening, diagnosing, and monitoring a variety of medical disorders. Preanalytical and analytical variables are responsible for more than 50% of laboratory errors that may lead to spurious CBC results. The effects of blood sampling, transport, storage, and analytical errors on hematological parameters have been well described. Circadian variation and changes in lifestyle and environment can also affect blood cells. It has been extensively studied in the past, but highly variable methodology and the presence of confounding factors have provided scattered and inconsistent results. We have investigated the literature to define the impact of circadian variation, modification of the sleep-wake cycle, acute and chronic exercise, eating habits, alcohol, tobacco, drugs of abuse, high-altitude, heat/cold exposure, and air pollution on CBC results. The affected cell type along with the intensity and duration of changes are detailed for each condition. We aim at providing a comprehensive overview of which situations may induce clinically significant changes and have to be taken into account by healthcare professionals before considering a hematological parameter as pathological and requesting complementary tests.

Error Evaluation in the Laboratory Testing Process and Laboratory Information Systems

Introduction: The laboratory testing process consists of five analysis phases featuring the total testing process framework. Activities in laboratory process, including those of testing, are error-prone and affect the use of laboratory information systems. This study seeks to identify error factors related to system use and the first and last phases of the laboratory testing process using a proposed framework known as total testing process-laboratory information systems. Materials and Methods: We conducted a qualitative case study in two private hospitals and a medical laboratory. We collected data using interviews, observations, and document analysis methods involving physicians, nurses, an information technology officer, and the laboratory staff. We employed the proposed framework and Lean problem-solving tools namely Value Stream Mapping and A3 for data analysis. Results: Errors in laboratory information systems and the laboratory testing process were attributed to failure to fulfill user requirements, poor cooperation between the information technology unit and laboratory, the inconsistency of software design in system integration, errors during inter-system data transmission, and lack of motivation in system use. The error factors are related to system development elements, namely, latent failures that considerably affected the information quality and system use. Errors in system development were also attributed to poor service quality. Conclusion: Complex laboratory testing process and laboratory information systems require rigorous evaluation in minimizing errors and ensuring patient safety. The proposed framework and Lean approach are applicable for evaluating the laboratory testing process and laboratory information systems in a rigorous, comprehensive, and structured manner.

Termination of Repeat Testing in Chemical Laboratories Based on Practice Guidelines: Examining the Effect of Rule-Based Repeat Testing in a Transplantation Center

BACKGROUND

Although the automation of instruments has reduced the variability of results and errors of analysis, in some laboratories, repeating a test to confirm its accuracy is still performed for critical and noncritical results. However, the importance of repeat testing is not well established yet, and there are no clear criteria for repeating a test.

MATERIALS AND METHODS

In this cross-sectional study, all repeated tests for 26 biochemical analytes (i.e., albumin, alkaline phosphatase (ALP), alanine aminotransferase (ALT), amylase, aspartate aminotransferase (AST), bilirubin total (BT), bilirubin direct (BD), blood urea nitrogen (BUN), calcium, chloride (Cl), cholesterol total (CholT), creatine kinase (CK), creatinine (Cr), glucose, gamma-glutamyl transferase (GGT), high-density lipoprotein-cholesterol (HDL-c), iron, lactate dehydrogenase (LDH), LDL-c, lipase, magnesium (Mg), phosphorus (Ph), protein total (ProtT), total iron binding capacity (TIBC), triglyceride (TG), and uric acid) were assessed in both critical and noncritical ranges over two consecutive months (routine subjective test repeats in the first month and rule-based repeats in the second month). To determine the usefulness of test repeats, differences between the initial and verified results were compared with the allowable bias, and repeat testing was considered necessary if it exceeded the allowable bias range. All causes of repeat testing, including linearity flags, delta checks, clinically significant values, and critical values, were also documented. All data, including the cause of repeats, initial and verified results, time, and costs in the two consecutive months, were transferred to Microsoft Excel for analysis. For comparison of data between the months, Student's t-test was used.

