Combining and New Diagnostic to Help Clinicians Achieve Patient Outcomes at per Healthcare Encounter
Holly McDaniel, MD hmcdaniel@clinpath.com Holly.mcdaniel@bannerhealth.com
Holly McDaniel, MD AP/CP and Cytopathologist Clin Path Associates Laboratory Medical Director Banner Estrella Medical Center Phoenix, AZ
Largest non profit health care system in the country serving patients across 7 states. Ten Medical Centers in the Phoenix Area
LABORATORY Day 5 CASE #1 Peripheral Blood Smear submitted for Path Review Metamyelocytes present Criteria based on Hematology Analyzer with a 5 Part Diff WBC Diff Type 33 H MANU Segs% 67% H Bands% 3% Meta% 3% H Myelo% 0% Pro% 0%
CASE #1 New Hematology Analyzer has 6 Part Diff Automated differential identifies Metas, Myelos and Pros as Immature Granulocytes (IG) IG = 6-Part Diff! Day 1 Day 5 IG 1.1% H IG 3.3% H
CASE #1 34 year old woman with multiple medical problems, treated with steroids for autoimmune disease. Increasing WBC, but mature neutrophilia. I think its demargination secondary to the steroids. What do you think? Her IG was mildly elevated on admission and is increasing. I think she has an infection. There are no clinical features of infection. I think it is demargination. Infection. Infection. Demargination. Demargination.
CASE #1 Day 5 ID Consult obtained Infection. Present on admission. NOT a Hospital Acquired Infection. Sputum culture taken Placed on empiric antibiotics Day 7 WBC and IG decreasing Discharged Day 9 Sputum positive for H. influenza LABORATORY Day 1 Day 3 Day 5 WBC 13 H 19 H 33 H Diff Type AUTO AUTO AUTO Segs% 65% H 65% H 67% H IG% 1.1% H 2.3% H 3.3% H
CASE #1 CBC Day 5 WBC 33 H Diff Type MANU CBC Day 5 WBC 33 H Segs% 67% H Diff Type AUTO Bands% 3% Segs% 70% H Meta% 3% H IG% 3% H Myelo% 0% Pro% 0% Which Lab results would you prefer?
IG (Immature Granulocyte) RET-He (Reticulocyte Hemoglobin Equivalent) IPF (Immature Platelet Fraction)
Our Set Up XE 5000 Reflex IPF RET-He NRBCs Cellavision WAM Flag for smear review Release Results Autoverification
TESTS LAB What do they mean? PHYSICIAN What do they MEAN? IG RET-He IPF Metas, Myelos, Pros Hb in Retics Immature platelet fraction Left Shift Iron Deficiency BM response to low PLTs
TESTS IG RET-He IPF LAB What do they mean? Metas, Myelos, Pros Hb in Retics Immature platelet fraction Patient Care PHYSICIAN What do they MEAN? WHAT DO Left Shift Iron Deficiency BM response to low PLTs THEY MEAN? 1. With or without anemia (new ICD10 code for Iron Deficiency!) 2. IV Iron, with or without Epo Support diagnosis of infection on admission Identify MPD Follow treatment LOS and HAI Identify Iron Deficiency 1 Treatable anemia 2 Pre operative Dx & Tx Readmissions RBC Transfusions LOS and HAI Unnecessary BM Bx Predict PLTrecovery PLT Transfusions LOS and HAI
Situation Need physicians to utilize improve patient care to Background Assessment Recommendation
IG (Immature Granulocyte) Myeloblast Pro Myelo Meta Band Seg mature immature IG ANC Identifies and quantifies immature myeloid cells 32,000 cells More sensitive and more precise than manual diff definition of Left Shift Early screen for sepsis Better indicator for infection than WBC IG% >1% indicates a left shift IG% >3% may predict positive blood cultures
Automated Differential Basophil Eosinophil Neutrophil Monocyte Lymphocyte Previous Analyzer 5 Part Diff Current Analyzer 6 Part Diff Basophil Eosinophil IG Neutrophil Monocyte Lymphocyte
How does IG compare to Band Count? Band Count is poorly reproducible Criteria for Bands is subjective Three different definitions How pinched is the nucleus? Neutrophil Band IG is than the Band Neutrophil? Band?
