management of normal and abnormal laboratory results in … · 2020-05-13 · contact details for...

Management of normal and

abnormal laboratory results in

TIER.Net guidance

Enquiries, please contact:

[email protected]

of 15

APPROVAL

Document control

Document name: Management of normal and abnormal laboratory results in TIER.Net

Compiled by: TB/HIV Information System National Implementation Team

Contact details for queries: Dr. Riona Govender ([email protected])

Date of this version: October 2019

Version control

Date updated Version Updated by Comment on changes

November 2017 1.0 THIS NIT New document

October 2019 2.0 THIS NIT Change name to: Management of Normal and Abnormal Laboratory Results in TIER.Net

Updating to include management of abnormal results in addition to normal results.

Approval

Date approved Version Approved by

November 2017 1.0 Riona Govender

October 2019

2.0 Gail Andrews

of 15

Background: Laboratory tests are used as to investigate, diagnosis and monitor disease progression and

treatment interventions. The National Department of Health uses various laboratory tests and

investigations to monitor the TB/HIV programme, including Viral Loads for HIV treatment

adherence and GeneXpert for TB disease investigation. Normal TB/HIV results, once received at

a facility, are triaged by a clinician and captured into the TB/HIV information system by the

administrative clerk prior to the clinician discussing the results with the patient. Following this, the

TB/HIV information system generates reports based on the type of tests requested and the results

of the tests done, all of which are linked to a specific patient.

One of the main indicators used by the HIV programme to monitor adherence are Viral Loads.

These results (undetectable and detectable) contribute to the Viral Load rates reflected in the ART

cohort data as reported in webDHIS. Due to the successes of the HIV treatment programme and

the efficacy of ARVs, the majority of viral loads are considered ‘undetectable’ or ‘normal’, meaning

they indicate suppression of the HIV virus.

Rationale: The current National Implementation Team (NIT) guidance document for the management of

TB/HIV laboratory results1 focuses primarily on the processing of normal laboratory results. To

increase efficiencies in the management of laboratory results, the guidance instructs the

administrative clerk to capture ‘normal’ results into the TB/HIV information system using the bulk

capturing functionality immediately after being triaged by the clinician and prior to the clinician

discussing the results with the patient. Once captured, the results are filed in the patient folder by

the administrative clerk. In contrast to the triaged and signed off normal results being captured

prior to the clinical consult, triaged and signed off abnormal results are captured into the TB/HIV

information system after the clinical consult.

Whilst most patients with abnormal results are timeously recalled to the facility for consultation, and

the results subsequently captured into the TB/HIV information system, there is potential for

deviation from this norm. As a result, there is potential for the incorrect reporting of VLS rates in

the ART cohort data, and/or the latest laboratory test results not reflecting on the patient line lists

(i.e. appointment lists, missed appointment lists).

The NIT has therefore acknowledged that the process for managing abnormal results, including

unsuppressed Viral Loads, requires more rigorous oversight as delayed clinical intervention for

patients with abnormal results can result in poor treatment outcomes, including death. For

abnormal results, strict time bound interventions must include the timeous return of results to the

facility, triaging by the clinician, patient recall, documentation in the clinical folder of results and

recall intervention, and capturing of that information into the TB/HIV information system.

To mitigate the potential for the non-capturing of abnormal results, the guidance document has

been revised to include the management of both normal and abnormal results.

1 Management of Normal Laboratory Results in TIER.Net

of 15

This revised guidance includes step by step instruction for all activities relating to NHLS

laboratory results as conducted by both the clinician and the administrative clerk (AC); including

the requesting of laboratory tests, the triaging of results, recall of patients (if required), the

capturing of results and recall intervention into TIER.Net, and the filing of the results in the patient

folder.

Requesting diagnostic tests: 1. During the clinician consultation, the Clinician to indicate in the clinical stationery the requested

tests.