RESULTS

A total of 7714 repeat tests were performed over two consecutive months. Although a significant decline (38%) was found in repeated tests in the second month (P < 0.001), there was no significant change in the percentage of unnecessary repeats (77% in the first month and 74% in the second month). In both consecutive months, AST and ALT were the most commonly repeated tests, and delta check was the most common cause of repeat testing. Mg, ALP, AST, and lipase showed the highest rates of necessary repeats, respectively (the least stable tests), while albumin, LDL, and CholT tests showed the highest rates of unnecessary repeats, respectively (the most stable tests). The total cost and delay in turnaround time (TAT) due to repeated testing decreased by 32% and 36%, respectively.

CONCLUSION

Although repeat testing has been shown to be unnecessary in most cases, having a strict policy for repeat testing appears to be more valuable than avoiding it completely. Each laboratory is advised to establish its own protocol for repeat testing based on its own practice.

Integrating quality control and external quality assurance

Effective management of clinical laboratories relies upon an understanding of Quality Control and External Quality Assurance principles. These processes, when applied effectively, reduce patient risk and drive quality improvement. In this Review, we will describe the purpose of QC and EQA and their role in identifying analytical and process error. The two concepts are linked, and we will illustrate that linkage. Some EQA providers offer far more than analytical surveillance. They facilitate training and education and extend quality improvement and identify areas where there is potential for patient harm into the pre-and post-analytical phases of the total testing process.

Assessment of the effects of repeated freeze thawing and extended bench top processing of plasma samples using untargeted metabolomics

INTRODUCTION

Clinical metabolomics has utility as a screen for inborn errors of metabolism (IEM) and variant classification in patients with rare disease. It is important to understand and characterize preanalytical factors that influence assay performance during patient sample testing.

OBJECTIVES

To evaluate the impact of extended thawing of human EDTA plasma samples on ice prior to extraction as well as repeated freeze-thaw cycling of samples to identify compounds that are unstable prior to metabolomic analysis.

METHODS

Twenty-four (24) donor EDTA plasma samples were collected and immediately frozen at - 80 °C. Twelve samples were thawed on ice and extracted for analysis at time 0, 2, 4, and 6 h. Twelve other donor samples were repeatedly thawed and frozen up to four times and analyzed at each cycle. Compound levels at each time point/freeze-thaw cycle were compared to the control samples using matched-paired t tests to identify analytes affected by each condition.

RESULTS

We identified 1026 biochemicals across all samples. Incubation of thawed EDTA plasma samples on ice for up to 6 h resulted in < 1% of biochemicals changing significantly. Freeze-thaw cycles affected a greater percentage of the metabolome; ~ 2% of biochemicals changed after 3 freeze-thaw cycles.

CONCLUSIONS

Our study highlights that the number and magnitude of these changes are not as widespread as other aspects of improper sample handling. In total, < 3% of the metabolome detected on our clinical metabolomics platform should be disqualified when multiple freeze-thaw cycles or extended thawing at 4 °C are performed on a given sample.

Biological variation: Understanding why it is so important?

This Review will describe the increasing importance of the concepts of biological variation to clinical chemists. The idea of comparison to 'reference' is fundamental in measurement. For the biological measurands, that reference is the relevant patient population, a clinical decision point based on a trial or an individual patient's previous results. The idea of using biological variation to set quality goals was then realised for setting Quality Control (QC) and External Quality Assurance (EQA) limits. The current phase of BV integration into practice is using Patient-Based Real-Time Quality Control (PBRTQC) and Patient Based Quality Assurance (PBQA) to detect a change in assay performance. The challenge of personalised medicine is to determine an individual reference interval. The Athletes Biological Passport may provide the solution.

Current Practice and Regional Variability in Recommendations for Patient Preparation for Laboratory Testing in Primary Care

BACKGROUND

Preparation of the patient for laboratory tests is crucial. Our aim was to investigate the current practice and regional variability of recommendations regarding patient preparation for laboratory testing.

METHODS

A call for data was posted by email. Spanish laboratories were invited to fill out and submit a survey.

RESULTS

Sixty-eight laboratories participated in the study. In 73% of those laboratories, fasting was always recommended regardless of the requested tests. Only one-third of the laboratories systematically recommended a 12-hour fast before the tests. In 71% of the laboratories, water intake was allowed without restrictions during the fasting period. In 57% of the laboratories, computerized order entry offered the possibility to print customized recommendations automatically in the primary care doctor's office according to the requested tests. Seventy-two percent of the laboratories agreed with the proposed recommendation.

