Clinical pathology selected abstracts

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Editor: Deborah Sesok-Pizzini, MD, MBA, chief medical officer, Labcorp Diagnostics, Burlington, NC, and adjunct professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

A method to decrease repeat, same-day WBC differentials at a tertiary care center

July 2022—A complete blood count with a white blood cell differential (CBCD) is often ordered when a CBC alone would suffice. Even though a CBCD can be performed with automated technology, it requires more reagents than a CBC. Furthermore, if an automated CBCD is flagged, a laboratory will perform a manual WBC differential, adding to labor and material costs. Therefore, identifying medical scenarios in which a repeat CBCD is unnecessary will help reduce laboratory and patient care costs. The authors conducted a study as part of their effort to implement a laboratory middleware algorithm that would cancel repeat and same-day WBC differential requests. They examined the practice of ordering a CBCD more frequently than a CBC alone at their large tertiary care academic hospital in Vancouver, Canada, from September 2019 through December 2020. The authors found that a CBCD repeated within the same calendar day had questionable clinical benefit. Based on this finding, they developed an algorithm to limit repeat, same-day WBC differentials. If a CBCD was ordered but a WBC differential had already been performed that day, only the CBC was repeated, and a comment was attached stating, “See previous differential.” The middleware used was highly customizable and allowed WBC differentials for repeat CBCD orders to be canceled automatically. The study initially was performed only on intensive care patients, but after a successful trial period, the algorithm was applied hospitalwide. The results showed that employing the algorithm resulted in a monthly WBC differential cancellation rate of 5.4 percent for a total of 10,195 canceled WBC differentials. Of interest, 99.4 percent of the differentials remained canceled. Only a few differentials were canceled for unrelated reasons, including insufficient sample quantity and wrong test ordered, and these were excluded from the analysis. The rate of canceled differentials primarily impacted ICU orders. Even though these orders represented only five percent of total orders, they accounted for 23 percent of canceled differentials. Most patients only had one WBC differential canceled. The authors estimated the savings to be 1,060 minutes (17.7 hours) of technologist time and $0.99 (Canadian dollars) per canceled differential. They concluded that it is possible to reduce unnecessary WBC differential testing and improve utilization after implementing a software algorithm to cancel repeat and same-day WBC differentials. Customized middleware rules may optimize laboratory resources without providers having to change their test-ordering behaviors. This is a simple and sustainable way to improve laboratory stewardship.

Tran A, Hudoba M, Markin T, et al. Sustainable laboratory-driven method to decrease repeat, same-day WBC differentials at a tertiary care center. Am J Clin Pathol. 2022;157:561–565.

Correspondence: Dr. Ann Tran at ann.tran3@vch.ca

Use of an operational huddle and communication app to improve laboratory processes

Laboratory sections often share patient samples and workflows. However, this can be challenging due to lack of awareness about other laboratory sections’ needs, limited sample amounts, delays in turnaround time (TAT), and transportation issues for sections that are not in close proximity. The authors addressed some of these challenges as they pertain to Gram staining of cerebrospinal fluid (CSF) to diagnose central nervous system infections, such as meningitis. Gram staining is a widely available, inexpensive, and rapid method to diagnose bacterial meningitis and, thereby, hasten the administration of life-saving antimicrobial treatments. Staff had encountered challenges in meeting the target TAT for CSF Gram staining (60 minutes) at the main campus laboratory at Texas Children’s Hospital, Houston, one of the largest pediatric health systems in the United States. This was due, in part, to the microbiology laboratory being relocated to another building that is further away from central receiving and other sections of the main lab. The authors studied TAT at the main campus lab over five years (July 2014 to November 2019) and evaluated multiple tools and strategies to improve CSF Gram stain. They assessed conventional strategies for process improvement and more novel interventions, including a daily operational huddle and an internally developed electronic communication app called Electronic Quality for Laboratories (EQL). The TAT was based on the time interval between when a sample arrived in the lab’s central receiving section and when the results were reported in the electronic medical record. TAT results were compared in the preintervention and post­intervention phases. Two laboratories in the health system that did not undergo the quality interventions served as controls for the study. The results showed that process standardization reduced the variability of TAT but shortened the TAT itself only minimally. However, employing the inter-team lab medicine division huddle to monitor key quality metrics, as well as the communication app, significantly and consistently improved TAT. One of the key quality metrics for the microbiology lab was TAT of CSF Gram stain. Each Gram stain TAT that exceeded the target TAT was recorded in the huddle. All laboratories impacted by the workflow for the CSF Gram stain participated in identifying the potential root cause for the delays. They determined that the lack of an alert when the specimen was delivered to the microbiology laboratory for testing was a key failure. Consequently, the authors implemented the EQL app across laboratory sections to strengthen communication between labs and shifts. In addition, real-time sample tracking and a large monitor in the microbiology lab helped technologists view alerts and track sample testing in progress. The authors concluded that daily huddles and an electronic communication platform promoted horizontal integration of workflow and may help other areas of the laboratory improve TAT.