Jane C. Dale

Diurnal variation of serum iron, iron-binding capacity, transferrin saturation, and ferritin levels

Serum iron levels vary throughout the day. Morning levels are generally assumed to be higher than afternoon or evening levels. We studied whether our practice of restricting serum iron collections to the morning was necessary. Serum iron, iron-binding capacity, transferrin saturation, and ferritin levels were determined on blood specimens obtained from 20 healthy adult volunteers at 8 AM, noon, and 4 PM (day 1) and 8 AM (day 2). Although statistically significant differences among mean values for the collection times were observed for iron, iron-binding capacity, and (log) ferritin, no consistent diurnal variation was seen. Morning iron levels were higher than afternoon levels for only half of the subjects. Between-day variation for all 4 analytes was similar to within-day variation. We conclude that the practice of restricting iron specimen collections to a specific time of day does not improve the reliability of the test result.

Outpatient Phlebotomy Success and Reasons for Specimen Rejection A Q-Probes Study

OBJECTIVES To determine the rate with which blood collection is successful on the initial phlebotomy encounter, the rate with which laboratory personnel judge specimens unsuitable for analysis, and the practice characteristics associated with fewer unsuccessful collections and fewer rejected specimens. DESIGN Clinical laboratories participating in the College of American Pathologists Q-Probes laboratory improvement program prospectively characterized the outcome of outpatient phlebotomies for 3 months or until 20 unsuccessful phlebotomy encounters occurred. By questionnaire, participants provided information about test ordering, patient preparation, and specimen collection. SETTING AND PARTICIPANTS Institutions in the United States (n = 202), Canada (n = 4), Australia (n = 3), and South Korea (n = 1). MAIN OUTCOME MEASURES Percentage of successful encounters and percentage of unsuitable specimens. RESULTS Of 833289 encounters, 829723 were successful. Phlebotomies were unsuccessful because patients were not fasting as directed (32.2%), phlebotomy orders were missing information (22.5%), patients specimens were difficult to draw (13.0%), patients left the collection area before specimens were collected (11.8%), patients were improperly prepared for reasons other than fasting (6.3%), patients presented at the wrong time (3.1%), or for other reasons (11.8%). Only 2153 specimens (0.3%) were unsuitable; these samples were hemolyzed (18.1%), of insufficient quantity (16.0%), clotted (13.4%), lost or not received in the laboratory (11.5%), inadequately labeled (5.8%), at variance with previous or expected results (4.8%), or unacceptable for other reasons (31.1%). Facilities staffed by laboratory-administered phlebotomists reported higher success rates than facilities staffed by nonlaboratory-administered phlebotomists (P =.002). CONCLUSIONS Most outpatient phlebotomy encounters are successful and result in specimens suitable for laboratory analysis.

Phlebotomy—a Minimalist Approach

For each patient, laboratories usually collect more blood than is needed for specific determinations. We reviewed the amount of blood collected for laboratory measurements for an entire hospital stay of 113 patients admitted during a 1-week period to a medical ward or to a medical intensive-care unit in our tertiary-care facility. The amount of blood obtained was also compared with the minimal amount needed for analysis for 18 of the most frequently ordered laboratory tests in our facility. For routine collections, a mean of 45 times the required volume of specimen (range, 2 to 102 times) was obtained. For optimal utilization of laboratory services, both the positive and the negative consequences of testing must be thoughtfully considered. Two potential adverse effects of withdrawal of blood for laboratory determinations are iatrogenic anemia and infection. Moreover, the cost of care is increased with additional analyses. Practical strategies for decreasing the amount of blood collected include an increased awareness of ordering practices, a thorough knowledge of the volume of blood needed for each laboratory test, experienced phlebotomy personnel, storage of blood specimens for potential subsequent use, and communication of accurate minimal volumes needed for specific measurements.

