LEANING Away Waste and Improving Patient Care with Advances in Hematology

Transcription

1 LEANING Away Waste and Improving Patient Care with Advances in Hematology Selke Mantie, MLS (ASCP), CLS (CSMLS), SSGBC Disclosure I am receiving an honorarium from Sysmex for today s presentation Objectives Discuss how automation and new technology can be applied to improve workflow and reduce cost. Describe new parameters Immature Granulocyte (IG), Immature Platelet Fraction (IPF) and Immature Retic Fraction (IRF) and Reticulated Hemoglobin (RET-He) and their impact on patient care and hospital budget. Understand how new technology can impact SCAN/MDIFF workflow. Explore new pathways to improve six part autodifferential reporting. Understand defining new criteria as it relates to value added information to improve patient care. 1

2 Banner Health System (BHS) Is the largest non profit health care system in the country serving patients across 6 states. 27 hospitals Alzheimerʹs Institute Health Clinics Research Health Clinics Home care services Medical Equipment services Senior Center & Residences Surgery Centers Urgent Care Banner Arizona/LSA Banner Goldfield (2013) Banner Casa Grande (2014) Banner Payson Medical Center (2015) Banner University Medical Center ( ) Phoenix, Tucson North/South What did we want? Instrumentation Easy to use Reliable and accurate Automation (Hands off) for analysis & PBS review New technology to improve patient care Decrease SCAN/MDIFF rate IT Auto-verification Downtime Results Improve or maintain TAT for ER and In-patients Report FDA any new FDA cleared test(s) Improve patient outcome 2

3 Work Area Manager (WAM) Plus: BGFMC BCGMC BPMC Work Area Manager (WAM) 3

4 WAM Result Validation WAM: M2I WAM Count Statistics Report 4

5 WAM Count Statistic Report Emulator Establishing New Workflow 5

6 Analysis Tools Define o Project w/boundaries & exclusions o Define what needs to be improved, changed, etc. o Stakeholders o Voice of the customer o What are you going to measure? E.g. Decrease TAT, reduce steps? Analyze o Process Map, Fishbone, FMEA, 5 Why, XY Matrix Measure o Review previous date o Measure o Process Map of current state Improve o Process Map of future state o Identify quick hits o Implement new workflow, process, etc. Control o Set up a plan to control the improvement. o Example monitor monthly TAT within goal. o Develop an action plan if data starts to fail. Define & Measure (1) Reduce non added value steps for specimen/tech travel (2) Decrease SCANS/MDIFF performed (3) Improve/maintain CBC ED TAT 90% w/in 30 minutes. Analyze Spaghetti Diagram 6

7 Analyze/Measure/Improve Spaghetti Diagram Measure/Improve Measure/Improve Time Value Analysis Improve TAT 7

8 Measure/Improve Control Summary Workflow Consolidation of workstations with automation of sample handling. Standardized 13 hematology laboratories with one LIS System into one Sysmex WAM middleware system. Established standardized rules that will help the technologist follow the same procedures on flagged specimens. Improved capacity and throughput. Maximize existing work space. Automated peripheral blood smear review with Cellavision. Implemented auto-verification system wide with an average rate 85%. Decrease peripheral blood smear review by 30%. Maintained ED CBC TAT goal throughout learning curve Standardized SOP s. Improved and standardized workflow. 8

9 Why Sysmex XN? Action XE XN NRBC w/ every order NRBC s report only via Reflex (nrbc? flag) and Pre Flex Rules location (ICU, ONCO, NICU) NRBC s with every sample. (Corrected WBC counts) Low WBC <0.5 N/A Extended Low WBC QC Submit to Insight QC submitted each run to Insight via SNCS RU Reagent diluter Not available Dilutes Cellpack DST to ready to use Cellpack DCL. (Replaces 25 Cubes) Improved differential Review rate: 13% Review rate: 8.7 logarithm Rerun reflex Manual process Hands free Platelet Count Impedence and Optical Impedence and Fluorescent Load Balancing Not available Automatically Reagents w/ RIDF* Not available Easy to use Mode to Mode Mode to mode validation One path way for sampling XN Series: Auto % XN s Series: Re Run % Rate 9

10 XN Series: Manual % Technology & ACP s What is the Impact? 10

11 ACP Interpretative Comments IG#: Increased Immature Granulocytes define a left shift. They are an automated count of metamyelocytes, myelocytes and promyelocytes. In neonates, the IG results should be used in place of the Band count and Immature to Total Ratio (ITR). IGs, along with ITR and Band count, are poor positive predictive values for sepsis in neonates. They are most useful for excluding infants without infection rather than identifying infected neonates. IRF Immature Platelet Fraction ( IPF) Clinical Uses: Helps identify if it s a consumption vs production cause of thrombocytopenia Predict platelet count recovery over time Determine need for platelet transfusion Determine if bone marrow study is needed due to thrombocytopenia Pharmacy uses to determine if thrombocytopenia is due to HIT. Case Study Thrombocytopenia Clinician prepared to order various, expensive, send-out tests. IPF was elevated Tests were avoided Treated with corticosteroids Excellent outcome 11

12 Case Study Continue Reticulated Hemoglobin (RET HE) Case Study RET He 40 year old woman presents to the ED with an episode of syncope the previous night with loss of consciousness for 1 minute. History of menorrhagia. History of iron deficiency anemia treated with blood transfusions, Temp 36.8 HR 70 BP 106/60 RR 18 Sat 98% on room air 12