1.1. HIV/ART clinical stationery: Indicate the type of specimen requested in the visit column of

the ART clinical visit summary corresponding to the clinical visit date.

1.2. TB clinical stationery: Indicate in the laboratory tests and diagnostics section, or in the TB

ID register the type of test requested.

Note: If the test is requested by one clinician but referred to another for completion of the test, then

the clinician conducting the specimen collection, will need to complete section 2 and 3 below.

2. Clinician, who is conducting the test, to complete the NHLS Laboratory request form.

2.1. Place the barcoded lab specimen number sticker from the corresponding NHLS form on

each specimen tube/jar and in the clinical stationery or TB ID register next to the requested

test.

3. Clinician to record results from point of care (POC) instruments in the clinical stationery,

indicating the type of test, the result, date, and document using ‘POC’ to indicate that the test

was conducted using a POC machine.

Capturing of requested tests: 1. AC (using the patient folders and TB Identification register) to capture requested lab tests into

TIER.Net.

1.1. Open patient record, and in TIER.Net, capture the test requested against the

corresponding visit.

of 15

FIGURE 1. TEST REQUEST CAPTURING IN TIER.NET

Management of laboratory test results: Note: All results (normal and abnormal) must be captured into the TB/HIV information system on

the same day they are triaged by the clinician.

Triaging of Results: 1. Clinician to triage all test results as soon as they are received (via NHLS hard copy or SMS

printer).

2. Document all TB case finding results in the TB ID register, irrespective of result.

3. Return all triaged results to the admin clerk.

3.1 Clinician to request patient folder from the admin clerk for all abnormal results received.

3.1.1 Once folders are received; clinician to review and document intervention in clinical

stationery.

3.1.2 Clinician to open TB blue card for all TB positive patients.

Processing of Results: Note: The AC will receive all results once triaged from the clinician for further processing.

Abnormal Results:

1. AC must first prioritize the processing of abnormal results.

1.1. The AC to retrieve patient folders for those patients with abnormal results.

of 15

1.2. AC to place the results in the patient folder.

1.3. AC to give the folder to the clinician for intervention.

2. Once intervention is completed and documented by clinician, folder will be returned to the AC

for capturing.

2.1. AC to capture abnormal result into the TB/HIV Information System and initial on clinical

stationery next to the result.

2.2. AC to capture intervention activities of important information such as changes to next

appointment date, outcomes etc.

Normal Results

1. Once the results have been triaged by the clinician, they are to be returned to the AC for

capturing.

2. The AC must use the ‘Tests Awaiting Results’ functionality in the TB/HIV information

system to capture all normal lab results that are triaged by a clinician (click here or refer to

Annexure A).

Note: Results can only be captured against test requests captured in TIER.Net.

3. AC to initial and date on the returned test result once captured in the TB/HIV information

system.

4. All lab results that have been captured must then be returned to the patient folder and filed.

Missing test results: 1. If, during the patients next clinical visit, the clinician identifies that there were tests

requested (as indicated in the clinical stationery), but the results are not available in the

patient folder, then the clinician is to telephone the NHLS or look up the result using

TrakCare.

1.1. If the result is found in the NHLS or on TrakCare, the clinician must record the result,

the date, and the method of obtaining the result in the clinical stationery.

1.2. If the test is not found the clinician is to redo the test at the same visit.

1.3. If the test is not found, action should be taken to determine why the test was not

returned (i.e. issues with receiving the laboratory result from the NHLS), or not

captured in TIER.Net (i.e. issues with laboratory test results process flow within the

facility).

Using the TB/HIV information system line lists and reports for effective patient management 1. The various line lists and reports generated from TIER.net will indicate if the laboratory

tests and subsequent results were not requested and/or done by the clinician or captured

in TIER.Net.

of 15

2. All patients appearing on the various line lists, should have their folder pulled, reviewed

and actioned accordingly.

3. If the patient does not return for their scheduled next appointment, they will present on the

missed appointment lists.

