On May 2–3, 2019, IQMH hosted an engaging forum centered on pre-analytical best practices. About 75 delegates spent two rainy May days in a beautiful ballroom in Toronto’s DoubleTree by Hilton hotel where they were treated to a combination of heart and science related to pre-analytical issues as seen through the eyes of 22 astonishing speakers. The event was driven by a single intention — to inspire purposeful action.
| Every intention is a trigger for transformation.
~ Deepak Chopra
Although the energy generated in the DoubleTree by Hilton hotel on May 2–3 cannot be reproduced here, we are pleased to provide this summary of the event for those who were not able to attend in person.
Hélène Campbell – Keynote – A Lung Story
Canada’s Other Double/Double: Hélène Campbell Hélène and Julie Coffey
At only 28 years of age, Hélène is a two-time double lung transplant recipient who possesses unbridled enthusiasm, limitless optimism, passion and iron will. Having always loved connecting with people, her journey through disease, surgery and recovery launched her into the spotlight as she harnessed the power of social media and imprinted herself into the hearts and minds of Canadians and people all over the world. She provided a shining example of how one person can have a massive impact, her efforts alone have increased registrations for organ donations by thousands, a feat she has accomplished despite her fragile health and with an amazing variety of clever puns.
Julie Coffey – Pre-Analytical Challenges and Barriers
Prior to the forum, IQMH conducted a survey to illuminate the pre-analytical challenges of our readers. Julie Coffey, IQMH Director of Education, presented the results of that survey in comparison to published international data.
Julie also introduced a running theme for the rest of the forum — The power of letting go of limiting beliefs. Limiting beliefs constrain and prevent us from moving forward:
- I’m too old to parasail
- I’m too fat to wear a bikini
- Pre-analytical issues are outside of the lab’s control.
- I can’t make a difference.
The participants were challenged to shed their limiting beliefs about lack of ability to effect change and to leave this forum with a sense of empowerment.
Anne-Marie Martell – Blood Collection Process: New Recommendations
There are a staggering 22 steps in proper phlebotomy technique. Anne-Marie Martel from the Ordre professionnel des technologistes médicaux du Québec (OPTMQ) diligently walked through each one, pointing out new recommendations from ISO and CLSI along the way. We learned the optimal ways to identify the patient, to choose a vein, to cleanse the venipuncture site, to apply the correct order of draw, to label the specimens, and to prevent bruising.
Joe Bottos – Knowing sooner: Laboratory Test Utilization for the Emergency Room — Early Diagnosis of Sepsis
In this presentation, sponsored by Beckman Coulter, Joe Bottos walked through the costly healthcare burden of sepsis and the role of the laboratory in its diagnosis and management. Sepsis accounts for about 11,000 deaths annually, and the economic burden in Canada is estimated to be $325 million annually. The signs and symptoms of sepsis are not specific, making the optimal choice of tests challenging. On review of the key biomarkers for sepsis, Joe pointed out that traditional biomarkers (lactate, WBC, neutrophil count, procalcitonin, IG) have limited utility in the prediction of sepsis. Better early sepsis indicators can potentially provide an alert to sepsis before the patient rapidly worsens, specifically he discussed the use of the monocyte mean distribution width (MDW) to assist in the sepsis decision path.
Robyn Lippett, Sitara deGagne, Don Ross and Robert Molloy – Priceless Insight from a Diverse Patient Panel
The forum included the unique addition of a patient panel designed to highlight the importance of storytelling and, equally important, our personal responsibility when we have been on the receiving end of a generous recount of experience, even if the story makes us uncomfortable. Robyn Lippett, Patient and Family Engagement Coordinator at SickKids introduced the concept that storytelling can be a vehicle for change in health care with the following quote:
A patient’s description of an encounter with the health care
can be more impactful than a landmark clinical trial,
because it forces us to share the patient’s emotional experience.
~ Arden R. Barry
Left to right: Robert Molloy, Sitara de Gagne, Don Ross and Robyn Lippett
We then heard three very different perspectives:
- Sitara de Gagne, a mother of 3 unique children, one of whom was diagnosed with cancer at the age of two. She poignantly explained how even a child needs to be an active partner in their care.
- Don Ross, who spent the better part of a year in hospital fighting a life-threatening illness. He describes himself as a typical man, therefore beautifully suited to share his story.
- Student and poet Robert Molloy, a trans man on the autism spectrum who recited his awe-inspiring poem to help us understand his point of view.
It’s too bad patient-centred care is not rocket science,
because if it was, we would be really good at it.
~ Laura Gilpin
Larissa Matukas and Shafqat Tahir – St. Michael’s Hospital Laboratory’s Odyssey to Reduce Pre-Analytical Errors
We heard about three exciting projects from Larissa Matukas and Shafqat Tahir of St. Michael’s Hospital laboratory. Medical laboratory technologist, Shafqat, described their odyssey to reduce specimen rejection of samples originating in the emergency department. Their goal was to reduce the number of specimens rejected by 25%. The intervention, done in collaboration between lab and nursing, consisted of education, tours in both areas, and tools such as tip sheets and blood draw cards, all of which Shafqat shared. As a result of the intervention, the number of specimens rejected was reduced from 845 to 587 (30%).
