Saturday Night Live used to have this recurring skit about a rude computer technician played by Jimmy Fallon. He’d appear and respond to polite questions with snarking geek jokes, yell “MOVE!” and type the solution in a few keystrokes. “Was that so hard?”
There’s more than a grain of truth in this humor. While jargon-laden professions with obscure silo-based rules tend to make fun of outsider mistakes (think specimen collection and rejection, for starters), a lot of the humor comes from how the company employees react. They just want to print a file, stop their computer from locking up, and other everyday tasks so they can get work done. They don’t care about firewalls, IP addresses, print servers, clearing the cache, creating a macro, and most (if not all) of the other stuff IT geeks talk about.
How about your company’s computer guy? Is he (or she) like Nick Burns on Saturday Night Live? Let’s hope not.
It’s frustrating to be asked to use something that doesn’t work, doesn’t save time, or breaks down. Computers and networks are often all three. And with the expansion of their use into all areas of healthcare, the guys in IT are doing double and triple duty to repair, upgrade, and install software and hardware to meet the needs of users who are not trained in the whys and hows. Nor do most care.
I appreciate the Nick Burns character, having worked in IT many years ago. (I’m ashamed to admit I get his jokes, too.) In his defense, some users don’t seem to want to help themselves by learning what appear to be simple rules. To his shame he doesn’t create teachable moments, unless it’s teaching users to hate computers.
Your IT staff may not be a room of Nick Burns, but they probably don’t have the time to figure out how to really help. They deal with all systems, not just the laboratory. How does a laboratory help itself get out of this frustrating rut of depending on the company computer guy? Has your lab done it? Share in the comments below.
NEXT: Customer or Self Service?
Lab techs typically think of “corrective action” as it relates to quality control. A QC point is out, the tech checks reagent levels, finds out the reagent level in the well is low, puts on fresh reagent, and repeats the controls. But was this really the problem? If the QC is in e.g. “corrected,” we all assume yes.
Experience with methods teaches techs the most likely causes of error. It could be temperature, water, reagent levels, mixing probes, carryover, or any number of variables. Typically a tech will learn problematic methods that require TLC, too, and make sure reagents are fresh in advance, controls are fresh, or a different artificial set of circumstances to avoid wasting time and material.
This is particularly obvious in coagulation testing, where methods are sensitive to changes in temperature and pH. I’ve seen techs put fresh reagent on and reconstitute controls that aren’t “fresh,” e.g. made up during the last shift. Despite package guidelines on storage and stability, techs learn through trial and error how to avoid common problems.
For similar reasons techs will run all quality control for the day after performing maintenance and system functions checks. It’s easy, it’s expedient, and it saves time later during the day. It’s better to fix a problem early.
But is this effective quality control? I wonder. Shouldn’t controls be run at random times by different techs throughout the day to control all states?
While there isn’t anything wrong with choosing a most likely culprit for QC being out, too, I wonder if that’s really good corrective action. After all, corrective action itself should be unnecessary. If, for example, a method consistently fails with a low volume of reagent in a reservoir, shouldn’t the corrective action be collected as quality improvement data and a change in practice made? Sample lookbacks are tedious and can be expensive.
Corrective action is important quality information that is often overlooked. We should collect and plot these actions, effective or not, to tweak and improve our quality systems. Does anyone do this? Has any middleware been programmed to do this?
NEXT: Your Company’s Computer Guy
Imagine two offices in different parts of the building, and you work in both of them. Many times you need to share information between the offices, a task complicated by the distance between them and the time it takes to move papers, telephone contacts, etc. from one to the other. If only you could someone connect both offices seamlessly, your productivity would improve.
That’s what it’s like to have two computers, an increasingly common situation with laptops, tablets, and even smartphones. Sure, your data might be “in the cloud,” but it’s quite another thing to use two computers as one. Fortunately, two apps make this easier.
The first is easy: Google Chrome. If you’re signed into Google Chrome on two devices open tabs on both are easily visible by checking “Recent Tabs.” This lets you open a tab on one machine that is open on another, saving you the trouble of saving bookmarks, writing down web addresses, etc. This can be very handy with smartphones.
Google Chrome also records your history of sites visited across devices, which can also be handy. Think, “I know I looked at that web page on my phone during the meeting,” and you’ll be able to find it on your desktop.
