Press Start: Lead an Empowered Life as a Clinical Laboratorian

Early Stroke Diagnosis

2008-07-21T13:35:00Z

Cerebrovascular accident (CVA) or stroke is one of the major causes of impairment and morbidity in this country. Stroke is the third leading cause of death in the U.S. and costs billions of dollars in care and disability. Both the American Heart Association (AHA) and the American Stroke Association (a division of AHA) classify CVA as an emergency ranking up there with a heart attack that should be responded to with the same degree of urgency; from calling 911 to receiving prompt medical attention and immediate intervention in the emergency department.

A stroke is usually diagnosed by observations of behavior, slurred speech, partial paralysis, a neurological assessment, and tests like a CT, doppler ultrasound and an MRI. . These are not definitive since many diseases share or mimic symptoms of other conditions. With over 3 million people presenting to the ED with stroke-like symptoms each year and almost 700,000 being positively diagnosed with a stroke, early diagnosis is important for both financial and clinical reasons.

Generally, the lab has not been in the forefront of the diagnosis of CVA. However, recently, there has been renewed interest in pursuing certain in vitro tests some think might serve as early markers of stroke. The current thinking is if those who have suffered a stroke can be positively identified and aggressive intervention pursued within 3 hours, the outcomes can be vastly improved.

Clinical laboratory researchers are optimistic about a group of markers such as Lp-PLA2, NMDA-receptor autoantibodies, and NR2A that they believe could play a significant role not just in the diagnosis of stroke, but also in early risk assessment. Once again, the clinical laboratory appears to have the potential for playing a significant role in early diagnosis of a serious illness.

Never Events

2008-07-14T14:19:00Z

New York Medicaid program has announced it will not pay for what it terms 14 "never events."

I recently wrote a blog discussing the fact that Medicare, a major healthcare payer, will no longer pay hospitals for the cost of care deriving from medical mistakes or nosocomial infections.

State Medicaid programs have been hit with lowered federal payments and have been looking for ways to reduce cost while improving quality of care.

New York has identified 14 events that in its estimation are the results of hospital errors, incompetence or failure to follow established procedures. As in the case of the Medicare (CMS) list, these "never events" often add to the cost of care and use valuable hospital resources. However, providers should not be rewarded for delivering less than optimum care. The nation's largest Medicaid program might very well nudge other states to follow suit.

Two of these "never events" relate to laboratory tests: blood incompatibility and patient disability from failure to treat hyperbilirubinemia in neonates. As stated in the earlier blog, it is not a stretch to imagine that this list will be expanded to include other lab tests and might even lay more responsibility for turnaround time, incorrect results used to guide treatment inappropriately, and how lab tests are utilized at the feet of laboratorians in the near future.

Ignoring Problems

2008-07-07T19:30:00Z

Recently on a TV news show, real estate tycoon Donald Trump indicated the biggest mistake in the real estate foreclosure crisis is to ignore a request for payment from lenders. He cited anecdotal findings that many homeowners become so overwhelmed, they ignore bills and requests for payment in the unlikely event the problem will just go away.

This "ignorance is bliss" method of dealing with crises is not unique to this situation. A few years ago, I had a boss who would ignore any e-mails pointing out a problem or asking for intervention in a potentially uncomfortable situation.

It was not uncommon for him to interact with the parties involved over several days without mentioning the conflict or the e-mail. This is so unlike my own natural style of management, that it would drive me nuts. Besides, this manager would very often have to deal with a forest fire later on because he ignored the issue when it was just a smoldering flame.

There are times when it is a legitimate tactic to deliberately allow an issue to work itself out if:

tensions are very high and you want to allow time to cool off;
the issue is really not that significant to the organization and the two parties can work it out and learn from their mistakes;
you need time to gather more information to make a sound decision; or
there are much higher priorities to deal with.

However, these are the exceptions and even then the manager might still acknowledge the problem while explaining it will be looked at some time in the future-and will be escalated if necessary. Rarely does ignoring an issue completely solve it satisfactorily and permanently.

If you are the manager faced with addressing a problem you must:

admit there is a problem, don't be in denial; remember perception is reality for the parties involved;
gather information including talking to the parties, get their version of the problem and possible solutions;
look at viable possible alternatives-based on policy, organizational goals and a host of factors;
institute corrective action; and
get feedback to ensure the problem remains fixed.

