LEANING Away Waste and Improving Patient Care with Advances in Hematology
Selke Mantie, MLS (ASCP), CLS (CSMLS), SSGBC
Objectives
• Discuss how automation and new technology can
be applied to improve workflow and reduce cost.
• Describe new parameters Immature Granulocyte
(IG), Immature Platelet Fraction (IPF) and Immature
Retic Fraction (IRF) and Reticulated Hemoglobin
(RET-He) and their impact on patient care and
hospital budget.
• Understand how new technology can impact
“SCAN/MDIFF” workflow.
• Explore new pathways to improve six part autodifferential reporting.
• Understand defining new criteria as it relates to
value added information to improve patient care.
BHS
Is the largest non profit health care system in the country serving patients across 6 states.
28 hospitals
Alzheimerʹs Institute
Health Clinics
Research Health Clinics
Home care services
Medical Equipment services
Senior Center & Residences
Surgery Centers
Urgent Care
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Banner Arizona/LSA
Banner Goldfield (2013)
Banner Casa Grande (2014)
Banner Payson Medical Center (2015)
Banner University Medical Center (2015‐
2016) – Phoenix, Tucson – North/South
What did we want?
 Instrumentation
 Easy to use
 Reliable and accurate
 Automation (Hands off) for analysis & PBS review
 New technology to improve patient care
 Decrease SCAN/MDIFF rate
 IT
 Auto-verification
 Downtime
 Results
 Improve or maintain TAT for ER and In-patients
 Report FDA any new FDA cleared test(s)
 Improve patient outcome
Instrumentation 2
WAM4.1/ 5.0 Virtual Server
LIS
Workflow
• Define
o
o
o
o
o
Analysis Tools
Project w/boundaries & exclusions
Define what needs to be improved, changed, etc.
Stakeholders
Voice of the customer
What are you going to measure? E.g. Decrease TAT, reduce steps?
• Analyze
o Process Map, Fishbone, FMEA, 5 Why, XY Matrix
• Measure
o Review previous date
o Measure
o Process Map of current state
• Improve
o Process Map of future state
o Identify quick hits
o Implement new workflow, process, etc.
• Control
o Set up a plan to control the improvement.
o Example – monitor monthly TAT within goal.
o Develop an action plan if data starts to fail.
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Define & Measure
(1) Reduce non added value steps for specimen/tech to travel
(2) Decrease SCANS/MDIFF performed
(3) Improve/maintain CBC ED TAT 95% w/in 30 minutes.
Analyze ‐ Spaghetti Diagram
Variations Identified:
 Pre analytical workflow
 Labelling
 Transportation  Analytical workflow
 Specimen drop area
 Loading analyzers
 Middleware
 Action Limits
 Lack of middleware
 Manual sampling handling
 Manual slide making/staining
 Post Analytical
 Criticals
 Reference ranges
Analyze/Measure/Improve – Spaghetti Diagram
Identifies “waste” and “variation”
 Reruns required additional handling & physical steps
 Different equipment used to process samples
 Analyzers not connected causing manual intervention
 No automated differential reader
 No middleware to standardize workflow criteria
Remove “waste” and “variation”
 Automated line
 Same equipment process samples
 Automated reader
 Standardized middleware
 Physical steps reduced:
 From 107 steps
 To 27 steps
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Measure / Improve– Spaghetti Diagram
Goals
Site
Baseline Metric
Target Metric
Improvement
Reduce non‐value A
added specimen travel B
distance
C
97 feet
8509 feet
96 feet
29 feet
3886 feet
67 feet
63%
54%
26%
Current Review Rate of SCANS/MDIFF
21.8%
21.7%
18.7%
14.5%
14.6%
13.1%
32.0%
7.1%
5.6%
Meet ED CBC TAT Goal of 90% w/in 30 minutes
A
B
C
All sites met goal even during learning curve.
Measure/Improve‐ Time Value Analysis
Auto‐Verification Range:
85 – 90%
Measure/Improve Decreased by 38%
Goal:
Decrease SCAN/MIDFF by 30%
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Measure/Improve
YEAR 2012, 2013, 2014
22,442
3,785
6,800 less MDIFFS!!