But if you have two computers side by side - let’s say you’ve brought a laptop back from a meeting and have it sitting on your desk beside your PC monitor - it would be nice to literally connect the two. A Microsoft app called Mouse Without Borders does that. Installation is easy: download it on both machines, install it, and follow the prompts. You’ll be able to run both computers from one keyboard and one mouse, extending your desktop. You can drag files and share the clipboard, too. This means, for example, that you can copy text from one computer and paste it into another.
These apps make possible what the laws of time and physics can’t: they eliminate space between data. More importantly, they make it feasible (not a waste of time) to use different computers in different settings.
NEXT: Correcting Corrective Action
Let’s face it. So far the “Information Age,” what futurist Alvin Toffler coined The Third Wave in 1980, has been a headache of electronic junk, slow computers, confusing software, extra work, and ergonomic nightmares. Geeks aside, computers are often more trouble than they are worth. But every now and then there are glimpses of a future that seamlessly connects spaces between data.
The AAB Clinical Microscopy survey requires techs to go online to see an image using Microsoft Silverlight, a browser plugin that plays animations similar to Adobe Flash. There is no other way to view this image, which is designed to simulate a microscopic field, allowing one to pan and zoom in. It’s a nifty idea but a pain when it doesn’t work.
A recent firewall update broke our Silverlight plugin, for example, and all we got was a cryptic error message when we tried to look at the image on the AAB website. Our IT department played around with it, we tried it on different computers and browsers, and I called AAB. The due date arrived without a local solution.
An Android app called Chrome Remote Desktop saved the day. Since Silverlight worked on my home computer, I used this app to connect via my smartphone, opened a browser window, and showed the tech the image.
The app has two components: an app you need to install from the Google Play Store on your Android phone, and another installed from the Chrome Web Store on your PC using Google Chrome. Both are free. When you run the program on your PC, it asks you to create a PIN. Open the app on your phone, enter that PIN, and you see a mirror image of your PC screen. You can move the mouse, run programs, type web addresses, and even restart or shutdown your PC remotely.
Connecting to my desktop at home (Android has no Silverlight plugin) was a trivial but intriguing solution. Are we, as Toffler claims, “building a remarkable new civilization from the ground up?” The tech was just happy to hand in her survey on time.
NEXT: Connecting Desktops
Viruses make the rounds during the winter months, and here in northern Maine with Spring finally here we’re still seeing coughing, stuffy heads, and wheezing. Allergy season is fast on the heels of a winter season that never seemed to end.
I’ve not been sick, but coworkers have not been so fortunate. Some call in sick, others work out of guilt wearing a mask, and I’ve sent a few home because they were too sick to work. I understand that some people don’t mind working under the weather, others can’t imagine who would cover an evening or holiday shift, and others feel guilty.
But as US News and World Report correctly states, “If you’re contagious, you should try to stay home regardless ... Your co-workers won’t appreciate you spreading germs, and some of them may have compromised immune systems or are going home to family members who do.” This also applies to infants, the elderly, pregnant family members, and others at risk. Spreading germs to others is a nasty side effect of working sick.
But the question is often complicated by organizational culture. You may work in a place where higher ups work when sick, monitor sick time abuse, or refuse to allow reductions in workload to account for absenteeism. Face it, it’s easier to work sick then worry when you return your boss will look at you and say, “Sick again? That’s the third time this month.”
Employers need to be wary of malingering, abuse, and situations where employees punish coworkers or supervisors by calling in sick, but they also need to send a compassionate insistence that the truly “too sick to work” crowd needs to stay home, get well, and don’t bring it into work. Especially in hospitals.
Too, Baby Boomers are much more likely to load up on OTC meds, wear a mask, and work through it than Xers or Millennials. It’s dumb, but the generation that raised the Boomers didn’t have the work benefits we consider entitlements today. A job was work. Is it still? I wonder.
Consider your workplace. When are you too sick to work?
NEXT: Remote Desktops
In the movie Harry Potter and the Sorcerer’s Stone a magical hat (what else?) decides where to place the young wizard students at Hogwart’s. The hat almost places Harry with his arch enemies (Myers-Briggs isn’t perfect, either). It’s a great story, one which I read summer mornings on a playground bench while my children played nearby. That was nearly as enjoyable as summer afternoons at a laundromat reading The Adventures of Tom Sawyer.