A tip sheet posted in St. Michael’s Hospital Larissa Matukas and Shafqat Tahir
Dr. Matukas demonstrated the results of a project to reduce blood culture contamination rates through the introduction of a blood culture bundle and routine audit and feedback. Prior to the intervention, an average of 4.26% of cultures were considered contaminated, most often due to organisms that are inadvertently introduced into specimen bottles at the time of inoculation. The intervention by the lab reduced contamination rates to an average of 2.67%.
A second intervention described by Dr. Matukas was an effector to eliminate swab collections from the operating rooms, which was a Choosing Wisely initiative. Since swabs are always inferior specimens to tissues and fluids, the microbiology laboratory took the lead and put a full stop on all swabs from the OR.
Blood Culture Project - Education Swab project - Results
Mary Costantino – Cases for Reflection
The day saw it’s close with a series of interactive case studies that the participants viewed on their smartphones. These cases induced reflection on common pre-analytical challenges involving labelling and samples of unacceptable quality.
Would you accept these?
Lori Taylor and Brittany Jenkins – Improved Collaboration Among Healthcare Providers
On the second day of the event, we greeted the morning with a dynamic pair of nurses from the University Health Network — Lori Taylor and Brittany Jenkins. The pair gave an honest account of familiar pre-analytical issues, but from a nursing perspective. Their key message is that nursing absolutely does want to hear from, collaborate with, and learn from laboratory. They emphasized that nursing typically gets only 30 minutes to one hour of training in phlebotomy, and that nursing managers would greatly benefit from the receipt of quality indicator data by unit to aid in improvement. In addition, the best intervention is likely a combination of technology, honest collaboration and education.
Lori Taylor and Brittany Jenkins
Jessica Gifford – Biotin Interference in Clinical Immunoassays: What you Really Need to Know
Biotin (vitamin B7) use has seen a dramatic rise in popularity due to claims that it can beautify hair and nails. Dr. Gifford elegantly reviewed the biochemistry and physiology of the vitamin and its use as a health product and pharmaceutical. She then explained the good, the bad, the ugly and the very ugly around this vitamin. The very ugly being the fact that a large amount of biotin in a patient’s sample can interfere with a shockingly broad range of diagnostic tests. In the US, of 374 methods performed by eight popular immunoassay analyzers, 221 of the methods are biotin-based, and 97 are deemed to be at high-risk for biotin interference. This is not a new phenomenon, this potential interference has been known for years, but recently a striking increase in reports of biotin interference has occurred due to increased use of the vitamin by persons seeking its beauty benefits. Dr. Gifford outlined the analytical and educational strategies to mitigate the effects posed by biotin:
Retest suspicious samples on a biotin-unaffected platform
: The use of streptavidin particles
Diluting the specimen with validated assay diluent
: Choose test methodologies that are free from biotin interference
Educate healthcare providers – Comments on reports, memos
: Educate patients
Timothy Willett – New Frontiers in Simulation: From Individual Skill to System Reliability
It was a rare treat to be in the same room as Dr. Timothy Willett, the charming CEO of SIM-one (now Simulation Canada). Tim reiterated the thoughts of the nurses that spoke the previous day by emphasizing that to do better, we must focus less on changing people, and focus more on changing behaviours and changing the system and to look beyond the quick fix. He introduced the concept of Implementation Science and Reliability Science and related them to simulation training. He used fascinating examples that convinced all those in attendance that simulation training does work better, particularly when a good needs assessment is conducted. He expanded on a very interesting idea that simulation is also useful for Failure Modes Effects Analysis and Cause Analysis.
Dr. Timothy Willett
Juha Wahlstedt - Pre-Analytical EQA – A Powerful Tool to Learn and Share Best Practices
We were honoured to be graced with a visitor from Finland, Juha Wahlstedt from LabQuality. We learned about the three types of pre-analytical programs offered by LabQuality.
- Use of preanalytical quality indicators. Juha referenced an important list of quality indicators published by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). Click here to view the document:
IFCC is encourages national societies to organize EQA of pre-analytical quality indicators, and this has been happening internationally for several years.
- Use of EQA samples with pre-analytical errors. LabQuality uses occasional samples with haemolysis (H), icterus (I) and lipaemia (L) in its surveys and monitors the comments made by laboratories.
- Use of preanalytical questionnaires. These are questionnaires where a variety of healthcare personnel are asked to declare their practices regarding certain aspects of preanalytical phase using case studies. For these surveys, a laboratory subscribes to pre-analytical EQA and gives the questionnaire to 5 persons (for example a phlebotomy unit).