1,786
Manual Differentials cost 2012: $22, 442
2013: $3,785
2014: $ 1, 786
Control Start
Pull TAT per Data
Collection Plan
In Goal?
No
Review Outliers
and determine
cause
Yes
Add TAT to
Control chart
Is cause an IT
issue?
Yes
Send information
to IT
No
End
Is this a trend?
Take appropriate
action
Summary Workflow
 Consolidation of workstations with automation of sample
handling.
 Standardized 13 hematology laboratories with one LIS
System into one Sysmex WAM middleware system.
 Established standardized rules that will help the
technologist follow the same procedures on flagged
specimens.
 Improved capacity and throughput.
 Maximize existing work space.
 Automated peripheral blood smear review with
Cellavision
 Implemented auto-verification system wide with an
average rate 85%.
 Decrease peripheral blood smear review by 30%
 Maintained ED CBC TAT goal throughout learning curve
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Technology
Our New Parameters
•
•
•
•
•
•
Immature Granulocytes (IG% & IG#)
RDW-SD
Immature Platelet Fraction (IPF)
Immature Retic Fraction (IRF)
Reticulocyte Hemoglobin (RET-He)
Automated NRBC’s
Immature Granulocytes ‐
IG
•Identifies & Quantifies
Immature Myeloid cells
Immature Granulocyte (IG) Promyelocytes
Myelocytes
Metamyelocytes
Neutrophil count Bands
Neutrophils
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Automated Differential
Previous Analyzer
5 Part Diff
Basophil
Eosinophil
Neutrophil
Monocyte
Lymphocyte
Current Analyzer
6 Part Diff
IG% IG#
Basophil
Eosinophil
Neutrophil
IG
Monocyte
Lymphocyte
Automated IG Count
• More precise than 100‐cell diff (Fernandes).
• Good correlation with flow (Fernandes).
• Better sensitivity and specificity than WBC alone in predicting infection in patients admitted through the ED with suspected bacteremia (Ansari‐Lari).
• 92% PPV in patients with positive blood cultures and IG >3% (Ansari‐Lari).
• IG can elevate in infection/inflammation even when the WBC and other markers are not elevated (Briggs).
• IG, a direct cellular measure of leukopoiesis, may aid the ability to detect infection if added to current protocols
What does IG mean to my patient?
IG% and IG# –Early screen for sepsis
–Better indicator for infection than WBC
–Comparable to ANC
–IG% >1% indicates a left shift
–IG% >3% may predict positive blood cultures with: •98% specificity
•92% PPV
–Detect myeloproliferative disorders
–Infection – identification upon admission
–Replace I/T Ratio and Bands
Neutrophil count includes bands
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Immature Platelet Fraction (IPF)
IPF (Immature Platelet Fraction)
% Immature PLT/Total PLT
Plts + IPF = Production disorder
Plts + IPF = Destruction mechanism or BM Recovery
Reflex to IPF when PLTC < 100,000
Test Code: PLTC with IPF
IPF and Platelet Count
Briggs, Carol et al. Assessment of an immature platelet fraction (IPF) in peripheral thrombocytopenia. British Journal of Haematology, 126, 93‐99; 2003. Case Study ‐ IPF
Marked Thrombocytopenia
IPF cut off 7.1
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IPF Clinical Uses
Docs:
Helps identify if it’s a “consumption” vs “production” cause of thrombocytopenia
Predict platelet count recovery over time
Determine need for platelet transfusion
Oncologist:
Using to triage patients as IPF recovers ~3 days earlier than
PLTC
Pathologists:
Determine need for platelet transfusion
Determine if bone marrow study is needed due to
thrombocytopenia
Pharmacy:
Uses to determine if thrombocytopenia is due to HIT.
Reticulated Hemoglobin RET-He
Qualitative measure of Hgb in reticulocytes.