Share with us personal experiences in which a problem has been ignored and the possible consequences. I'd also be interested in finding out how you reacted, or would react if this occurred again in the future.

New Supervisor Marches to a Different Beat

2008-06-27T15:04:00Z

The following scenario was presented to me in a client hospital recently. A new supervisor was hired and immediately rubbed several long-time employees the wrong way because of what was seen as his threatening tone and brusque manner. Employees were "ordered" to perform tasks and were threatened with being written up or "dealt with" for every minor infraction. Copious memos were written in all caps reminding employees of the rules and the consequences of not towing the line.

The laboratory manager intervened after getting numerous employee complaints, and the supervisor claimed he was just "trying to raise the bar" and was not interested in coddling or babying adults. It's obvious there was a fundamental difference in interpretation of what the problem was in the situation. The manager, meeting with supervisor and staff, pointed out there was a difference in perception, different personalities and different ways of achieving the same goal. She made all involved pledge to be professional and try to get along for the good of the laboratory and the patients. She considered the matter closed.

Suggesting the employees were marching to the wrong beat, the supervisor threatened to quit rather than "lower my standards." The employees wrote a petition to Human Resources asking for termination of the supervisor or they would quit.

Universal HIV Screening

2008-06-16T14:52:00Z

In September 2006, the CDC issued new guidelines recommending a wider screening of the general public for HIV.

This aggressive guideline resulted from the finding that of new HIV diagnosis, almost a half (over 40 percent) went on to develop AIDS in about a year after diagnosis. This suggests the initial diagnosis was made late--maybe as late as 10 years after infection. The CDC still recommends screening in high risk patients, but also suggested healthcare providers screen all patients in the age group 13-64. Those considered high risk or who engage in one episode of risky behavior should be screened annually.

While well-meaning, universal screening means that many smaller sites would have to provide the personnel, equipment to perform testing, arrange for confirmatory testing and to be prepared for test interpretation and patient counseling. I am not sure many sites such as rural sites or smaller physicians' offices are ready to do even rapid testing.

Widescale testing is bound to yield a higher level of false positives than would be seen when testing a high-risk population. I am not sure how many providers are prepared to understand and explain that nuance. Imagine the trauma of telling a young mother incorrectly after a single rapid test that she has HIV?

It's been almost 2 years since the CDC guideline was published. Have you noticed increased testing in your lab from outpatients, ED patients for example? What are the pros and cons of this CDC recommendation?

National Health Record

2008-06-10T15:38:00Z

The Bush administration has said the U.S. should have a national electronic health record system (EHR) by the year 2014.

This discussion regarding the need for electronic medical records goes back several years, but was really focused in this administration when the Department of Health and Human Services (HHS) created a federal advisory board called the American Health Information Committee (AHIC) to look specifically at recommendations for establishing a national health record system.

There are many advantages, of course, such as easy access and portability of information from rural to urban sites, from small to large providers, from coast to coast. There are also challenges, such as maintaining privacy and confidentiality, interoperability (various systems talking to each other) and the individual cost especially to smaller healthcare providers. Ideally, there would also be one large platform on which the entire system is built. This is not an easy task. The UK went through this headache a few years ago.

What is truly baffling is that neither AHIC, nor the "AHIC successor organization" (abbreviated ASO) have clinical laboratory representation on their boards. Despite the fact that a large part of the medical record consists of laboratory data and there are regulatory requirements for the storage of lab data (by the Joint Commission, state, CMS, CLIA, etc.) the lab has been lumped in as "ancillary services" with pharmacy and other groups.

There is a great potential to serve patients who might, for example, be able to access their lab results through the Internet within hours, and for providers to have access to a patient's entire medical history wherever the patient presents, but the system will be lacking unless the laboratory community has input early on.

Clinical Lab Science Still Competitive

2008-05-28T18:49:00Z

According to an article in Money magazine, laboratory technologist (clinical laboratorian) ranks 46 out of the 50 best jobs.

This ranking is based on a report from the Bureau of Labor Statistics which makes projections of which professions--requiring at least a bachelor's degree--will grow at an above-average rate over the next 10 years. The Bureau uses a formula that factors in criteria such as starting and average salaries, growth rate, training required and even level of stress expected.