Continuous Monitoring of Stat and Routine Outlier Turnaround Times: Two College of American Pathologists Q-Tracks Monitors in 291 Hospitals

CONTEXT The laboratory test turnaround times (TATs) that exceed the expectations of clinicians who order those tests, the so-called outlier test reporting rates, may be responsible for perceptions of inadequate laboratory service. OBJECTIVE To monitor outlier test reporting rates for emergency department stat potassium results and routine inpatient morning blood tests. DESIGN In 2 different monitors, each conducted for 2 years, laboratory personnel in institutions enrolled in the College of American Pathologists (CAP) Q-Tracks program tracked the percentages of emergency department stat potassium results and/or the percentages of morning rounds routine test results that were reported later than self-imposed reporting deadlines. SETTING A total of 291 hospitals participating in 2 CAP Q-Tracks monitors. RESULTS Participants monitored 225,140 stat emergency department potassium TATs, of which 33,402 (14.8%) were outliers, and 1,055040 routine morning test reporting times, of which 123,554 (11.7%) were outliers. For both monitors, there was a significant (P <.05) downward trend in the outlier rates as the number of quarters in which participants submitted data increased. CONCLUSION Outlier reporting rates for emergency department stat potassium and routine morning test results decreased during the 2-year period of continuous monitoring. The CAP Q-Tracks program provides an effective vehicle by which providers of laboratory services may improve the timeliness with which they deliver the results of laboratory tests.

Specimen Collection Volumes for Laboratory Tests

CONTEXT Unnecessary tests, inefficient ordering practices, and collection of more blood than is required for testing contribute to iatrogenic anemia in hospitalized patients. Laboratories accredited by the College of American Pathologists are expected to review phlebotomy practices for specimen collection volumes periodically. OBJECTIVE To report specimen collection, analytic, and discard volumes for routine laboratory tests and to identify practice variables associated with overcollection and blood wastage. DESIGN Clinical laboratories participating in the College of American Pathologists Q-Probes laboratory improvement program recorded collection container size, laboratory-defined requested volume, manufacturer-defined analytic volume, and average discard volume for routine complete blood cell counts and electrolyte panels ordered for patients in intensive care units. Participants provided information about their specimen collection, processing, and analytic practices in a questionnaire. SETTING AND PARTICIPANTS A total of 140 public and private institutions. MAIN OUTCOME MEASURES Overcollections for routine collections and for situations in which a reduced volume of specimen is collected, and average discard volume per tube. RESULTS Laboratories collected a median of 2.76 mL (or 8.5 times) more than their instruments analytic volume for routine complete blood cell counts and 1.75 mL (or 12 times) more than their instruments analytic volume for routine electrolyte panels. For clinical situations in which reduced collection volumes were necessary, overcollection for the same analytes was 0.5 mL (3 times) and 0.44 mL (4.2 times), respectively. The median discard volume was 2.8 mL/tube for complete blood cell counts and 2.0 mL/tube for electrolyte panels. Specimen collection container size was directly associated with overcollections and discard volumes. Instrument analytic volume was not a determinant of blood wastage. CONCLUSIONS Most laboratories can decrease collection volumes without compromising the ability of the laboratory to report a reliable and timely result. Use of smaller collection tubes can help reduce blood wastage.

Accidental Needlesticks in the Phlebotomy Service of the Department of Laboratory Medicine and Pathology at Mayo Clinic Rochester

OBJECTIVE To determine the change in accidental needlestick rates in the Phlebotomy Service at Mayo Clinic Rochester and to identify safety practices implemented from 1983 through 1996. MATERIAL AND METHODS We retrospectively reviewed yearly Phlebotomy Service accidental needlestick rates from 1983 through 1996. Interviews were conducted with representatives of the Infection Control Committee and the management team for the Phlebotomy Service, and minutes of meetings of these two groups were reviewed to identify implemented safety improvements that may have had an effect on accidental needlestick exposures. RESULTS Accidental needlestick exposures in the Phlebotomy Service declined from a high of 1.5/10,000 venipunctures to 0.2/10,000 venipunctures. Several safety improvements were made during that time, including the implementation of a one-handed recapping block, change to single-use evacuated tube holders, increased number and improved locations of disposal containers for needles, implementation of resheathing needles and retractable capillary puncture devices, discontinuation of the practice of changing needles before inoculation of blood culture bottles, increased emphasis on safety for new and experienced phlebotomists, and improved exposure reporting tools. CONCLUSION We believe that the decrease in our accidental needlestick exposure rate is correlated with the changes in education, practices, and products that we have implemented.