Valentina Konstantopoulos – It’s Irretrievable! How Pathology Pre-analytical Improvements Increased Patient Safety and Staff Satisfaction
Valentina Konstantopoulos’ goal was to share what the pathology lab at Mackenzie Health has done to document, monitor and improve collection pre-analytical practices. She emphasized that the prime motivation was the fact that pathology samples are irretrievable and that a patient’s positive experience in the most caring, clean, modern hospital is meaningless when their specimen’s integrity has been compromised. At the beginning of this project, their pathology lab averaged 36 pre-analytical issues each month, most of which were due to samples being mislabelled at the source of the procedure. They did an initial intervention in 2011 in the endoscopy area that involved standardized specimen placement, new stickers and a red-green double bin check. This intervention served to increase animosity between lab and endoscopy, and decreased errors only to an average of 31 per month. In 2017, processes were redesigned to create an order entry interface between the Epic Electronic Medical Record system and the CoPath Laboratory Information System. Post Epic Go-live statistics revealed an increase in labelling issues due to limitations in the system. Eventually, there were resolved and new data showed that labelling errors were now averaging at 13 per month (a 65% decrease).
Daniel Beriault, Hina Chaudhry and Michelle Sholzberg – Utilization Innovation: Hardstops and EnACT
The final presentations were a series of case studies from St. Michael’s Hospital. We heard about three separate and very successful laboratory interventions:
1. Hard- stops:
Redundant testing recognized as a widespread phenomenon (2012) at St Michael’s Hospital. St. Mike’s previously attempted to tackle this issue by implementing prompts/alerts on a variety of tests, this only reduced tests by 5% and the changes were not sustained. To finally address the issue, hard-stops based on repeat intervals were built into the HIS and LIS on the following tests because there was no clinical value to repeating the test:
- HbA1C: all repeat HbA1C measurements within 60 days of a previous result were cancelled
- Serum protein electrophoresis (SPEP) / immunofixation (IFE): Hard-stop within a 21 day window
- Urine protein electrophoresis (UPEP) / immunofixation (UIFE) Hard-stop within a 21 day window
- Serum free light chains (sFLC) Hard-stop within a 21 day window
- FT4 & FT3 are no longer orderable at St Mikes (TSH reflex algorithm); lead to a 40% and 50% reduction hospital-wide, respectively
- Revamping ED ordersets (Removed PT, aPTT, Urea, Alb, CK, Amylase); lead to 67% reduction across all tests
2. Routine Coagulation Tests
The aPTT and PT tests were never designed nor validated to screen for hemostatic defects in unselected patients, but they nevertheless have become ubiquitous in medical practice with minimal clinical benefit to the patient. St. Michael’s laboratory uncoupled aPTT/PT testing options, developed and circulated educational materials, revised emergency department testing panels, prepared an e-learning module and presents at grand rounds and to nurses. This intervention led to a greater than 2-fold reduction in coagulation testing volumes.
3. Use of Bleeding Assessment Tools (BATs)
- INR/PTT are often used as screening tests for bleeding disorders despite sensitivities of 1–2%. The most sensitive test for a bleeding disorder is the clinical history. To that end, validated questionnaires, bleeding assessment tools (BATs) have been shown to be effective screening tests. The hospital sought to minimize unnecessary coagulation testing and maximize appropriate use of a BAT in the outpatient setting over a 24-month period, this effort has been extremely effective in reducing coagulation testing. The hospital even hopes to validate the use of a self-administered bleeding assessment tool to be completed by the patients themselves.
Daniel Beriault Hina Chaudhry Michelle Sholzberg
IQMH offers gratitude to the 22 talented speakers who took the time to prepare and present at this unique event, to those who attended, to our sponsors and to our staff who worked energetically to create this event. Together, we CAN make a difference.
Our intention was to inspire purposeful action. Here are some examples of ideas actions generated as reported by the participants.
- Speak to upper management to work more closely with non-lab personnel to get better feedback from them as to what they need to improve on pre-analytical errors. The non-lab employees usually only hear when they make errors but I now feel that if we ask for their feedback and opinion perhaps they will learn and therefore make less errors.
- To prepare and discuss future pre-analytical expectations for pre-analytical EQA or new IQMH accreditation requirements
- We are looking into how biotin is affecting our immunoassay results.
- We are going to see if we can trial a phlebotomist in emergency.
- We plan to organize phlebotomy cards with colour coding and order of draw.
- Add comment on biotin interference to specific lab test results.
- Identify quality indicators from list provided.
- Work with endoscopy to reduce labelling errors.
- Create a more robust program for monitoring and feedback to those who are directly involved in pre-analytical specimen quality.
- Become more involved in helping nursing staff become more efficient with sample collection.
I spent the entire weekend talking to my co-workers about it!.
The following sponsors were vital contributors to this event:
Gold Sponsor: Beckman Coulter
Silver Sponsor: Instrumentation Laboratory
Bronze Sponsors: Becton Dickenson, Bio-Rad and Paradigm 3
The Centre for Education is planning a Fall Forum titled Innovation in Cancer Diagnostics on November 7–8, 2019, the details of which will be available soon.