Euan J. McCaughey

External Quality Assessment beyond the analytical phase: an Australian perspective

External Quality Assessment (EQA) is the verification, on a recurring basis, that laboratory results conform to expectations for the quality required for patient care. It is now widely recognised that both the pre- and post-laboratory phase of testing, termed the diagnostic phases, are a significant source of laboratory errors. These errors have a direct impact on both the effectiveness of the laboratory and patient safety. Despite this, Australian laboratories tend to be focussed on very narrow concepts of EQA, primarily surrounding test accuracy, with little in the way of EQA programs for the diagnostic phases. There is a wide range of possibilities for the development of EQA for the diagnostic phases in Australia, such as the utilisation of scenarios and health informatics. Such programs can also be supported through advances in health information and communications technology, including electronic test ordering and clinical decision support systems. While the development of such programs will require consultation and support from the referring doctors, and their format will need careful construction to ensure that the data collected is de-identified and provides education as well as useful and informative data, we believe that there is high value in the development of such programs. Therefore, it is our opinion that all pathology laboratories should strive to be involved in an EQA program in the diagnostic phases to both monitor the diagnostic process and to identify, learn from and reduce errors and near misses in these phases in a timely fashion.

Imaging for patients presenting to an emergency department with back pain: Impact on patient pathway.

The objective of the present study is to quantify utilisation of imaging for patients presenting to an ED with back pain, their characteristics and dispositions.

What is the impact of an electronic test result acknowledgement system on Emergency Department physicians’ work processes? A mixed-method pre-post observational study

OBJECTIVEnTo examine the impact of an electronic Results Acknowledgement (eRA) system on emergency physicians test result management work processes and the time taken to acknowledge microbiology and radiology test results for patients discharged from an Emergency Department (ED).nnnMETHODSnThe impact of the eRA system was assessed in an Australian ED using: a) semi-structured interviews with senior emergency physicians; and b) a time and motion direct observational study of senior emergency physicians completing test acknowledgment pre and post the implementation of the eRA system.nnnRESULTSnThe eRA system led to changes in the way results and actions were collated, stored, documented and communicated. Although there was a non-significant increase in the average time taken to acknowledge results in the post period, most types of acknowledgements (other than simple acknowledgements) took less time to complete. The number of acknowledgements where physicians sought additional information from the Electronic Medical Record (EMR) rose from 12% pre to 20% post implementation of eRA.nnnCONCLUSIONSnGiven that the type of results are unlikely to have changed significantly across the pre and post implementation periods, the increase in the time physicians spent accessing additional clinical information in the post period likely reflects the greater access to clinical information provided by the integrated electronic system. Easier access to clinical information may improve clinical decision making and enhance the quality of patient care. For instance, in situations where a senior clinician, not initially involved in the care process, is required to deal with the follow-up of non-normal results.

Key factors influencing the incidence of hemolysis: A critical appraisal of current evidence

Abstract Hemolysis is a leading cause of pre-analytical laboratory errors. The identification of contributing factors is an important step towards the development of effective practices to reduce and prevent hemolysis. We performed a review of PUBMED, Embase, Medline and CINAHL to identify articles published between January 2000 and August 2016 that identified factors influencing in vitro hemolysis rates. The 40 studies included in this review provide excellent evidence that hemolysis rates are higher in Emergency Departments (EDs), for non-antecubital draws, for specimens drawn using an intravenous catheter compared to venipuncture and for samples transported by pneumatic tube compared to by hand. There is also good evidence that hemolysis rates are higher when specimens are not collected by professional phlebotomists, larger volume specimen tubes are used, specimen tubes are filled less than halfway and tourniquet time is greater than one minute. The results of this review suggest that hospitals and clinical laboratories should consider deploying phlebotomists in EDs, drawing all blood through a venipuncture, using the antecubital region as the optimum blood collection site and transporting specimens by laboratory assistant/other personnel, or if this in not practical, ensuring that pneumatic transport systems are validated, maintained and monitored. Studies also recommend making hemolysis a hospital-wide issue and ensuring high-quality staff training and adherence to standard operating procedures to reduce hemolysis rates. Awareness of the factors that influence hemolysis rates, and adoption of strategies to mitigate these risk factors, is an important step towards creating quality practices to reduce hemolysis rates and improve the quality of patient care.

Point-of-care testing across rural and remote emergency departments in Australia: staff perceptions of operational impact

New South Wales (NSW) Health Pathology is implementing one of the worlds largest managed PoCT services across rural and remote Emergency Departments (EDs) in New South Wales, Australia to improve patient access to care. The aim of this qualitative study was to gain a context-rich understanding of the operational impact of the NSW rollout of PoCT across rural and remote ED settings as experienced by frontline clinical staff. Clinical professionals (n=14) participated in interviews and focus groups in August 2015 at four rural and remote NSW EDs. Participants perceived that PoCT provided greater access to pathology thus facilitating more efficient and effective patient care via faster test turnaround and time to treatment and more effective decisions about the need to transfer patients to appropriate sites when required. These factors have a potentially important role in saving lives. Staff also identified innovative and disruptive challenges to clinical work patterns associated with PoCT implementation, particularly in relation to work flows, resource allocation and the governance arrangements.