Our careers are far less predestined, although they do involve hats. In small hospitals, it’s quite common for people to wear many hats. Performing “duties other than assigned” can be educational, give your job meaning and excitement, and provide a boost to your career.
Being offered such opportunities is something of a mixed blessing. It’s a manager’s job to recognize high potential, high performing employees and nurture their development before they leave for greener pastures. But employees don’t always see their own potential or lack self-confidence to jump ahead of the pack. Being given extra projects or asked to serve on a committee can seem like just extra work. And who wants extra work?
If your laboratory has a career ladder, advancement and expectation are built in. The good thing about a career ladder is it often includes some kind of recognition and tangible reward. But it’s difficult to implement in a small laboratory where everyone is a generalist and the staff includes part-timers and per diem techs to fill the gaps.
Bench level supervision is another path to greater responsibility, a somewhat different hat. This can be a difficult transition for a bench tech, typically being a task with responsibility and no authority. But it can be a great job for techs with a lot of knowledge who want to delve deeper into details and make a difference in the quality of work produced. It’s often a good niche for high performers without high potential.
Wearing one hat for too long can be boring. Harry Potter at least would have been much more interesting if the Sorting Hat had put him in Slytherin once.
NEXT: When Are You Too Sick To Work?
April is a busy month. It is Alcohol, Foot Health, Autism, Hepatitis, Child Abuse, Humor, Facial Protection, Minority Health, Occupational Therapy, Sexually Transmitted Diseases,
Sport’s Eye Safety, and Woman’s Health and Safety Awareness Month, according to one 2014 marketing brochure. During the month there is a Healthcare Access Personnel, Healthcare Volunteer, Cancer Registrars, Public
Health, Healthcare Administration Professionals, Neurodiagnostic, and (finally) Medical Laboratory Professionals Week. There is also Radiologic and Imaging Nurses Day, Health Day,
and... you get the picture.
Lab week falls in a busy month with April school and other vacations, but it’s a big deal. As I look back at many years of lab weeks, a few stand out:
- We set up displays in a conference room explaining what the lab does. I created a hanging display of styrofoam red blood cells and antibodies (the points on the antibodies fit into
slots on the cells) to explain ABO groups. This was a big hit and fun to do.
- Administration came by the break room one day with a cart carrying a decorated cake. This was also fun, because it was a surprise. And who doesn’t like cake?
- Endless amounts of food one week. Pizza, cookies, cake, potluck, and anything else people could think of. A week of celebration is a good excuse to eat yummy food.
For the last dozen or so years I’ve written about lab week in our monthly newsletter, and for the last few also written the press release for our local newspaper. This year we created
a pamphlet of recipes to share with everyone.
Enthusiasm for Medical Laboratory Professionals Week varies from year to year, depending on what’s happening with the hospital, the lab, or people’s personal lives. Some years it’s
a lot of fun, and other years there is little time to do anything. It’s always a chance to remind ourselves and our coworkers in other departments how much we love our profession.
Hopefully, your lab week was a good one and you took time to be recognized in some way. April is a busy month, after all.
NEXT: Many Hats
“Use it or lose it” is true in exercise, neuroscience, and our work lives. If a small laboratory doesn’t use its micro department to its fullest, it could lose it. In my last blog I described
how cultures are processed for the convenience of the laboratory, which neither serves customers nor impresses bean counters. Microbiology is relatively expensive; if there is no
difference in treatment as a result of in house or reference diagnostic testing, why keep it?
Eventually this “make it or buy it” question arises. The trick is to make something that can’t be bought. And only we can do that.
Working at a lab’s convenience is an outmoded paradigm dating before discrete analyzers when workloads were batched to optimize reagents, controls, and tech time. But today’s
technology is faster, cheaper, and able to run nearly everything in a rapid cycle from door to floor. Many laboratories have replaced batching with a more fluid, less variant model of
rapid testing. The difference between routine and STAT have become almost academic.
Microbiology is an exception. Many laboratories may batch culture workups, examining plates during the morning, delaying testing for late-plated specimens from the previous day.
Can this be changed? Is it possible to read micro around the clock?