CONCLUSIONS

There was high variability in patient preparation for laboratory testing. A significant proportion of centers did not follow international guidelines.

Extra-Analytical Clinical Laboratory Errors in Africa: A Systematic Review and Meta-Analysis

BACKGROUND

Clinical laboratory testing is a highly complex process involving a different procedure. Laboratory errors may occur at any stage of the test process, but most errors occur during extra-analytical phases. The magnitude of clinical laboratory errors, in particular extra-analytical errors, was inconsistent in different studies.

METHODS

A systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The extracted data were entered into a Microsoft Excel spreadsheet and transferred to STATA version 11 for the analysis. Random effect model was used to estimate pooled prevalence of extra-clinical laboratory errors and I² statistic was used to assess heterogeneity between the studies. Funnel plot analysis and Egger weighted regression test were performed to detect the publication bias. Egger weighted regression test with P-value <0.05 was considered to be a statistically significant publication bias.

RESULTS

A total of 1,381 studies were searched, 19 were included in this systematic review and meta-analysis. A total of 621,507 pre-analytical and 51,859 post-analytical outcomes of quality indicators were reported. A total of 145,515 samples were assessed for rejection and 62,513 laboratory requests were evaluated for incompleteness. The pooled prevalence of pre-analytical and post-analytical errors in Africa was 17.5% (95% Cl: 11.55, 23.45) and 10.99% (95% Cl: 5.30, 16.67) respectively. The pooled prevalence of specimen rejection and laboratory request forms incompleteness in Africa was 2.0% (95% Cl: 0.86, 3.14) and 7.55% (95% Cl: 2.30, 12.80) respectively.

CONCLUSION

The study found high prevalence of pre- and of post-analytical clinical laboratory errors in Africa. In addition, the study showed that the standard completion of the laboratory request forms was poor and there were significant numbers of specimen rejections. Therefore, clinical laboratories should ensure compliance with standard operating procedures, the laboratory information system, the cooperation of the entire staff and the targeted training of sample collectors.

Evidence-based approach to setting delta check rules

Delta checks are a post-analytical verification tool that compare the difference in sequential laboratory results belonging to the same patient against a predefined limit. This unique quality tool highlights a potential error at the individual patient level. A difference in sequential laboratory results that exceeds the predefined limit is considered likely to contain an error that requires further investigation that can be time and resource intensive. This may cause a delay in the provision of the result to the healthcare provider or entail recollection of the patient sample. Delta checks have been used primarily to detect sample misidentification (sample mix-up, wrong blood in tube), and recent advancements in laboratory medicine, including the adoption of protocolized procedures, information technology and automation in the total testing process, have significantly reduced the prevalence of such errors. As such, delta check rules need to be selected carefully to balance the clinical risk of these errors and the need to maintain operational efficiency. Historically, delta check rules have been set by professional opinion based on reference change values (biological variation) or the published literature. Delta check rules implemented in this manner may not inform laboratory practitioners of their real-world performance. This review discusses several evidence-based approaches to the optimal setting of delta check rules that directly inform the laboratory practitioner of the error detection capabilities of the selected rules. Subsequent verification of workflow for the selected delta check rules is also discussed. This review is intended to provide practical assistance to laboratories in setting evidence-based delta check rules that best suits their local operational and clinical needs.

Measurement uncertainty as a universal concept: can it be universally applicable in routine laboratory practice?

Measurement uncertainty (MU) of results is one of the basic recommended and accepted statistical methods in laboratory medicine, with which analytical and clinical evaluation of laboratory test quality is assessed. Literature data indicate that the calculation of MU is not a simple process, but that its assessment in daily laboratory practice should be reduced to routine and simple presentation, understandable to both laboratory professionals and physicians. In order to achieve this, it is necessary to understand the purpose of the test for which MU is to be determined. Various suggestions have been given for presentation of MU as a quantitative indicator of the quality of the final measurement result in the medical laboratory. Although MU refers to the final measurement result, this metrological concept reflects the entire laboratory measurement process. The data on estimated MU is used to interpret the measured numerical result, and represents quantitatively the quality of the measurement itself, i.e. how different are the results of multiple measurements of the analyte of interest in the same sample, as well as whether the method of determination itself is subjected to significant random and systematic deviation. Initially, in the metrological concept, the MU is viewed in relation to the true value of the analyte of interest. However, the true value of the analyte measured in the biological fluid matrix of the study population cannot be known. It is therefore considered the closest value obtained by the perfect method, for which the bias and inaccuracy, as measures of systematic and random error, are equal to zero, which is practically impossible to achieve in routine laboratory practice. Although current standards require accredited medical laboratories to estimate MU, none of these guidelines provide clear guidance on how this can be achieved in daily laboratory work. This review examines literary data and documents dealing with MU issues, but also highlights what additional terms and data should be considered when interpreting MU. This paper ultimately draws attention, and once again points out, that a simpler solution is needed for this universal concept to be formally and universally applicable in routine laboratory medicine practice.

