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How the Clinical How the Clinical Laboratory Enhances Laboratory Enhances

Patient CarePatient Care

Fred V. Plapp, MD PhDMedical Director

Saint Luke’s Regional Laboratories

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Diagnosis of MeningitisDiagnosis of MeningitisExpediting Patient CareExpediting Patient Care

Infection of tissues surrounding the brain & spinal cord

Bacterial or viral◦ Mostly viral

Viral usually mildBacterial is life-

threatening

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Diagnosis of MeningitisDiagnosis of MeningitisTraditional PracticeTraditional Practice

Patient presents to Emergency Room Lumbar puncture to collect CSF

◦Bacterial cultures require 3 days◦Viral cultures require 10 days

Patient admitted to hospitalTreated with IV antibiotics until likely

that bacterial culture will be negativeDischarged with outpatient antibiotics

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Viral MeningitisViral Meningitis Traditional DiagnosisTraditional Diagnosis

4 – 10 Days

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Viral MeningitisViral MeningitisReal Time PCR DiagnosisReal Time PCR Diagnosis

1 million viral copies in 30 minutes instead of 10 days

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New Meningitis AlgorithmNew Meningitis Algorithm

D ischarge

EnterovirusD etected

Adm it to H ospita l

EnterovirusN ot D etected

R T PC R w hile patient is in ER

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Meningitis OutcomesMeningitis OutcomesDownstream Cost SavingsDownstream 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

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Rapid ID of CoNSRapid ID of CoNSImproved Antibiotic Improved Antibiotic

StewardshipStewardshipPeptide 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 $$$$$

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Rapid ID of CoNSRapid ID of CoNSLab & Pharmacy Cost SavingsLab & Pharmacy Cost Savings

Time to ID

Antibiotic Dose per Patient

Cost per Patient*

Culture Alone

132 hours

5.8 $72.02

Culture + PNA

38 hours 2.8 $14.28

Cost per patient included antibiotics & laboratory tests

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Rapid ID of CoNSRapid ID of CoNSDownstream Cost SavingsDownstream Cost Savings

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

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Recombinant rFVIIa UsageRecombinant rFVIIa UsageLaboratory as a WatchdogLaboratory 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

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Reining in the OutlierReining in the Outlier

Surgeon

1Q09 1Q10

1 $5450 $0

2 $0 $0

3 $0 $0

4 $0 $12,220

5 $98,690 $16,000

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Open Heart SurgeryOpen Heart Surgery Transfusion ReviewTransfusion Review

OHS transfused ~one third of componentsClinical 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

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Average Number of Units Transfused per OHS

Case

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Ave

rag

e #

Un

its p

er P

atie

nt

RBC FFP Platelets

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Benefits of Decreased Benefits of Decreased TransfusionTransfusion$260,000 cost savings in blood

products per yearTransfusion reaction risks decreasedBlood Bank workload decreasedNursing time for transfusion

decreased

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Order SetsOrder SetsEnsuring Appropriate TestingEnsuring Appropriate Testing

Nurses & physicians write order setsClinical Pathologists review lab tests

◦Additions, deletions, substitutionsSuggestions returned to authorsOrder sets publishedTest utilization monitored before &

after

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70 Order Sets70 Order SetsImpact on Test UtilizationImpact on Test Utilization

Year Cases/Yr Tests/Cs Test/Yr

1992 8823 50.3 443,797

1996 9630 44.3 426,609

Diff 807 -6 -17,188

% Diff +9% -12% -4%

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Inpatient Tests per Inpatient Tests per DischargeDischarge

010

2030

4050

60

1Q94 1Q95 1Q96 1Q97 1Q98 1Q99 2Q00 1Q01 1Q02 1Q03 1Q04

75th percentile

25th percentile

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Specimen in Lab PolicySpecimen in Lab PolicyDecreasing WastageDecreasing 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

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Specimen in Lab PolicySpecimen in Lab PolicySLH OutcomesSLH Outcomes

11,244 requests for tests on SIL

$51,726 savings in labor & supplies

Avoided 11,244 venipuncturesConserved 71,428 mL of blood

◦Equivalent to 140 units of RBCs

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POC Blood Glucose POC Blood Glucose TestingTesting

Improving Patient SafetyImproving Patient SafetyManual 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

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Glucose Meter ID ErrorsGlucose Meter ID Errors

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Err

or

Ra

te %

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Test Utilization IdeasTest Utilization Ideas www.clinlabnavigator.com