RET-He (Reticulocyte Hemoglobin Equivalent) Nucleated RBC Immature Reticulocyte Reticulocyte Equivalent to Reticulocyte Hemoglobin Content (CHr) Measurement of iron available to cells Not affected by uremia or inflammation Diagnose iron deficiency and response to treatment RET He shows treatment effect in 3 days Pre op evaluation of orthopedic patients can decrease RBC transfusions Inexpensive losing money if not utilized! Red Blood Cell RET-He is the Cellular Iron Level
CASE #2 40 year old woman presents to the ED with an episode of syncope the previous night with loss of consciousness for 1 minute. PMH Menorrhagia. Iron deficiency anemia treated with blood transfusions, 2010. Physical Exam Vital Signs Normal
Microcytic anemia RET He < 29 pg = Iron deficiency in adults (KDOQI Guidelines) Iron Transferrin Trans % Sat Ferritin High Normal High Low
Diagnosis: Severe iron deficiency anemia secondary to menorrhagia RET He confirmatory Iron studies: Conflicting results IV iron given prior to lab draw Treatment: IV iron Check RET He in 3 days for response Add Epo if needed Treat the cause of menorrhagia X Don t transfuse if hemodynamically stable
IPF (Immature Platelet Fraction) Megakaryocyte Immature Platelets Platelets Decreased Thrombopoietin Thrombopoietin stimulates decreases megakaryocytes platelet and production increases platelet production Normal or increased platelet count Low decreases platelet count thrombopoietin stimulates production thrombopoietin production Plts + Plts + % Immature PLTs Total PLTS Evaluate mechanism causing thrombocytopenia IPF recovers ~3 days earlier than platelet count Determine need for platelet transfusion Predict platelet count recovery IPF Peripheral destruction or BM Recovery IPF BM production disorder
IPF and Platelet Count Briggs, Carol et al. Assessment of an immature platelet fraction (IPF) in peripheral thrombocytopenia. British Journal of Haematology, 126, 93 99; 2003.
Situation Need physicians to utilize improve patient care to Background One analyzer Multiple which can impact: Infection/sepsis IG Anemia RET-He Blood utilization RET-He & IPF Assessment Recommendation
Our Process What we did Right Pick the right instrument Educate Lab and Pathologists Successful implementation in AZ hospitals
Our Process Communication o Educate Physicians Articles Handouts Table toppers SBAR Laboratory Memo Interpretative messages in EMR Presentations at Department Meetings o Educate Pharmacy & Nursing o Educate Administration Gave my CMO a mug!
Our Process What we could have done Integrate into Care Pathways and Caresets
Reticulocytes Dropped from Careset **Discontinued** Iron/Epoetin Careset **New current** Iron/Epoetin Discern Advisor RET-He part of Reticulocyte Comprehensive Order
Our Process What we could have done Integrate into Care Pathways and Caresets Sepsis Alert Fever 101 F or hypothermia (<96.8 F) Heart rate >90 beats/minute Respiration rate >20 breaths/minute White blood count >12,000 µl or <4,000 μlor with >10% bands
Situation Need physicians to utilize improve patient care to Background Assessment One analyzer Multiple which can impact: Infection/sepsis IG Anemia RET-He Blood utilization RET-He & IPF Under utilized Not available in Care Sets Recommendation
Our Process What we could have done Get a Seat at the Table Functional Teams Clinical Consensus Groups Strategic Clinical Initiative Teams Clinical Performance Groups Discipline Teams
Our Process What we could have done Reflex Testing for RET He Started with Hgb < 9.0 AND MCV <78 AND No previous in 30 days Need to adjust! X X X Don t need low Hb Don t need microcytic RBCs Can change in 3 days with treatment Recommend RET He Patients at risk for iron deficiency: Children, Women, Elderly Fractures Elective surgery pre op evaluation Inpatients receiving iron +/ Epo (Test every 3 days)
Our Process What we could have done Reflex Testing for IPF Thrombocytopenia: When to reflex to IPF? Started with PLT < 30,000 Moved to PLT < 50,000 Now at PLT < 100,000 Seeing cases where IPF impacts management BM biopsies not required Decreased PLT transfusion
CASE #3 40 year old woman presented with abdominal pain Recent diagnosis of Breast Carcinoma Treated with chemotherapy ~ 2 weeks ago Admission findings Ovarian mass Thrombocytopenia PLT 30 L IPF 15.0 H
35 Plts + IPF 30 25 Peripheral destruction or BM Recovery 20 15 Platelet Count Immature Platelet Fraction (IPF) Clinical impression No active bleeding Stable vital signs Surgery consult not an acute abdomen. 10 5 0 Day 1 IPF cut off 7.1 Options 1. Transfuse platelets to raise PLT > 50 and perform surgery to remove ovarian mass. 2. Wait to see if platelet count recovers, then perform surgery.