The clinically effective use of cardiac markers by restructuring laboratory profiles at Cardiology wards

Background

Laboratory overutilization is associated with diagnostic error and potential patient risk. We applied a demand management strategy in collaboration with the local Department of Cardiology to reduce the cardiac markers high-sensitive troponin T (hsTropT) and N-terminal pro brain natriuretic peptide (NTproBNP) in laboratory ordering profiles (LOPs). The present study aimed to retrospectively evaluate the implemented strategies.

Methods

Strategies included educational measures and evidence-guided, active test de-selection from all cardiology ward LOPs, and/or permanent removal from LOPs. Tests remained available at all times. We evaluated overutilization by reductions in monthly orders, and assessed differences in 30-day all-cause readmission rate and length of patients' hospital stay.

Results

Overall, we observed a mean reduction of 66.1% ± 7.6% (n = 277 ± 31) in hsTropT tests. Educational measures effectively reduced NTproBNP orders by 52.8% ± 17.7% (n = 60 ± 20). Permanent removal of tests from LOPs additionally decreased orders to a final extent of 75.8% ± 8.0% (n = 322 ± 31) in NTproBNP tests. The 30-day readmission rate and overall length of hospital stay did not increase.

Conclusions

Our results indicate that cardiac markers in routine care are subject to extensive overutilization when used within LOPs. Educational measures are an effective strategy to overcome the overutilization of cardiac markers but may be more effective when combined with the removal of cardiac markers from LOPs.

Frequency and classification of errors in laboratory medicine at a veterinary teaching hospital in the United States

BACKGROUND

The accuracy of laboratory data is of utmost importance. Data regarding laboratory error in human laboratories are often extrapolated into veterinary settings. One study investigated the rate and type of errors in a European commercial veterinary laboratory, but that data might not directly apply to an educational setting.

OBJECTIVES

This study determined the frequency and type of errors in laboratory medicine at a veterinary teaching hospital.

METHODS

Errors associated with clinical pathology samples were recorded over two 60-day periods. The first period included a time when new students and house officers started at the veterinary school. The second time period was 6 months later. The errors were assigned to categories, and the frequency of each was calculated. Sample hemolysis, icterus, and lipemia were evaluated separately using an automated index, as these conditions could be pathologic or the result of error. Frequencies of error and hemolysis, icterus, and lipemia were assessed between the groups.

RESULTS

Total error rates were 4.7% and 3.5% for the first and second periods, respectively. The frequency of each error subclassification was similar to those observed in the veterinary and human literature, with preanalytic error predominating. Statistically significant differences in the overall error rate and percentage of preanalytic errors that occurred outside of and within the laboratory were observed comparing differences between the two periods.

CONCLUSIONS

The overall error rate in this veterinary teaching hospital was slightly higher than that previously reported in other settings, although a proportion of errors was as expected. Areas needing improvement were identified, and strategies to reduce error could be developed.

Changes in error rates in the Australian key incident monitoring and management system program

Introduction

The Key incident monitoring and management system program (KIMMS) program collects data for 19 quality indicators (QIs) from Australian medical laboratories. This paper aims to review the data submitted to see whether the number of errors with a higher risk priority number (RPN) have been reduced in preference to those with a lower RPN, and to calculate the cost of these errors.

Materials and methods

Data for QIs from 60 laboratories collected through the KIMMS program from 2015 until 2018 were retrospectively reviewed. The results for each QI were averaged for the four-year average and coefficient of variation. To review the changes in QI frequency, the yearly averages for 2015 and 2018 were compared. By dividing the total RPN by 4 and multiplying that number by the cost of recollection of 30 AUD, it was possible to assign the risk cost of these errors.

