working together to improve patient safety: 'to screen or not to screen' in suspect...
DESCRIPTION
This presentation was delivered in session F1 of Quality Forum 2014 by: Anita Kwong Director, Laboratory Quality and Process Improvement Lower Mainland Pathology and Laboratory MedicineTRANSCRIPT
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To Screen Or Not To Screen In Suspect Urinary Tract Infections
BCPSQC Quality Forum 2014 Session F1 February 28, 2014
Vancouver General Hospital Laboratory
VCH Regional Laboratory Medicine Lower Mainland (LM) Laboratories
Anita Kwong, Director, Quality and Process Improvement, LM Laboratories
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Project Team
• Disclosure: No project team members has affiliation (financial or otherwise) with a commercial organization that is related to this presentation
Multi – Discipline Collaboration Team Members
VGH Medical Biochemistry Dr. Morris Pudek, Adelina Lim, Karen Ng, Alisha Thompson, Biochemistry technologists
VGH Medical Microbiology Dr. Diane Roscoe, Charlene Porter, Jackie O’Connell, Microbiology technologists
VCH Operations Richard Walker Sharon Stapleton
LM / VCH Labs Quality Team Sara Garcha (up to Oct 2013) Anita Kwong
Data Analysis Jason Pal (up to Dec 2013)
VCH Regional Laboratories Vancouver General Hospital
VCH Regional Laboratories: – Include 11 sites – VGH – One of the largest
diagnostic laboratories in Western Canada
– Referral centre for other VCH Laboratories
– Referral centre for special tests across the province
Who We Are Laboratory Physicians, Medical
Technologists and Medical Laboratory Assistants working in: • Medical Biochemistry • Hematopathology • Medical Microbiology • Transfusion Medicine • Anatomical Pathology • Cytology • Cytogenetics and Molecular
Genetics • Transplant Immunology
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Patients We Serve at VGH Laboratory
Partial list of samples / procedures Per day
Blood collections (lab staff procedures only)
900
Chemistry samples 1,800
Chemistry urine samples for urinalysis 140
Microbiology samples 1,100
Microbiology urine samples for culture 185
Urinary Tract Infections (UTI) • 1 in 3 women will experience UTI by age 24 • Female lifetime probability of UTI is >50% • UTI most common bacterial infection for both
hospitalized and community patients • Major healthcare cost driver:
• VCH: UTI is the most common Hospital-Acquired Infection (HAI), 18,900 cases over 4 years, $16.3m in costs (Raschka, S. 2012. Health Economic Evaluation of Quality and Patient Safety Within an Organization, Quality Forum 2012.)
• Diagnosis and Management algorithm
• Gold standard for bacterial cause of UTI = culture
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Urinalysis • If laboratory testing is required, perform urinalysis
dipstick first: • May be automated • Costs ~$0.30 • Results ready in 2 minutes
• If dipstick positive → microscopy for cellular elements
• Microscopy is labour intensive • Costs ~$5 (labour) • Results ready in 1-2 hours • At VGH, of 140 urinalysis requests per day, 30% require
microscopy exam
• Outpatients UTI laboratory protocol: – dipstick leukocyte and/or nitrite positive → urine culture
• Inpatients: – Urinalysis and urine culture are independent orders
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Urine Cultures
• Urine cultures for bacterial cause of suspect UTI • Labour intensive • Costs ~$5 to $40 per culture • Results ready in 1 to 2 days • At VGH, 185 urines are processed for cultures per day
• Many patients are treated with antibiotics without culture results being known
• Many UTIs are diagnosed without the supporting information of a urinalysis
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New Technology • Current technology:
– Dipstick, microscopy, urine cultures
• New technology: • Flow cytometry uses scattered
light which reflects the size and volume of each cellular element, e.g. WBC, RBC, and bacteria.
• Fluorescent stains specifically targets mitochondrial and nuclear DNA of these cells.
• Cellular elements are counted and quantitative values are available in minutes.
New Approach to UTI Diagnosis
Automated Urinalysis +
Fluorescent Flow Cytometry (FFC) =
Rapid and powerful tool to screen urine samples for
absence / presence of UTI
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Cross Discipline Collaboration
• Evaluation of Fluorescent Flow Cytomery (FFC) at VGH laboratory
• September 18 to October 18, 2013 • Urine samples (n=432) were tested for:
• Urinalysis & FFC on instrument A • Urinalysis & FFC on instrument B • Urine cultures – read at 24 hours and 48 hours
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Study Findings * Using urine culture results as gold
standard: • FFC threshold was identified to correlate
to negative cultures • Sensitivity 90% • Specificity 74%
• Applying the FFC threshold in this study: • Of 430 urine samples, 257 (60%) would
not have been cultured using FFC negative bacteria count cutoff
(Both instruments A and B yielded similar results)
Correlating Results Biochemistry Microbiology
430 urine samples in FFC study
185 urine samples for culture per day
60% would not have been cultured
40% no growth 19% no significant growth
FFC negative
Results in 5 minutes No growth or no significant growth
Results in 1 to 2 days
Cost of urinalysis and FFC $1.50 (excluding capital cost)
Cost savings for not processing no growth urines: ~$135K per year
Reference: US study reduced
unnecessary urine cultures by 55%
Gieson, Greeno, Thompson et al, 2013. Clin Biochem.
Surrogate Marker for No Growth Urine Culture Results
Available in <1 hour
• Patient Safety Benefits: • Avoids unnecessary antibiotic treatment • Potential reduction of side effects related to
antimicrobial therapy
• Systems Benefits: • Reduces healthcare costs • Reduces laboratory operations cost • Promotes team building across laboratory
disciplines
Next Steps • Validate findings with identified patient
groups • Validate findings with samples specifically
ordered for urine cultures • Laboratory workflow re-design across
Biochemistry and Microbiology • Collaborate with clinical partners to change
practice of laboratory UTI diagnosis
Thank You!
Questions