Given the current state of disillusionment among some in the profession, readers might be surprised that CLS made the list. It is instructive to visit the Money site, click on the various links and see how a CLS compares with other professionals like Physician Assistant (No. 5), Pharmacist (No. 9), physician (No. 30) and even a CEO. It might surprise you to know that nurse ranks below CLS at No. 47.

Given a dwindling workforce, closing programs, attrition, retiring baby boomers, stress, increased automation and the like, it's positive that CLS is a viable option for those looking for a "growth career"

There is some independent data that some older workers are choosing CLS as their second career when they make a career change. This will not address the aging profession, but might well bring in workers who are mature and motivated to join the profession. Interestingly in the nursing profession, some professional nurses claim "older newcomers" choose nursing simply as Plan B after burn out, or choose it simply because it pays relatively well.

Do you see the same thing happening in clinical lab science? More importantly, do you still see CLS as a competitive profession? Why or why not?

MRSA-A Deadly Threat on the Rise

2008-05-21T16:03:00Z

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) is increasing at an alarming rate. In fact, MRSA is now the No. 1 diagnosis in people presenting to U.S. emergency departments with skin and soft tissue infections. The infection is not entirely benign either; MRSA infections result in approximately 19,000 deaths annually. With over 94,000 people being infected with MRSA each year, there exists a real need for surveillance programs including prompt diagnosis and treatment.

As a relatively healthy person, not hospitalized, living in a typical community, I had my own sudden frightening brush with community acquired MRSA (CA-MRSA) just over a year ago.

Another consideration: With Medicare's decision not to reimburse hospitals for treating otherwise-preventable episodes such as nosocomial infections and states beginning to mandate MRSA surveillance programs now is the time for your lab to evaluate its protocols.

As I indicated in that ADVANCE article: Many European countries use an aggressive "search-and-destroy" tactic whereby patients are screened on admission and immediately decolonized and placed on contact isolation if MRSA is present. Many U.S. hospitals regard this as overkill, but the incidence of MRSA (including CA-MRSA) in Europe is much less than in the U.S., largely due to this aggressive procedure. For example, in France it is less than 1 percent, according to sources at the American Hospital of Paris (personal communication, January 2007).

The CDC is pretty equivocal and still trying to find its footing on coming up with consistent recommendations. How big a problem do you consider MRSA infections (nosocomial and community acquired)? What is your laboratory's strategy to fight this new villain? Any experience with rapid kits?

Paying for Lab Services Based on Effectiveness

2008-05-07T15:08:00Z

In recent years we have heard a lot about evidence-based medicine (EBM). Many physicians practice medicine out of habit; doing what is familiar or what they have been taught. Evidence-based medicine, however, is based on doing what the research shows is most efficacious; despite popular or conventional wisdom. In reality, EBM has been practiced in various ways, such as instituting care maps whereby for example a patient with chest pain is always given aspirin or clot busters on arrival at the ED, is given an EKG, has cardiac enzymes drawn stat and repeated every 6 hours, starts cardiac rehabilitation within 48 hours of admission and so on.

Laboratory tests have been an integral part of EBM from the beginning (consider HBA1C for all diabetics, using PTT and INR to guide anticoagulant dosages, for example). However, not much has been done in terms of investigating the efficacy of laboratory tests.

With major payers like managed care plans and Medicare trying to reduce cost at every turn, it is no wonder that they are starting to suggest that reimbursement should be tied to the proven efficacy of lab tests.

Congress is considering several bills that may result in an increase in federal funding for what is termed comparative effectiveness research (CER). If passed, this could have huge implications for how lab testing is used and reimbursed.

CER is an evidenced-based research tool, which compares different health services or treatment options for the same condition, so healthcare professionals can personalize patient care.

The possible upside is successful CER studies may well provide laboratories with important information for assessing tests and improving test selection. In addition, these studies may provide needed data for new guideline development. However, there are also potential pitfalls associated with CER, such as how payers use the data. Will they use it to restrict coverage or reduce payments for certain tests? If insurers choose this route, what will it mean for clinical laboratories and test developers?

A Rose By Any Name

2008-04-21T13:17:00Z

What's in a name? Does a rose by any other name smell just as sweet? In the very first regular column I wrote for ADVANCE in 1991 (September 30), I posed that question and proposed that our image as a profession is affected by the name we call ourselves.