Results

The analysis showed a drop in the overall frequency of incidents (6.5%), but a larger drop in risk (9.4%) over the period investigated. Recollections per year in Australia cost the healthcare industry 27 million AUD. If the RPN data is used, this cost increases to 66 million AUD per year.

Conclusions

Errors with a higher RPN have fallen more than those with lower RPN. The data shows that the errors associated with phlebotomy are the ones that have most improved. Further improvements require a better understanding of the root cause of the errors and to achieve this, work is required in the collection of the data to establish best-practice guidelines.

Real-time display of laboratory testing status improves satisfaction levels in an emergency department: A pilot study

Background

Clinicians need to know timelines of requested laboratory tests to provide effective patient management. We developed a real‐time laboratory progress checking system and measured its effectiveness using appropriate indicators in an emergency room setting.

Methods

In our original in‐house health information system display, blank spaces, which were generated for test results when tests were ordered, remained empty until the final results reported. We upgraded the laboratory reporting system to show real‐time testing information. The stages included requests for test, label printing, sampling, laboratory receipts, performance of tests, verification of results, and interpretation of results and final report by laboratory physician. To assess the usefulness of the function, we measured the emergency department healthcare workers' satisfaction and compared the number of phone calls about test status before and after implementation.

Results

After the system upgrade, the healthcare workers' understanding of the testing process increased significantly as follows. More clinicians could estimate the time of final test results through the real‐time testing status information (61.9% and 85.7%, P = .002), and respondents reported that the upgraded system was more convenient than the original system (41.3% and 22.2%, respectively, P = .022). The number of phone calls about the test status decreased after implementation of the upgrade; however, the difference was not statistically significant (before, 0.13% [63 calls/48 637 tests] and after, 0.09% [42/46 666]; P = .066).

Conclusions

The real‐time display of laboratory testing status increased understanding of testing process among healthcare workers in emergency room, which ultimately may increase the usefulness and efficiency of the laboratory service use.

Roots of the total testing process

Laboratory professionals can contribute to improvement of diagnosis in the context of the total testing process (TTP), a multidisciplinary framework complementary to the diagnostic process. While the testing process has been extensively characterized in the literature, needed is accurate identification of the source of the term "total testing process". This article clarifies first appearance of the term in the literature and supplies a formal definition.

A Comparative Study of Blood Sampling From Venipuncture and Short Peripheral Catheters in Pediatric Inpatients

This prospective, comparative study examined blood test results, hemolysis rates, and patient perceptions related to 2 blood sampling methods in pediatric inpatients (N = 95). Blood specimens were drawn via venipuncture and a short peripheral catheter used for fluid administration. Results revealed no significant differences in potassium and glucose levels. No clinically significant difference in hemoglobin was noted. Hemolysis rates were 4% for venipuncture samples and 15% when drawn from peripheral catheters. One catheter became occluded after a blood draw. Patients/parents rated distress and dissatisfaction with venipuncture as significantly greater compared with short peripheral catheter blood sampling (P < .001).

Monitoring unfractionated heparin therapy. 4 hour-stability of anti-Xa activity in unspun citrated tubes

Current guidelines recommend performing laboratory tests aimed at monitoring unfractionated heparin (UFH) treatments within a delay not exceeding 1 to 2 h(s) after sampling when blood is collected into citrated tubes. As such a short delay could be an issue, we evaluated the potential impact of longer delays. For that purpose, two citrated tubes were obtained from patients on UFH: one was centrifuged and tested for anti-Xa activity and aPTT within 1 h after collection (T1 h) and one was stored for 4 h at room temperature (T4 h) before being processed. A total of 123 paired tubes were investigated. Anti-Xa activity was significantly lower at T4 h than at T1 h, with a mean bias, calculated according to Bland-Altman, of 0.05 IU/mL. Considering 0.30 to 0.70 IU/mL as the therapeutic range, there were 12 cases of discrepant test results (9.8%). Most of them being around the lower limit of the therapeutic range had no impact on patients' management. APTT was significantly shortened (p < 0.0001) at T4 h vs. T1 h, with a mean bias of -7.9 s. Considering anti-Xa correlated aPTT therapeutic range, 29 cases of discrepant test results (23.6%) were found, 10% would have induce dosage changes. The concordance between anti-Xa activities measured at T4 h and T1 h was excellent (kappa = 0.813) and good for aPTT (kappa = 0.661). In conclusion, extending the delay between blood collection and measurement of tests prescribed for monitoring UFH therapy up to 4 h was found to lead to a systematic reduction in both anti-Xa activity and aPTT in unspun citrated tubes. As changes at T4 h were limited and had few clinically relevance than the ones observed with aPTT testing, a 4 h-delay was found to be acceptable for anti-Xa activity. The maximum delay for aPTT should remain around 1-2 h as changes were more relevant.