Cellular evaluation of iron status
Help diagnose iron deficiency (ID)
Monitor response to iron treatment
Decrease RBC transfusions by treating iron
deficiency in preoperative setting
• Improve patient care and decreased
re-admission rate in ER Ortho patients.
•
•
•
•
•
RET‐He Case Study
• 40 year old woman presents to the ED with an episode
of syncope the previous night with loss of consciousness
for 1 minute.
• History of menorrhagia.
• History of iron deficiency anemia treated with blood
transfusions, 2010.
•
•
•
•
•
Temp 36.8
HR 70
BP 106/60
RR 18
Sat 98% on room air
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RETIC, Comprehensive
Anemia Trick:
MCV/RBC
 <13 favors thalassemia
 >13 favors iron deficiency
The RET‐He threshold for defining iron deficiency in adults is less than 29 pg. (KDOQI Guidelines)
Casa History
RETIC‐ Comprehensive
Retic %, Retic # (Reticulocyte Count)
IRF (Immature Retic Fraction)
RET‐He (Reticulocyte Hemoglobin Equivalent)
1.
2.
3.
4.
5.
Care Sets:
Iron Profile
Anemia
Iron/EPO
Orthopedic ER
Pre‐operative work up for elective surgery
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Improvements: RET‐He
What do NRBC’s mean to my patient?
 One NRBC in an adult is important finding
Indicate health of patient Changes in NRBCs important to follow
New finding of NRBCs
Increasing number of NRBCs
Decreasing number of NRBCs
Can use to help determine whether to move a patient into or out of the ICU –
Patient Flow
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Published Studies
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Getting the Word Out
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•
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•
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Presentations to individual pathologist
One on one discussions with CMO
Formal presentations at Medical Staff meetings
Pathologists presenting the clinical advantages of
ACP’s to different medical groups
Nursing – SBAR for nursing communications
Pharmacist included in the discussions / presentations
Vendor on site support during go live
Advertising to medical staff
Interpretative Date
IRF
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Summary ‐ Technology
 Leveraged new technology to improve patient
care, which includes the following:




Immature Granulocyte (IG)
Immature Platelet Fraction (IPF)
Immature Retic Fraction (IRF)
Reticulocyte Hemoglobin (RET-He)
 Improve coding and billing
 CPT code for IPF (85055)
 Nosocomial infection vs. acquired – IG
 Financial
 Decrease LOS
 Decrease re-admission rate due to anemia
 Decrease RBC / PLT transfusions
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STOP – STOP ‐ STOP
Case Study ‐ IG
•
•
•
•
34-year-old female with autoimmune disorder
Admitted to hospital with severe hemolytic anemia
Treated with steroids but no improvement
Elevated WBC:
o
o
o
o
o
o
Mild cough
No signs and symptoms of infection
Chest x-ray negative.
No fevers or chills.
WBC was coming down on discharge
Clinical impression: Leukocytosis due to steroids
IG Case Study
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Clinical Impact – IG
Infection or Inflammation?
Cellavision and Path Review
Graphing Lab Results in Cerner
Reporting AUTO Diffs, can make trends more apparent for physicians.
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Define: Issued a S B A R
S B A R
Situation
Background
Assessment
Recommendation
Ig reported with ADIFF only IG not reported with MDIFF’s
Mandatory MDIFF in babies < 1 year
Path Reviews
Scan and MDIFF criteria defined for old technology. Path review criteria Manual diffs are subjective, imprecise and labor intensive
6 Part Automated Diffs with IG’s are objective, precise with no extra work
PBS SCAN still required for instrument generated flags
Did current path reviews add value to patient care?
Virtual View away CBCM from CPOE
Doctors call pathology to request CBCM
Patients < 1 year old – Perform PBS with coded comment on bands < 10 present.
‐
If no abnormal cells seen – report ADIFF
‐
If abnormal cells/blasts seen, perform MDIFF
Re‐define path reviews criteria to identify the truly abnormal cases.