It’s an interesting question. If a culture workup is not delayed, results go out not just sooner but more consistently, allowing docs to plan treatment. But if culture workups are
batched in the morning, physicians are never quite sure when to expect results. In house or send out makes little difference.
What we do is work up cultures on two shifts - night and day - and report throughout those two shifts. Our evening tech, who works alone, is trained to read and report negative
urine and blood cultures. An afternoon read is also a possibility. This has meant training everyone in microbiology (we did not add staff) and actively communicating culture results to
nurses and doctors instead of passively printing. Use it or lose it.
Does anyone else read micro around the clock?
NEXT: The Lab Week That Was
If your small laboratory still performs microbiology testing in house, competency and competition present stiff challenges. If only a few people on your staff do micro identification and susceptibility testing, that leaves a staffing gap you’re forced to schedule around. If you use a reference lab to perform extra testing using methods such as MALDI, physicians may think your techniques are too primitive. And if you haven’t updated your technology, they may be. Bigger competitors with deeper pockets have more resources to solve problems. Their testing can be cheaper, too. It’s one of those cases where on paper it looks better to buy it than to make it.
But it depends on what you’re making. What we do isn’t about money, anyway, but the patient. And while we often hear “the patient is being treated empirically,” increased antibiotic resistance have made local microbiology a necessity more than ever. (Is giving someone vancomycin because of their risk factors and not a culture result “treating empirically?” Isn’t it more like playing odds?) Small labs can excel at patient care over reference lab testing in many cases.
To start with, when do you do micro?
Traditionally, microbiology testing revolves around the rest of the lab’s workload and not when cultures are planted. A day shift is top-loaded to handle outpatients, opening volleys from offices, inpatient morning draws, early OR cases, and the daily startup. Micro fits into this mix early to midday, with most testing completed by mid-afternoon. Day one plate reads that happen around seven a.m. depend on a 18 to 24 hour incubation period. Thus, afternoon, office closing drop offs, clinic drop offs, and evening cultures wait up to an extra day.
If we make a physician wait an extra day, “treating empirically” is a real thing. Why not send it to the reference lab and expedite all testing? The question is confused by a perceived limitation of technology and priority of cost. The only question is, “Can we give the physician a result in time to make a difference in care?”
The answer has to be “Yes!” Micro is no exception, and next I’ll consider how.
NEXT: Micro Around the Clock
When I took High School physics, we were not allowed to use calculators. This was just as well, since they were bulky and expensive. The Texas Instruments SR-50 sold for $170 in 1974, which is over $860 today. Slide rules were cheap. Pen and paper was cheaper.
Point is it’s always tempting to use a computer. Write a program, spreadsheet function, or LIS calculation to do the heavy lifting, and the results are error-free.
But are they? Do you know for sure that every time your LIS calculates an INR it is accurate? I performed a test a few years ago and found a subtle rounding error that caused a small
discrepancy. Maybe, this kind of thing isn’t important. But if we aren’t using our brains we may forget how or - even worse - we may not learn how.
With that in mind, here are a few suggestions to improve a body fluid calculation:
- Use color. It’s easy to forget that modern printers can cheaply print color if we don’t have it online. Using a software tool like Paint you can add color to an Neubauer ruling image to
signify common counting chamber areas for white and red cells, for example, and paste it into your procedure.
- Emphasize using the hemocytometer formula. Shortcuts can be difficult to adapt to all settings, and this can be a real problem with body fluids.
- Give plenty of examples. Many times a tech will perform a calculation correctly but want to make sure with an example. It might sound dumb, but everything can sound dumb at 3
AM when you’ve had only a few hours sleep.
- Include a “cheat table.” I added this with some reluctance to our procedure, but it’s been useful. It crosses number of squares counted by the dilution factor to a multiplier (e.g. no
dilution, all nine square counted, multiplier is 1.1). This can double check the hemocytometer formula or be used by itself.
I wish I had one of those old calculators, though. Antiques are worth something. Do they even sell slide rules anymore, I wonder?
NEXT: When Do You Do Micro?
I became comfortable working up body fluids when I worked in a hospital with two pediatricians and several orthopedists on the medical staff. Every few days (it seemed) we received
a septic joint fluid, synovial fluid for crystal analysis, or a septic workup cerebrospinal fluid. For me these became routine.