A critical review of laboratory performance indicators

Healthcare budgets worldwide are under constant pressure to reduce costs while improving efficiency and quality. This phenomenon is also visible in clinical laboratories. Efficiency gains can be achieved by reducing the error rate and by improving the laboratory's layout and logistics. Performance indicators (PIs) play a crucial role in this process as they allow for performance assessment. This review aids in the process for selecting laboratory PIs-which is not trivial-by providing an overview of frequently used PIs in the literature that can also be used in clinical laboratories. We conducted a systematic review of the laboratory medicine literature on PIs. As the testing process in clinical laboratories can be viewed as a production process, we also reviewed the production processes literature on PIs. The reviewed literature relates to the design, optimization or performance assessment of such processes. The most frequently cited PIs relate to pre-analytical errors, timeliness, resource utilization, cost, and the amount of congestion. Their citation frequency in the literature is used as a proxy for their importance. PIs are discussed in terms of their definition, measurability and impact. The use of suitable PIs is crucial in production processes, including clinical laboratories. By also reviewing the production processes literature, additional relevant PIs for clinical laboratories were found. The PIs in the laboratory medicine literature mostly relate to laboratory errors, while the PIs in the production processes literature relate to the amount of congestion in the process.

Barriers and facilitators impacting reliability of the electronic health record-facilitated total testing process

OBJECTIVE

Despite ongoing efforts to improve reliability of the total testing process (TTP), breakdowns continue to occur resulting in diagnostic delays and suboptimal patient outcomes. We performed an exploratory study to identify factors that impact TTP reliability in electronic health record (EHR)-enabled care.

MATERIALS AND METHODS

We interviewed experts at three large EHR-enabled health care organizations and identified all TTP steps performed from clinician test ordering to result communication to patients. Findings from all sites were combined to develop a detailed process map of known TTP activities. We additionally asked experts about factors that positively or negatively impacted TTP reliability at each step. We describe the specific TTP steps identified and associated barriers and facilitators to TTP reliability.

RESULTS

We interviewed 39 experts involved in or overseeing the TTP. Most TTP activities identified were similar across sites, but we found significant differences with test order transmission to diagnostic services and relay of results back to clinicians and patients. Twenty-five unique barriers were identified related to technology and EHR usability issues, time and resource constraints, suboptimal clinic workflows, patient-related factors, information access limitations, and insufficient clinician training. Twenty-four unique facilitators were identified related to personnel training, workflow optimization and standardization, helpful EHR features, and improved electronic communication between clinics and diagnostic services.

DISCUSSION

Barriers related to EHR usability and with communication between clinicians and diagnostic services increase TTP vulnerability and should be targeted by future efforts to improve process reliability. Several facilitators identified in the study could inform future strategies and solutions to improve TTP reliability.

Early alert from the microbiology laboratory improves the outcome of elderly patients with Enterococcus spp. bloodstream infection: Results from a multicentre prospective study

OBJECTIVES

This study describes the clinical features and outcomes of patients with bloodstream infection (BSI) due to Enterococcus spp. and identified factors predictive of mortality.

METHODS

This analysis is part of a prospective multicentre observational study of consecutive hospitalised patients with BSI conducted from March 2012 to December 2012 in 31 internal medicine wards in Italy. Patients with enterococcal BSI were selected from the entire cohort. Patient characteristics, therapeutic interventions and outcome were reviewed. Cox regression analysis was performed to identify factors associated with in-hospital mortality. Hazard ratios (HRs) and 95% interval confidences (CIs) were calculated.