The name "medical technology" as commonly used literally refers to the equipment, technique and state-of-the-art practice of medicine. It conjures up images of robotic arms, magic pills and surgery more than it does anything having to do with the clinical laboratory. The ambiguity inherent in this term has largely been responsible for the need to constantly answer the question "What exactly does a medical technologist do?"

I am amazed at the ongoing confusion of the term medical technologist with emergency medical technicians (EMTs) and the like in the public's mind. Even after many reminders, some of my friends and family insisted on calling me a lab tech, if for no other reason than (they claimed) it's a common term they didn't have to explain to others.

If you think that situation was frustrating, the umbrage was unbelievable when as a new laboratory supervisor, the "MT" on my brand new business card was interpreted as "massage therapist" by an innocent, if unsophisticated hostess at a party I attended.

With the increasing adoption of the preferred and more accurately descriptive terms clinical lab science/scientist by many, how much has changed? I still hear laboratorians refer to themselves as "techs" and perpetuate the use of the same generic descriptions often used by nursing and others such as "someone from the lab," "lab person" or, simply, "the lab."

Another interesting observation is that laboratorians who move on to careers outside the walls of the laboratory will often gladly dismiss their laboratory background as one would a seamy past: "back then I was a lab tech." Others, on the other hand, like doctors and nurses in executive positions, will often wear their doctor/nurse credential as a proud badge of honor, a value-added qualification, an asset, not a liability.

Using a strong descriptive moniker for ourselves will not increase our salary or give instant recognition, but it certainly will be a step in the right direction.

What's Your Favorite Archaic Test?

2008-04-15T13:26:00Z

As a student, one of my professors prided himself on being a CLS historian of sorts. He would regale us with tales of old tests, methods, instruments and innovative efforts to make do under trying circumstances. In our eyes, he was the McGiver of CLS! When we did our clinicals at the local hospital he showed us the tank out back where they used to keep frogs for doing pregnancy tests. He had an old Natelson blood gas instrument, a colorimeter with removable glass filters, and insisted that we do methods manually to comprehend the principle before we took the "easy route" of automation.

Most recent grads today cannot even fathom taking all day to perform fecal fats or doing a batch of enzymes with stopwatch and a water bath. If you talk about the need for producing a protein-free filtrate, you would most likely get a "huh?" In fact, now watching an instrument take 15 minutes to churn out a result is way too long! I am fascinated by details of old tests, old instruments and making do in the early years of your practice.

Please share some of those old stories with us here. I know there are some old-timers out there still practicing medicines who find it hard to relinquish an old test that has outlived its usefulness. In an article I read recently, expert laboratorians, not surprisingly, gave the boot to LE Cells, Schilling Test, FTI, Bence Jones Protein and others.

They also fingered more controversial tests like ESR, LDH, AST and even CKMB for being superseded by more specific tests in recent years, What do you think? I am also interested in hearing what is your "favorite" (or most annoying) useless test requested in your lab currently or fairly recently?

Lab Week Is About More Than Food and T-Shirts

2008-04-02T17:46:00Z

This year National Medical Laboratory Professionals Week (NMLPW) will be observed April 20-26. The theme this year is National Medical Laboratory Professionals: Delivering Today's Results for a Healthier Tomorrow.

Sponsored by 10 laboratory organizations this year (it's remarkable that any organizations can agree on anything) NMLPW is designed to highlight the importance of the nation's more than 260,000 clinical laboratorians.

Started by ASCLS (then called ASMT) in 1975, the week has been anticipated by laboratorians over the years because it is an opportunity to celebrate and toot our own horns a bit. In the Fall of 2005, the word "professional" was added to the title to emphasize that the celebration is about living, breathing, smart, dedicated individuals and not simply a room--"the lab."

One of the things most laboratorians look forward to during lab week is all the cool stuff--magnets, t-shirts, lunches and breakfasts courtesy of administration or one of the few vendors that still offer such perks.

That's all well and good, but the week is about way more than hanging banners, wearing cool t-shirts and celebrating in the lab. For one thing, this is no time for false modesty or insularity. Sing your own praises and loudly applaud each of your colleagues. By all means, provide tours and free testing, but also take time to educate healthcare colleagues and the public about the training and important role of the clinical laboratorian.

Who are all these people in the black box called "the lab?" What do they do to produce a valid result? What's their educational preparation? What are the relative roles of phlebotomists, customer service reps, lab assistants, CLS/MTs? What's the difference in training, role and specialties?

