Use of the IANC (Instrument Absolute Neutrophil Count)

to Improve Turn Around Time

Background on UCSD Health System

• 2 hospital campuses with Rapid Response Laboratories in each. Perform all inpatient testing.

• 1 Core lab where outpatients, special chem, special heme, special coag, microbiology, HLA, genetics, flow cytometry, cytogenetics, and toxicology testing is performed.

• Moore’s Cancer Center located on one hospital campus.

• Moore’s Cancer Center (MCC) had a small laboratory with 3.5 CLS FTEs where STAT hematology and chemistry tests were performed.

• Lab was located across hall from Infusion Center.

• Lab was closed in August, 2012 for budgetary reasons.

• STAT testing (100 patients/day) was moved to hospital lab located 10 minutes away (by foot).

In September 2012, the Infusion Center approached the Lab asking for help in improving their patient satisfaction survey. Patients were not satisfied with the long waiting time before they received their infusion.

One of the causes of long waiting time for infusion is the TAT for ANC (Absolute Neutrophil Count). In most cases, the release of ANC is tied to the completion of manual differential. Pharmacy will not release medications until an ANC value is available in the HIS.

Intend to reduce the time to post the ANC from 60 minutes 70% of the time to within 60 minutes 90% of the time, from time the samples are collected for Oncology patients at the Infusion Center by December 2013 thus reducing the patient wait time for chemotherapy and infusion of oncology patients.

Formulation of PDSA Project

Based on September 2012 data from the LIS: -ANC testing measured as part of CBC with diff is completed within 60 minutes 70% of the time from collection to posting of result.

-The mean TAT is 75 minutes.

Data Gathering

• Transport time from MCC to Thornton Hospital lab was about 10 minutes via walking courier.

• Each MCC patient had duplicate slides made by Sysmex sp1000i slide

maker/stainer. • Thornton only had one license to operate the automated slide reader

(Cellavision) so only one tech at a time could perform diffs.

Causes of Delay

1. Three couriers were hired to move samples from MCC to

Thornton - The couriers were timed to determine how long it takes to

walk from MCC to Thornton to deliver samples and back (12.5 minutes).

- Based on the study, a walking schedule was developed by MCC for the couriers.

Steps Taken to Improve TAT for ANC

2. Clinicians were asked to give up the requirement for duplicate

slides for their use. Clinicians agreed with the following conditions:

- Provide Cellavision access at MCC for Clinicians to remotely view slides.

- Retain the option to request the slide - Develop an orderable test for them to request slide review

regardless of CBC results

Steps Taken to Improve TAT for ANC

3. Thornton purchased a second CellaVision license to operate/edit automated differential results.

4. Hematology autoverification was instituted in December, 2012.

Steps Taken to Improve TAT for ANC

Sep12 Oct12 Nov12 Dec12 Jan13

Mean: 75 57 62 60 55 <60 mins 70.3 70.4 69.5 71.5 71

Monitoring of Improvements

Monitoring of Improvement

75

57 62 60

55

0

10

20

30

40

50

60

70

80

Tim

e in

Min

ute

s

Mean ANC TAT

Mean

70.3 70.4

69.5

71.5

71

68.5

69

69.5

70

70.5

71

71.5

72

Pe

rce

nt

ANC TAT % <60 minutes

< 60 minutes

Based on the initial results thru January 2013, it was apparent that there was more room to improve on the TAT of ANC.

Monitoring of Improvements

Our Medical Director asked Sysmex if the instrument generated ANC (IANC) could be released together with the Hemogram? The answer was “Yes” but would take some modifications in WAM by Sysmex.

Request for Additional Improvements

1. A change request was submitted to Sysmex to allow the IANC to be posted together with the hemogram for MCC location only.

The request took a little over a month to complete since it required a change in WAM software.

Steps taken to Release IANC with Hemogram

2. A separate request was submitted to HIS and LIS to add IANC to the CBC results. 3. Once all the changes were made, testing of the release of IANC with hemogram was conducted. Sysmex supplied a Test Plan.

Steps taken to Release IANC with Hemogram

On July 30, 2013, the release of IANC with the hemogram was implemented.

Implementation of IANC

Based on the September Data :

82% of IANC are posted within 60 minutes of collection with a mean TAT of 46 minutes.

September 2012 data shows 70% and 75 minutes respectively.

Results of Implementation

Based on the September Data :

98% of IANC are posted within 60 minutes of receipt with a mean TAT of 17 minutes!

The September 2012 data shows 82% and 54 minutes respectively.

Results of Implementation

1. Numerous WAM rules needed to be revised to hold the IANC under various conditions involving lots of rules testing.

Challenges of Implementation

2. Medical Director of HIS decided to include IANC for patients in ALL locations. Original test plan had to be revised and retested.

Challenges of Implementation

3. Hematology Medical Director noted that the difference between the ANC and the IANC was sometimes more than 10%, mostly with lowest WBCs. On 9/17/13, started reporting IANC only on patients at MCC location.

Challenges of Implementation

4. Are still determining whether to post the flagged IANCs before reviewing the smear.

Challenges of Implementation

The nurse manager at MCC stated that they are using the IANC to determine whether infusion will occur. She felt that the TAT had improved but didn’t have any statistical basis to support it. If the IANC is close to the infusion cutoff of 1.5, they will wait for the ANC. Sometimes the CBC is completed but they still need to wait for the chemistries to complete.

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