13 Case Study RET He Case Study RET He Case Study 13

14 Case Study Case Study Case Study 14

15 Case Study Case Study Blood Transfusions 15

16 Immature Granulocytes IG s Immature Granulocyte (IG) Promyelocytes Myelocytes Metamyelocytes Identifies & Quantifies Immature Myeloid cells! Neutrophil count Bands Neutrophils Rapid indication of left shift and or bone marrow disease Replace I/T Ratio and Bands Infection: Identified upon admission. Case Study IG 34-year-old female with autoimmune disorder Admitted to hospital with severe hemolytic anemia Treated with steroids but no improvement Elevated WBC: o Mild cough o No signs and symptoms of infection o Chest x-ray negative. o No fevers or chills. o WBC was coming down on discharge o Clinical impression: Leukocytosis due to steroids Patient s Chart 16

17 Cellavision and Path Review Path Review Performed Day 5 MANUAL DIFF o Agreed with tech o 1% Bands o 1% Metas o 1% Other = Lymphocyte AUTO DIFF IG% = 5.9% What? Day 5 What does WAM Say? IG%= 5.9% IG%: Left shift >1.0% IG# = 1.9 IG#: Left shift >0.1 17

18 Infection or Steroids? DAY 1 DAY 5 Infection or Steroids? Day 5 o Sputum culture taken o Placed on empiric antibiotics o Clinical impression = No infection Mild cough No signs and symptoms of infection Chest x-ray negative. No fevers or chills. o Pathology Review = Suspicious for infection Not based on Peripheral Blood Smear Review Based on increasing IG results Day 7 o WBC decreasing o Discharged Day 9 Infection or Steroids? 18

19 Graphing Lab Results MDIFF Situation Background Assessment Recommendation S B A R Ig reported with ADIFF only IG not reported with MDIFF s Mandatory MDIFF in babies < 1 year Path Reviews Scan and MDIFF criteria defined for old technology. Path review criteria Manual diffs are subjective, imprecise and labor intensive 6 Part Automated Diffs with IG s are objective, precise with no extra work PBS SCAN still required for instrument generated flags Did current path reviews add value to patient care? Virtual View away CBCM from CPOE Doctors call pathology to request CBCM Patients < 1 year old Perform PBS with coded comment on bands < 10 present. If no abnormal cells seen report ADIFF If abnormal cells/blasts seen, perform MDIFF Re define path reviews criteria to identify the truly abnormal cases. Current SCAN/MDIFF Criteria Highest Ranked: 1. Meta >1% 2. Age < 1 year 3. Morphology NRBCs 4. Smudge cells >10% 5. WBC >25 & IG >5% 6. MDIFF on Path Reviews 19

20 IG s, ITR, Bands ITR & Manual ANC double dip in the manual band count Babies and IT Ratio IT Ratio: Generally accepted reference range <0.2 Ban the Band Redefine left shift as >1.0% IGs 20

21 MDIFF s on Baby (< 1 yr.) TN TP FN 133 babies 35% of acceptable ADIFF forced to MDIFF. Why? FP 51.9 Legend: True Positive: results from both the instrument and the manual differential are positive (abnormal) True Negative: results from both the instrument and the manual differential are negative (normal) False Positive: results from the instrument are positive, but the manual differential is negative. False Negative: results from the instrument are negative, but the manual differential is positive. Work Aid SCAN vs MDIFF ADIFF vs. MDIFF Rule Cellavision Pass rule & the following: 1. No blast or malignant cells 2. < 20 mononuclear smudge cells 3. < 1 year old & < 10% bands 4. Valid ADIFF REPORT ADIFF 21

22 RBC Morphology Reporting NSAP: Nonspecific RBC morphology changes present. Review RBC indices Do not report RBCM: RBC morphology normal. IDA: RBC morphology changes suggestive of Iron Deficiency Anemia. Check Ret He if not already performed (Order as RETICcomprehensive). NSAP: Nonspecific RBC morphology changes present. Review RBC indices. Note*: IDA is specific to Sysmex instrumentation with WAM OP Alert. (Adult > 1yr: Hgb < 12, MCV <75, RDW CV >16 and MCV/RBC >13). (Kids <1 yr.: Hgb <12, MCV <85, RDW CV >16 and MCV/RBC>13). RBC Grading & PBS Path Review 22

23 Control: PBS QA Worksheet MDIFF Criteria *Scan Report with ADIFF: Less than 10% bands seen on PBS smear Improvements: CBC w/adiff DIFF Pre Post Auto 51% 87% Manual 49% 13% 23

24 Improvement: Graphing Lab Results ADIFF Improvement: Reporting Improvement: CBC w/mdiff YEAR 2012, 2013, ,442 3,785 1,786 6,800 less MDIFFS!! Manual Differentials cost 2012: $22, : $3, : $ 1,

25 Site A Improvements: Path Reviews PATH Review Old Procedure Pilot Procedure PATH Review required PATH Review NOT required Site B PATH Review Old Procedure Pilot Procedure Change 20% 2% Decreased Path Reviews 18% 80% 98% Change PATH Review required PATH Review NOT required 27% 3% Decreased Path Reviews 16% 73% 97% Summary: Pilot Study Reporting CBC w/adiff on babies with the following comment: Less than 10% bands seen on peripheral blood smear Leveraging the 6-Part Diff o Increased automated differential by 36% o Decreased PBS pathology reviews by 18% Standardize RBC Morphology Reporting Improved PBS Path reviews Summary Technology Leveraged new technology to improve patient care, which includes the following: Immature Granulocyte (IG) Immature Platelet Fraction (IPF) Immature Retic Fraction (IRF) Reticulocyte Hemoglobin (RET-He) Improve coding and billing CPT code for IPF (85055) Nosocomial infection vs. acquired IG% / IG# - New Left Shift definition. Financial Decrease LOS Decrease re-admission rate due to anemia Decrease RBC / PLT transfusions 25

26 Riding the Wave on Change!! Questions 26