We have a real opportunity that we mostly squander each year by looking inward way too much. We can wear cool t-shirts, eat good food and educate all at the same time.

Mission and Vision Should be More Than "Just Words"

2008-03-20T14:09:00Z

Ever notice when you join an organization how much they push their mission and vision? Many companies even have these statements on employee badges, plaques and the like. Yet for every one employee who buys into the words, there are a hundred who roll their eyes and point out the dissonance between the words on paper and the real organizational culture.

The problem is that many organizations view a mission and vision as something to be written down and trotted out when convenient, not a vibrant honest pledge that has to be lived daily. Organizations must work to change their culture so that employees feel actions match the "words on the wall." Engaged employees are those who feel proud, empowered, excited and a part of the organization.

There is a story about President Johnson visiting NASA and stopping to say hello to a janitor mopping the halls. The janitor introduced himself and proudly said "Mr. President, I helped to put a man on the moon."

That employee was engaged!

Lab managers often feel that as middle managers they can do little to affect employee morale. They even sometimes hate the mantle of being seen as representative of management. They do, however, have the ability and obligation to create employee engagement. They can do this by listening, walking in the shoes of their employees, encouraging employees to feel empowered to create solutions. Most importantly they can model and reward desired behavior.

Medicare New Reimbursement Rules and Laboratory Errors

2008-03-20T14:06:00Z

Under new Medicare regulations effective October 2007, hospitals will no longer receive higher payments for the additional costs associated with treating patients for certain hospital- acquired infections and medical errors.

Previously, complications could be used to increase the weighting of a diagnosis related group (DRG) over and above the diagnosis given to the patient on admission. For example, if a patient is admitted on a ventilator, with a central line and develops hospital-acquired MRSA, Medicare will no longer pay for treating the MRSA.

Initially eight commonly-encountered conditions have been targeted by CMS. These include blood/crossmatch incompatibility, pressure ulcers, injuries from falls and infections such as blood stream infections secondary to wounds or catheter contamination. If not present on admission, these complicating conditions will not be reimbursed.

This is all designed to improve patient safety-and to reduce Medicare spending. It is very likely that this list "unreimbursed conditions" will be expanded as time goes on. Because so much of medical care is dictated by the results of laboratory testing, the laboratory staff will play an increasingly important role. Laboratory data will be useful in documenting, for example, that a condition was present on admission (POA) and therefore reimbursable-or the converse: no lab results on chart, not reimbursable.

Under this regulation it is very possible going forward, laboratory data can be considered in other ways as well. What about a wrong diagnosis resulting from an incorrect test, delayed results or incorrect results. Might the lab be inducted into controlling preanalytical and postanalytical phases of testing more than is currently done?

Bottom line: the lab will continue to play a pivotal role in ensuring safe patient care.

Words Have Power, Choose Them Wisely

2008-03-06T15:45:00Z

A nurse calls from the oncology clinic wanting to know how long she would have to wait to get the results of a CBC in order to start the patient's chemotherapy. The lab assistant answering the phone stumbles and says something like "we are really short staffed today. We are working on it and will get out a soon as possible; I can't give you a time."

She does not tell the hematology technologist about the call. Ten minutes later, the nurse calls again, the tech realizes the smear is still in the stainer and says simply "It's on the machine and will be off in about 10 to 15 minutes." The nurse says sarcastically "You all need to get faster machines" and hangs up.

Fifteen minutes later, the physician himself calls and is really mad. He berates the laboratorian who answers the phone and asks if she realizes how important it is to get results back in a timely manner. He says he is especially interested in the platelet count and seeing if there are any blast cells.

This time the tech says, "I am sorry about the delay. The automated part of the CBC is ready and I can give you the platelet count, WBC and H&H right now. The smear has just been stained and I am about to take a look at it microscopically. It should take me about 5 minutes or so, but I will be happy to call you back if I see any blasts even before I do the entire differential. Would that help?"

Which conversation do you think is more useful and powerful? Not only did the tech provide valuable information to the physician, she used language indicating she was aware of the lab's role in patient care. The lab assistant was dismissive and vague. The first tech made the lab seem like a bystander, simply passing on automated results generated by instruments.

This is a very simple example of how laboratorians can either play into negative stereotypes or how subtle choice of words can present a more positive, progressive view of the laboratory's role in patient care.