RESULTS

Among 533 patients with BSI, 41 (7.7%) had BSI by Enterococcus spp. (28 Enterococcus faecalis, 4 Enterococcus faecium and 3 each of Enterococcus avium, Enterococcus casseliflavus and Enterococcus gallinarum). Six BSIs (14.6%) were polymicrobial. Median (IQR) patient age was 73 (66-85.5) years. In-hospital mortality was 24.4%. Polymicrobial infection (HR = 9.100, 95% CI 1.295-63.949; P = 0.026), age (HR = 1.261, 95% CI 1.029-1.546; P = 0.025) and SOFA score (HR = 1.244, 95% CI 1.051-1.474; P = 0.011) were risk factors for in-hospital mortality. Conversely, receiving an alert from the microbiology laboratory before obtaining final antimicrobial susceptibility results was associated with survival (HR = 0.073, 95% CI 0.007-0.805; P = 0.033).

CONCLUSION

BSI due to Enterococcus spp. in elderly patients is associated with high mortality. Polymicrobial infection, age and SOFA score are factors associated with poor outcome. Conversely, early alert from the microbiology laboratory improves patient survival.

European follow-up of incorrect biomarker results for colorectal cancer demonstrates the importance of quality improvement projects

Biomarker analysis for colorectal cancer has been shown to be reliable in Europe with 97% of samples tested by EQA participants to be correctly classified. This study focuses on errors during the annual EQA assessment. The aim was to explore the causes and actions related to the observed errors and to provide feedback and assess any improvement between 2016 and 2017. An electronic survey was sent to all laboratories with minimum one genotyping error or technical failure on ten tumor samples. A workshop was organized based on 2016 survey responses. Improvement of performance in 2017 was assessed for returning participants (n = 76), survey respondents (n = 13) and workshop participants (n = 4). Survey respondents and workshop participants improved in terms of (maximum) analysis score, successful participation, and genotyping errors compared to all returning participants. In 2016, mostly pre- and post-analytical errors (both 25%) were observed caused by unsuitability of the tumor tissue for molecular analysis. In 2017, most errors were due to analytical problems (50.0%) caused by methodological problems. The most common actions taken (n = 58) were protocol revisions (34.5%) and staff training (15.5%). In 24.1% of issues identified no action was performed. Corrective actions were linked to an improved performance, especially if performed by the pathologist. Although biomarker testing has improved over time, error occurrence at different phases stresses the need for quality improvement throughout the test process. Participation to quality improvement projects and a close collaboration with the pathologist can have a positive influence on performance.

Use of microbiology tests in the era of increasing AMR rates- a multicentre hospital cohort study

Background

Effective use of microbiology test results may positively influence patient outcomes and limit the use of broad-spectrum antibiotics. However, studies indicate that their potential is not fully utilized. We investigated microbiology test ordering practices and the use of test results for antibiotic decision-making in hospitals.

Methods

A multicentre cohort study was conducted during five months in 2014 in Medical departments across three hospitals in Western Norway. Patients treated with antibiotics for sepsis, urinary tract infections, skin and soft tissue infections, lower respiratory tract infections or acute exacerbations of chronic obstructive pulmonary disease were included in the analysis. Primary outcome measures were degree of microbiology test ordering, compliance with microbiology testing recommendations in the national antibiotic guideline and proportion of microbiology test results used to inform antibiotic treatment. Data was obtained from electronic- and paper medical records and charts and laboratory information systems.

Results

Of the 1731 patient admissions during the study period, mean compliance with microbiology testing recommendations in the antibiotic guideline was 89%, ranging from 81% in patients with acute exacerbations of chronic obstructive pulmonary disease to 95% in patients with sepsis. Substantial additional testing was performed beyond the recommendations with 298/606 (49%) of patients with lower respiratory tract infections having urine cultures and 42/194 (22%) of patients with urinary tract infections having respiratory tests. Microbiology test results from one of the hospitals showed that 18% (120/672) of patient admissions had applicable test results, but only half of them were used for therapy guidance, i.e. in total, 9% (63/672) of patient admissions had test results informing prescription of antibiotic therapy.

Conclusions

This study showed that despite a large number of microbiology test orders, only a limited number of tests informed antibiotic treatment. To ensure that microbiology tests are used optimally, there is a need to review the utility of existing microbiology tests, test ordering practices and use of test results through a more targeted and overarching approach.