kscls kcclma how the clinical laboratory enhances patient care fred v. plapp, md phd medical...

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kscls kcclma How the Clinical Laboratory Enhances Patient Care Fred V. Plapp, MD PhD Medical Director Saint Lukes Regional Laboratories kscls kcclma Slide 2 kscls kcclma Diagnosis of Meningitis Expediting Patient Care Infection of tissues surrounding the brain & spinal cord Bacterial or viral Mostly viral Viral usually mild Bacterial is life- threatening Slide 3 kscls kcclma Diagnosis of Meningitis Traditional 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 Slide 4 kscls kcclma Viral Meningitis Traditional Diagnosis 4 10 Days Slide 5 kscls kcclma Viral Meningitis Real Time PCR Diagnosis 1 million viral copies in 30 minutes instead of 10 days Slide 6 kscls kcclma New Meningitis Algorithm Slide 7 kscls kcclma Meningitis Outcomes Downstream 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 Slide 8 kscls kcclma Rapid ID of CoNS Improved 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 $$$$$ Slide 9 kscls kcclma Rapid ID of CoNS Lab & Pharmacy Cost Savings Time to IDAntibiotic Dose per Patient Cost per Patient* Culture Alone 132 hours5.8$72.02 Culture + PNA 38 hours2.8$14.28 Cost per patient included antibiotics & laboratory tests Slide 10 kscls kcclma Rapid ID of CoNS Downstream 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 kscls kcclma Slide 11 kscls kcclma Recombinant rFVIIa Usage Laboratory 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 Slide 12 kscls kcclma Reining in the Outlier Surgeon1Q091Q10 1$5450$0 2 3 4 $12,220 5$98,690$16,000 Slide 13 kscls kcclma Open Heart Surgery Transfusion 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 Slide 14 kscls kcclma Average Number of Units Transfused per OHS Case Slide 15 kscls kcclma 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 Slide 16 kscls kcclma Order Sets Ensuring 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 Slide 17 kscls kcclma 70 Order Sets Impact on Test Utilization YearCases/YrTests/CsTest/Yr 1992882350.3443,797 1996963044.3426,609 Diff807-6-17,188 % Diff+9%-12%-4% Slide 18 kscls kcclma Inpatient Tests per Discharge Slide 19 kscls kcclma Specimen in Lab Policy Decreasing 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 Slide 20 kscls kcclma Specimen in Lab Policy SLH 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 Slide 21 kscls kcclma POC Blood Glucose Testing Improving 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 Slide 22 kscls kcclma Glucose Meter ID Errors Slide 23 kscls kcclma Test Utilization Ideas Test Utilization Ideas www.clinlabnavigator.com