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How the Clinical Laboratory Enhances Patient Care. kscls. Fred V. Plapp, MD PhD Medical Director Saint Luke ’ s Regional Laboratories. kcclma. Patchwork of Knowledge. Diagnosis of Meningitis Expediting Patient Care. Infection of tissues surrounding the brain & spinal cord
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How the Clinical Laboratory Enhances Patient Care kscls Fred V. Plapp, MD PhD Medical Director Saint Luke’s Regional Laboratories kcclma Patchwork of Knowledge
Diagnosis of MeningitisExpediting Patient Care • Infection of tissues surrounding the brain & spinal cord • Bacterial or viral • Mostly viral • Viral usually mild • Bacterial is life-threatening
Diagnosis of MeningitisTraditional Practice • Patient presents to Emergency Room • Lumbar puncture to collect CSF • Bacterial cultures require 3 days • Viral cultures require 10 days • Patient admitted to hospital • Treated with IV antibiotics until likely that bacterial culture will be negative • Discharged with outpatient antibiotics
Viral MeningitisTraditional Diagnosis 4 – 10 Days
Viral MeningitisReal Time PCR Diagnosis 1 million viral copies in 30 minutes instead of 10 days
Meningitis OutcomesDownstream Cost Savings • Traditional Approach • Average LOS is 2.8 days • Average hospital charge is $14,050 • IV antibiotics during admission • Outpatient antibiotics for 10 – 14 days • SLH Molecular Approach • Avoid admission if Enterovirus detected • Avoid unnecessary antibiotics
Rapid ID of CoNSImproved Antibiotic Stewardship • Peptide Nucleic Acid FISH • Non-amplified fluorescent molecular probe • Recognizes species specific RNA • Distinguishes Coagulase Negative Staph from Staph aureus • Advantages • Timely & accurate same day results • Minimal equipment requirement • Other probes for Gram-negatives & yeast • Disadvantages • Expensive cost per test • Must batch test due to $$$$$
Rapid ID of CoNSLab & Pharmacy Cost Savings Cost per patient included antibiotics & laboratory tests
SLHS performed 23,652 blood cultures in 2009 452 contaminants (1.9%) 350 were CoNS Each contaminant adds ~$5000 to cost of hospital stay Rapid ID of CoNS saves ~$1.75M per year by preventing LOS Rapid ID of CoNSDownstream Cost Savings kscls kcclma Patchwork of Knowledge
Recombinant rFVIIa UsageLaboratory as a Watchdog • Recombinant Factor VIIa (Novoseven) • Binds directly to tissue factor & activates FX • FDA approved for hemophilia with acquired inhibitor • Off label use for acute bleeding • Very expensive ( $1 per ug) • Short half-life of 2-3 hours • Possible thromboembolic events
Open Heart SurgeryTransfusion Review • OHS transfused ~one third of components • Clinical Pathologist analyzed blood usage each year • Surgeon specific usage • Reviewed with CTS team • Evaluated risk factors, meds,practice variations • Published transfusion guidelines & risks • Presented to surgeons, Department Chair, Chief Medical Officer
Benefits of Decreased Transfusion • $260,000 cost savings in blood products per year • Transfusion reaction risks decreased • Blood Bank workload decreased • Nursing time for transfusion decreased
Order SetsEnsuring Appropriate Testing • Nurses & physicians write order sets • Clinical Pathologists review lab tests • Additions, deletions, substitutions • Suggestions returned to authors • Order sets published • Test utilization monitored before & after
Specimen in Lab PolicyDecreasing Wastage • Worked with Blood Management Team to reduce iatrogenic blood loss • SIL Policy implemented • Stored blood specimens for 1 week • Publicized in Lab Letter & Nursing publications • Avoided redrawing patients for add-on testing
Specimen in Lab PolicySLH Outcomes • 11,244 requests for tests on SIL • $51,726 savings in labor & supplies • Avoided 11,244 venipunctures • Conserved 71,428 mL of blood • Equivalent to 140 units of RBCs
POC Blood Glucose TestingImproving Patient Safety • Manual Patient ID entry • 12,000 tests per month • 9.7% average error rate • ~450 unidentified results per month • PI project to reduce errors • Accu-Chek Inform & RALS Plus • Barcoded armbands & handheld devices