4. Patients due for tests will appear on the various HIV/TB tests due/outstanding line lists.

5. If the patient has a visit rescheduled as a result of an abnormal results and those results

are captured into TIER.Net, the Appointment List will reflect the ‘abnormal’ results.

However, if the latest ‘abnormal’ results are not captured into the TB/HIV information

system when the recall visit date is captured into TIER.Net, the last captured test results

will appear on the Appointment List and not the most recent.

of 15

Annexure A:

Capturing lab results into TIER.Net, using ‘Tests Awaiting Results’: Note: This functionality is to be used only for ‘normal’ test results, as ‘abnormal’ results warrant

clinical intervention. Therefore, the abnormal test results will require additional information (i.e

change in next appointment date due to recall) to be updated in TIER.Net. For instruction on how

to capture in the patient visit screen, please click here or refer to the section or click on the link

‘Abnormal Results’

1. Open TIER.Net.

2. Click on Tools and select Pending Tests.

FIGURE 2. TESTS AWAITING RESULTS

3. This opens the “Tests Awaiting Results” pop-up grid. This grid lists all patient records that

are awaiting results of tests that have been requested (and captured in TIER.Net).

of 15

FIGURE 3. TESTS AWAITING RESULTS

4. Use the Search field to search for either the Folder number or Lab reference number. The

grid will reflect the details of the patient searched for.

5. To enter the test result for that patient, double click on the row of the patient whose test result

is to be captured.

6. The Test Details pop-up window will open.

FIGURE 4. CD4 OR VL TEST RESULTS

of 15

FIGURE 5. TB TEST RESULTS

7. Tick the Results returned checkbox to activate the Test result field.

8. Find the test result that requires capturing from the relevant section on the NHLS test result

(hard copy or sms).

8.1. Click here, or refer to ‘How to read and capture lab results reports’ section below for

specific capturing guidance.

9. Enter the test result in the Test results field.

10. Click Save.

Capturing Abnormal Results: 1. The ‘Test Awaiting Results’ functionality is not to be used with abnormal results because

it is important that proper business processes are followed, and tests are reviewed by a

clinician before they are captured into TIER.Net. The following steps must be followed:

1.1. Retrieve the patient folder

1.2. Open the patient record in TIER.Net.

1.3. Open the patient visit and depending on whether the test requested was for ART or

TB, the Test Details page will open.

of 15

1.4. Capture the lab results

FIGURE 6. TEST AWAITING RESULTS CAPTURING

of 15

How to read and capture lab results reports: Viral Loads: 1. Tick the Results returned checkbox to activate the Test result field.

2. Enter the precise viral load value from the HIV Molecular Investigations section on the lab

results report.

2.1. Note: if the result is returned as <50, then 49 must be captured.

2.2. Click the LDL button ONLY if the results are written ‘lower than detectable limit’. Note

that this will default to a viral load value of <20.

CD4: 1. Tick the Results returned checkbox to activate the Test result field.

FIGURE 7. CAPTURING VIRAL LOADS FROM RESULTS

of 15

2. For adult patients: Enter the absolute CD4 value from the CDARV section on the lab results

report.

3. For paediatric patients: Enter the CD4 percentage value from the CDARV section on the lab

results report.

FIGURE 8. CD4 CAPTURING

of 15

Negative GXP: 1. Tick the Results returned checkbox to activate the Test result field.

2. Enter the PCR result from the Real time PCR for M. tuberculosis (GeneXpert) section on

the lab results report.

Note: ‘Mycobacterium tuberculosis complex NOT detected’ means that the test result is

negative.

FIGURE 9. NEGATIVE GXP

of 15

Negative smear: 1. Tick the Results returned checkbox to activate the Test result field.

2. Enter the Result (concentrated) from the Auramine O stain section on the lab results

report.

FIGURE 10. NEGATIVE SMEAR

management of normal and abnormal laboratory results in … · 2020-05-13 · contact details for...

Documents