Reference Laboratory Telephone Service Quality

OBJECTIVES To establish the rates with which reference laboratories resolve inquiries telephoned to them from primary laboratories and to identify reference laboratory practices associated with higher rates of inquiry resolution. DESIGN AND PARTICIPANTS For 2 months, or until 50 contacts had occurred, 545 primary laboratories participating in the College of American Pathologists Q-Probes laboratory quality improvement program prospectively documented and characterized telephone inquiries they made to a reference laboratory of their choice. Participants also cataloged their own laboratorys demographic and practice characteristics and their reference laboratorys customer service characteristics. MAIN OUTCOME MEASURE Rates with which reference laboratories resolved telephone inquiries. RESULTS Participants characterized 11 031 (78.7%) of 14 017 telephone inquiries as resolved by the reference laboratories. Ranked according to inquiry resolution rates, primary laboratories in the 90th percentile characterized reference laboratories as resolving 100% of their inquiries; those in the 10th percentile characterized reference laboratories as resolving only 54.2% of their inquiries. The rate of resolved inquiries was significantly higher (P =.0047) for participants using reference laboratories with 24-hour customer service than it was for participants using reference laboratories with less than 24-hour service. Most primary laboratories (80.9%) chose to monitor 1 of 11 national reference laboratories; in this subset, median rates of inquiry resolution ranged from 90.2% to 55.0% (P <.0001), despite no significant variation in other measured customer service characteristics. CONCLUSIONS Primary laboratories experience significant differences in the rates with which reference laboratories resolve telephone inquiries. The performance benchmark for reference laboratories is resolution of at least 90% of telephone inquiries from primary laboratory customers.

Challenges and Opportunities for Medical Directors in Pathology and Laboratory Medicine

Because the practice of pathology and laboratory medicine evolves rapidly, laboratory medical directors must constantly introduce new tests and services and continue to provide consistent, reliable results for existing tests. Innovations in laboratory medicine are frequently introduced, and the number of commercial vendors of test kits and reagents increases yearly. These innovations, however, may pose barriers to standardization and integration of laboratories and to interpretation of results generated by different laboratories. We propose a practical framework for medical directors to address the seemingly contradictory challenges of standardizing and integrating while simultaneously providing the flexibility to introduce innovations. We recommend initiating standardization first, then integration, while maintaining flexibility for innovation. As organizations strive to create effective processes to enhance value, the role of the laboratory medical director will become critical in resolving the natural tension between standardization/integration and innovation in laboratory medicine and pathology.

Testing for Group A Streptococci

CONTEXT Laboratory diagnosis of group A streptococcal pharyngitis in physician office and small-hospital laboratories. OBJECTIVE To characterize laboratory practices for the diagnosis of group A streptococcal pharyngitis and to identify opportunities for improvement. DESIGN Voluntary self-assessment questionnaire, used to assess the laboratory practices of 790 laboratories subscribing to the College of American Pathologists Excel Microbiology Proficiency Testing Program. RESULTS We observed discrepancies between self-reported and recommended specimen collection and laboratory testing practices for some laboratories. The most notable discrepancies were failing to provide a written specimen-collection procedure (17.8%), sampling the tongue and oral mucosa (2%), failing to always perform back-up cultures when rapid antigen test results were negative (57.5%), and finalizing culture reports within 24 hours or less (34.0%). Additionally, among those respondents who used the bacitracin disk, 57.9% (277 respondents) applied the disk directly onto a primary plate. CONCLUSIONS Opportunities exist to improve testing practices for the diagnosis of group A streptococcal pharyngitis for some physician office and small-hospital laboratories.

Challenges and opportunities for medical directors in pathology and laboratory medicine: standardization, integration, and innovation.

Because the practice of pathology and laboratory medicine evolves rapidly, laboratory medical directors must constantly introduce new tests and services and continue to provide consistent, reliable results for existing tests. Innovations in laboratory medicine are frequently introduced, and the number of commercial vendors of test kits and reagents increases yearly. These innovations, however, may pose barriers to standardization and integration of laboratories and to interpretation of results generated by different laboratories. We propose a practical framework for medical directors to address the seemingly contradictory challenges of standardizing and integrating while simultaneously providing the flexibility to introduce innovations. We recommend initiating standardization first, then integration, while maintaining flexibility for innovation. As organizations strive to create effective processes to enhance value, the role of the laboratory medical director will become critical in resolving the natural tension between standardization/integration and innovation in laboratory medicine and pathology. The practice of pathology and laboratory medicine has evolved substantially in the past decade. Laboratory medical directors are faced with the dual challenges of introducing new tests and services while simultaneously providing consistent, reliable results for existing tests. Point-of-care testing, noninvasive testing, automation, genetic testing, and telepathology are just a few of the many innovations that have changed the practice of laboratory medicine and pathology. This burgeoning growth includes a similar increase in the number of commercial vendors of test kits and reagents. Although greater purchasing options may offer financial savings, lack of standardization across vendors and practices impedes integration of laboratories and often presents problems for physicians who