Define: Pilot Program Goal
• LAB:
o
o
o
o
o
o
o
Increase reporting CBC w/Auto DIFF. (IG) by 30%
Determine new SCAN/MDIFF Criteria
Remove mandatory MDIFF in kids < 1 yr.
Re-define “left shift”
Streamline path review criteria
Utilize Cellavision DM96 more
Review WAM OP Alert ru
• Hospital:
o Review Lab Care-sets with CCG.
o Computer alerts for sepsis to include IG’s
o Replace or modify ITR for babies
Measure/Analyze: SCAN/MDIFF Criteria 1.
2.
3.
4.
5.
6.
Highest Ranked:
Meta >1%
Age < 1 year
Morphology NRBCs
Smudge cells >10%
WBC >25 & IG >5%
MDIFF on Path Reviews
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Measure/Analyze: IG’s, ITR, Bands
ITR & Manual ANC – double dip in the “manual band count”
Measure /Analyze: Babies and IT Ratio
IT Ratio: Generally accepted reference range < 0.2 Measure / Analyze: Baby (< 1 yr.) 133 babies
12.8
0
35.3
TN
TP
FN
35% of acceptable ADIFF – forced to MDIFF.
Why?
FP
51.9
Legend:
True Positive: results from both the instrument and the manual differential are positive (abnormal)
True Negative: results from both the instrument and the manual differential are negative (normal)
False Positive: results from the instrument are positive, but the manual differential is negative.
False Negative: results from the instrument are negative, but the manual differential is positive.
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Improve: Band the Band
Redefine left shift as >1.0% IGs Improvement: Work Aid SCAN vs MDIFF
Improve: MDIFF Criteria
*Scan – Report with ADIFF:
“Less than 10% bands seen on PBS smear”
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Improve: ADIFF vs. MDIFF 40 – 20 – 5 Rule
Cellavision
Pass 40‐20‐5 rule & the following:
1. No blast or malignant cells
2. < 20 mononuclear smudge cells
3. < 1 year old & < 10% bands
4. Valid ADIFF
REPORT ADIFF
Improve: RBC Morphology Reporting
Improve: RBC Grading & Path Review
RBC Morphology Report as:
Normal
IDA
NSAP
Specific Poik.
RBCM: RBC morphology normal.
IDA: RBC morphology changes suggestive of Iron Deficiency Anemia. Check Ret‐He if not already performed (Order as RETIC‐
comprehensive).
NSAP: Nonspecific RBC morphology changes present. Review RBC indices.
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Control: PBS QA Worksheet
Gene Gulati, Ph.D., Jefferson Medical College and Thomas Jefferson University Hospital. Ann Lab Med 2013;33:1‐7 RESULTS
Decrease SCAN/MDIFF Rate
IG%
Increase ADIFF Reporting
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Results
• SCAN/MDIFF criteria
• PBS Path Reviews
Redefined
• Kids < 1 year: Report CBC W/ADIFF with the following
comment: Less than 10% bands seen on peripheral blood
smear”.
•
“Leverage the 6-Part Diff – (IG%, IG#)
o Increased automated differential by 36%
• Standardize RBC Morphology Reporting
Results – CBC w/ADIFF
Results: PBS Path Reviews
Site A
PATH Review
Old Procedure
Pilot
Procedure
Change
PATH Review required
20%
2%
Decreased Path Reviews 18%
PATH Review NOT required
80%
98%
Old Procedure
Pilot
Procedure
Change
PATH Review required
27%
3%
Decreased Path Reviews 16%
PATH Review NOT required
73%
97%
Site B
PATH Review
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Switching to XN’s – 2016/2017
XNs Improvements
Manual %
Sample Handling
ADIFF%
Elimination of Instrument‐Driven Reflex Manual Differential Leukocyte Counts:
Optimization of Manual Blood Smear Review Criteria In a High‐Volume Automated Hematology Laboratory
Kay L. Lantis, MT(ASCP) SH, University of Michigan Am J Clin Pathol 2003;119:656‐662
LDC= Leukocyte Differential Count
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Riding the Wave on Change!!
Questions
[email protected]
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