120 100 80 60 40 Platelet Count Immature Platelet Fraction (IPF) Follow up: Platelet count recovered. Surgery found a benign serous cystadenoma with torsion. No metastatic carcinoma. 20 IPF cut off 7.1 0 Day 1 Day 2 Day 3 Day 4
IG RET-He IPF Support diagnosis of infection on admission Identify MPD Follow treatment Identify Iron Deficiency Treatable anemia Pre operative Dx & Tx Won t lose reimbursement for misdiagnosis of HAI LOS and HAI ICD10 for Iron Def Readmissions RBC Transfusions LOS and HAI Unnecessary BM Bx Predict PLTrecovery PLT Transfusions Cost for PLTs LOS and HAI
Situation Need physicians to utilize improve patient care to Background Assessment Recommendation One analyzer Multiple which can impact: Infection/sepsis IG Anemia RET-He Blood utilization RET-He & IPF Under utilized Not available in Care Sets Continue to educate Incorporate tests into Care Sets Fine tune reflex testing Obtain outcomes data Proactively assert Laboratory and Pathologist s expertise to help the Hospital meet its goals
Hospital Lab Nursing Physicians Pathologists Technologists Administration Informatics Pharmacy Finance Quality Pathologists
Need to align criteria for Manual Diff and Path Review with Analyzer s Ability to perform a 6 Part Diff WHERE TO START? New Criteria for Determining Differential Type and Requirement for Path Review using New Hematology Analyzer (Sysmex XE 5000) which Reports a 6 Part Differential
Is a PBS indicated? XE 5000 PILOT Study YES Manual Diff Is a Manual Diff required? Determined by Analyzer & Middle Ware No changes for Pilot Study NO Autoverified YES PBS Review Is a Path Review required? NO YES NO Auto Diff 6 Part Diff No Path Review
Is a Manual Diff required? 944 PBS performed Previous Analyzer (5 Part Diff) New Analyzer (6 Part Diff) % Auto Diffs 51% 87% % Manual Diffs 49% 13% Leveraging the 6 Part Differential Automated Diffs increased 36%
Reason for Manual Diff on Previous Analyzer (5 Part Diff) 294 of the 944 (31%) cases with Manual Diff using 5 Part Diff Criteria due to the presence of Immature Granulocytes (Metas, Myelos and/or Pros)
Is a Path Review required? Previous Analyzer (5 Part Diff) New Analyzer (6 Part Diff) # Path Reviews 278 50 %Path Reviews 29% 5% 30% 25% 20% 15% 10% 5% Percent of PBS Requiring Path Reviews Leveraging the 6 Part Differential Path Reviews decreased 24% 0% Previous Analyzer (5 Part Diff) New Analyzer (6 Part Diff)
Reasons for Path Review following Previous Analyzer (5 Part Diff) Procedures Majority of PBS sent for Path Review due to presence of Immature Granulocytes (Metas, Myelos and/or Pros) Most in low numbers (E.G. 3 Metas)
Reasons for Path Review following New Analyzer (6 Part Diff) Procedures 8 7 6 5 4 3 2 1 0 Fewer PBS sent for Path Review due to presence of Immature Granulocytes (Metas, Myelos and/or Pros) when higher threshold used. Higher thresholds possible because IG identified by Auto Diff.
Pilot Study Summary Side by side comparison of criteria used on Previous Analyzer (5 Part Diff) to updated criteria for New Analyzer (6 Part Diff) Scan of PBS slide confirms presence of Automated Diff Leveraging the 6 Part Diff Increased Automated Diffs by 36% Better CBC Reports with clear trending of IGs Decreased Pathology Reviews by 24% Fewer non value added Pathology Reviews More time to spend on PBS with significant findings