Optimal electrode position for abdominal functional electrical stimulation

Abdominal functional electrical stimulation (abdominal FES) improves respiratory function. Despite this, clinical use remains low, possibly due to lack of agreement on the optimal electrode position. This study aimed to ascertain the optimal electrode position for abdominal FES, assessed by expiratory twitch pressure. Ten able-bodied participants received abdominal FES using electrodes placed: 1) on the posterolateral abdominal wall and at the motor points of 2) the external oblique muscles plus rectus abdominis muscles, and 3) the external obliques alone. Gastric (Pga) and esophageal (Pes) twitch pressures were measured using a gastroesophageal catheter. Single-stimulation pulses were applied at functional residual capacity during step increments in stimulation current to maximal tolerance or until Pga plateaued. Stimulation applied on the posterolateral abdominal wall led to a 71% and 53% increase in Pga and Pes, respectively, compared with stimulation of the external oblique and rectus abdominis muscles ( P < 0.001) and a 95% and 56% increase in Pga and Pes, respectively, compared with stimulation of the external oblique muscles alone ( P < 0.001). Stimulation of both the external oblique and rectus abdominis muscles led to an 18.3% decrease in Pga compared with stimulation of only the external oblique muscles ( P = 0.040), with inclusion of the rectus abdominis having no effect on Pes ( P = 0.809). Abdominal FES applied on the posterolateral abdominal wall generated the highest expiratory twitch pressures. As expiratory pressure is a good indicator of expiratory muscle strength and, thus, cough efficacy, we recommend this electrode position for all therapeutic applications of abdominal FES. NEW & NOTEWORTHY While abdominal functional electrical stimulation (abdominal FES) can improve respiratory function, clinical use remains low. This is at least partly due to lack of agreement on the optimal electrode position. Therefore, this study aimed to ascertain the optimal electrode position for abdominal FES. We show that electrodes placed on the posterolateral abdominal wall generated the highest expiratory twitch pressures. As such, we recommend this electrode position for all therapeutic applications of abdominal FES.

Delivering safe and effective test-result communication, management and follow-up: a mixed-methods study protocol

Introduction The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems. Methods and analysis This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia. Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions. Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes. Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings. Ethics and dissemination Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences.

Assessing Data Integration and Quality for the Evaluation of Point-of-Care Testing Across Rural and Remote Emergency Departments in Australia.

In Australia, New South Wales Health Pathologys implementation of managed Point-of-Care Testing (PoCT) services across rural and remote emergency departments (EDs) has the potential to significantly improve access to results for certain types of pathology laboratory tests and help to deliver timely patient care. The aim of this study was to assess the quality of the datasets, including the integration of PoCT results into clinical systems, as a precursor to the application of an evaluation framework for monitoring the delivery of PoCT services and their impact on patient care. Three datasets, including laboratory, ED presentations and hospital admissions data were extracted from the relevant clinical information systems. Each dataset was assessed on six dimensions: completeness, uniqueness, timeliness, validity, accuracy, and consistency. Data incompleteness was the largest problem. Assessing the PoCT data integration and data quality is a precondition for the evaluation of PoCT and for monitoring and improving service delivery.

How well do general practitioners manage laboratory test results for patients with diabetes mellitus and cardiovascular disease?: A systematic review

PurposenTo evaluate how well general practitioners (GPs) manage and respond to laboratory results for patients with diabetes mellitus (DM) and cardiovascular disease (CVD).nnnData sourcesnMEDLINE, CINAHL, Embase, EBM reviews, ProQuest and Scopus.nnnStudy selectionnPeer-reviewed journal articles published between 2000 and 2015 that assessed GPs management of laboratory results for patients with DM or CVD.nnnData extractionnStudy design and demographics, laboratory tests and key findings relating to GP management of laboratory results were extracted from studies.nnnResults of data synthesisnThirteen articles were included, comprising seven studies which utilized surveys, four observational studies, one cohort study and one randomized controlled trial. Findings indicate that GPs often overestimate the risk of complications associated with DM and CVD based on laboratory results and have unrealistically high expectations regarding the precision of laboratory tests. Considerable variation existed in the use of repeat testing for diagnostic confirmation and in GPs identification of the difference between two consecutive results required to indicate a change in patient condition. GPs also often failed to initiate appropriate treatment for patients with DM and CVD based on laboratory results. Feedback to GPs about their test ordering patterns and educational messages on laboratory results improved clinical outcomes.nnnConclusionnEvidence about how well GPs manage results and its impact on patient outcomes remains weak and inconclusive. This review identified a number of areas where interventions could support GPs to improve the interpretation and management of laboratory test results, including feedback to GPs and educational messages on test result reports.