Report of Pre-analytical Processes

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Nov 5, 2013 (3 years and 5 months ago)

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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 (T
EGH
)

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
labor
atory 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 with
in its

ambulatory care programs.

The department of Laboratory Medicine embraces the
h
ospital’s
v
ision

to be the
leader in
q
uality and
v
alue
.

A quality management system serves to articulate all
policies/processes/procedures while maintaining records of quality a
ctivities
.
Our
success i
n laboratory pre
-
analytical processes exemplifies our commitment
to
the
hospital

s mission and deep
-
seat
ed accountability framework and su
ccess factors: patient
focus,
ensure value,
encourage people,
collaborative spirit and inspire innovation.
L
aborato
ry process
es

(pre
-
anal
ytical
,
analytical and p
ost
-
analytica
l
) are patient focused

as we strive for
safety, quality
,
and
timeliness
. The effi
ciencies created ensure value
a
nd
appropriate use of resources.
We
appreciate

our people
and
have

made the

investm
ent

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 an
d
communication

ha
ve

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 O
rder Entry

Laboratory o
rder
s are placed on the nursing unit
s

using
the hospital
information
system

(HIS)
.
Specimen labels

are generated
via
the l
aboratory
i
nformation

s
ystem

(LIS
)
based on the orders
placed in the HIS
a
s

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
the
n

generated accordingly.
Building the orders interface required extensive
collaboration between laboratory staff, information technology services and
patient care
areas to ensure
appropriate o
rder

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 manag
ing

utilization o
f labor
atory tests.
Electronic l
aboratory order

en
try ha
s

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 s
ound foundation for the
computerized

provid
er

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

appro
priate utilization.
Planning

and implementation of this project included
physician participation,
redundant/downtime plans, extensive training,
extensive c
hange management and
physician
adoption strategies
. CPOE
has improved
cla
r
ity
in
physician’s

orders
,

utilization
and s
tandardized care
.
Improved efficiencies

have resulted in m
ore
appropriate use of resources

and improved timeliness of laboratory results. This initiative

is an e
nabler of patient safety
,
increasing the
quality of patient care through sta
ndardized
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order sets that support best practices
. The system s
upports availability of active clinical
decision support and reminders
.
W
ork flow
is improved
through streamlined care
processes

and re
duce
d

turnaround

times for patient investigations and the
rapies
.
I
mproved c
ommunication between clinicians

and the system
strengthens

training
of
locum
s

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
.

P
atient identification


P
atient identi
fi
cation

mishaps are the
greatest source of error
for
laboratories
.

At
TEGH
,
p
atients 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
; w
herever possible, the patient
is

involved in
th
e identification process. For personal information such as the patient’s name or date of
birth, the patient
is
asked to state the information in
it
s

entire
t
y, rather than ask
ing

for a
passive agreement
.
Acceptable patient identifie
r
s include
the patient
’s

name (
first
, middle
and surname)
,
date of birth
,
hospital number

and/or
the patient’s health car
d

number
.

Positive patient identification protocol
s

are

imparted during
clinical orientation
session
s

for new employees
and are regul
arly communicated by
nursing pr
acti
c
e 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
.


In
formation compared
includes
:

patient name(s)
,
g
ender

and
d
ate of
b
irth
.


Specimen
Collection


I
n

order to achieve the highest quality of
laboratory results,
speci
mens 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
. H
owever, a nurse collect
i
on

model exists in Emergency and
in critical care areas.
Education on s
pecimen collection and general laboratory
information is

provided to clinical staff as part of orien
tation and on an ongoing basis to
reinforce
compliance
.

An on
-
line specimen collecti
on 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 coll
ection 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 R
oadshow

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.
A
dditional sessions were
available on request

and
targeted sessi
ons
were
also
arranged
for area
s

that were
trending
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higher number
s

of specimen rejections. Laminated posters were also created to depict
appropriate specimen collection containers which were posted in clean utilit
y 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,
a
n electronic incident reporting system
facilitates
eas
ily

accessible reporting.
The hospital supp
o
rts a ‘
j
ust cult
ure


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
,
pattern
s

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
,
wi
th

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
A
utomation (
MPA
)

was fully
implemented

to receive, centrifuge, aliquot and sort all laboratory
specimens. Despite
only the chemistry analyzers being fully integrated, all c
o
re lab blood work is received
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and processe
d

using the automation. Specimens are sorted by a techn
ician
on designated
racks

and then
directly
loaded on
to

the instrument.
The t
echnology

is fully interfaced
with the HIS
,
LIS and the connected analyzers.
Specimen receipt in the lab is
acknowledge
d in the
patient record

via the
interface
.
Decapping,

cen
trifuging,
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 error
s
/
alarms

as they occur
.
The automatio
n 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 c
ontinuous processing
,
eliminat
ing
the
need for interrupted
loading of stat specimens.
It has als
o limited the use of batch testing thus reducing
manual intervention of stor
age

and retrieval.
The
automation
has significantly increased
the speed at which patient samples are
processed
in the sample receiving area
.
D
iminished r
eliance on technic
al
staff

for

manual tasks
has allowed t
echnologists
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 s
taff 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
serve
d

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

provid
ing

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 communica
t
ion, 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

time
s

(
see
A
ppendix
C
)
.

Average turnaround
times and predictability generally exceed benchmarks. Upon further investigation for
continuous improvement, delays were found to b
e predominantly due to instrument
downtimes, barcode reader malfunctions and/or staffing transition times.



M
etrics are reported daily
at the
departmental huddle each morning.
H
uddle
s

provide an effective venue for communicati
ng

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 laborato
ry huddle is well attended by staff
and
with
exception
al

enthusiasm. Ideas are solicited and welcomed for additional process
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improvements.
Such departmental huddle
s

are held throughout the hospital

and s
taf
f are
encouraged to visit other unit’s

huddles to

engage
in system

wide collaboration.
Members f
rom
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.

L
aboratory accomplishments are clearly demonstrated by the metrics and
staff feels

a
sense of pride. Labora
tory t
echnician
s

are empowered to
function

at a higher level while
wit
h
in
their
scope of practice
.
In a
recent staff satisfaction survey
, results

indicate
d

a high
level of employee commitment

and overall satisfaction
. Effective change management,
communic
ation 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 improvement
s
. 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. T
he
organizational culture of continuous
improvement enable
s

patient
safety

and quality
improvement

initiatives.
S
upport 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 comm
unicate 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 we
re 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 ed
ucation is
required to sustain and further reduce rejections
.

*Data does not include reject
ions for Pathology,
Blood Bank and Coagulation Labs.


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APPENDIX
C



TURNAROUND TIME METR
ICS




Figure 1. Average
t
urnaround
t
ime for

c
omplete 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
t
urnaround
t
ime for C
BC
s 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).

T
he predictability dropped slightly

when the tar
get was reduced to 30

min
.
in May
.


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Figure
3
. Average
t
urnaround
t
ime 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 chem
istry 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 t
ime 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.