The problem with body fluids isn’t those that arrive in the middle of the day when there are plenty of people and time, as we know. It’s those STAT fluids from the ED in the middle of
the night. And math is hard at 3 AM.
The classic hemocytometer formula is an algebraically condensed unit conversion:
Cells counted x depth factor (10) x dilution factor (1,5,10, etc)
Total cells / uL = --------------------------------------------------------------------------------
# large squares x 1
Although this is really all we need to remember, it can be confusing if we are trying to correct for units, exponential factors, or in comparison to automated counts. If the count is low
we might count all nine squares in the chamber, or if the count is high we might count a portion of the smaller squares in the center. All body fluids are different.
What makes this even more confusing are further shorthands employed in procedures and package inserts. For example, your CSF procedure might advise counting cells in all nine
squares in an undiluted sample and adding ten percent. This is derived as follows:
(cells) x 10 x 1
---------------------- = 1.1
9 (squares x 1)
Similarly, a procedure may say to count five of the smaller squares and multiply by 50. This is great if the count in the sample makes this easy, but many don’t. And what is easy to
calculate in the light of day when you have backup techs around is near impossible at 3 AM with an anxious pediatrician breathing over your shoulder.
While the hemocytometer should be burned into every tech’s memory, it still requires a manual calculation that is subject to significant errors. Next, I’ll consider one idea we’ve
added to our procedure to make this easier. In the meantime, share your ideas in the comments.
NEXT: A Better Cell Count Calculation
Critical access hospitals should be just that for communities. But USA Today reported last November in a story called “Rural hospitals in critical condition,” “Since the beginning of 2010,
43 rural hospitals — with a total of more than 1,500 beds — have closed, according to data from the North Carolina Rural Health Research Program.” Patients in need have to travel a
significant distance to receive care, unlike city residents. The article concludes, “partnering with big health systems is the only hope for survival.”
A partnership with a bigger institution adds bargaining power, more resources, and economies of scale. Consolidating laboratory services can reduce cost, too. It may not matter if a
chemistry panel is done on an analyzer in your lab, in a nearby city, or on the other side of the country.
Over the years I’ve seen small laboratories erode services as the “bigger is better” paradigm becomes truth rather than assumption. Labs outsource microbiology, most esoteric
testing, blood bank, even the laboratory itself. It’s a shame, because much of what makes a local service unique is lost. I can’t help but think some quality is lost, as well.
How can we make our service immune to outsourcing? I’m not sure it's possible, but here are a few ideas:
- Be proactive - outreach with local nursing homes, assisted living centers, and rural health centers. Include home draws, too.
- Be visible - daily rounding and communication with doctors and nurses about cultures, collection issues, downtime, etc. goes a long way.
- Be a resource - a rapid, friendly response in person can be invaluable when someone else on the team is in a bind. Offer to help whenever and wherever you can.
This amounts to “getting out of the basement” and opening the doors of the black box. Most healthcare workers outside the lab have almost no idea of what we do, but that doesn’t
mean they aren’t interested or would not find value in learning. Get out of the basement, connect daily with team members, and be an active resource.
Have any other ideas? Please share in the comments.
NEXT: Math is Hard at 3 AM
Are we seeing the last gasps of community hospital laboratories? Sometimes I wonder. A 2007 article in Clinical Chemistry states, “Many laboratories already outsource esoteric tests to other (reference) laboratories, but outsourcing should also be considered for non-esoteric tests (6). The motivation to outsource should be that a specific test can be done better, more often, and at a lower cost in an external organization. In other words, the external organization has a higher level of expertise, is more efficient, and can take advantage of greater economies of scale.”
The “O” word isn’t new. I’ve heard “economies of scale” so many times since 2007 the phrase has almost lost its meaning. Bigger is better, cheaper, and smarter. It is, in the words of bean counters that are the new agents of change in our industry, “the new normal.”
It’s true that bigger organizations have greater clout with vendors, have more resources, and can do more with less. The greater the ratio of billables to non-billables (quality control, calibration, etc.) the cheaper the cost per test and the higher the productivity of the laboratory. This industrial approach to laboratory medicine makes perfect sense for routine screenings, esoteric testing, and even urgent work if the service can be affiliated with Big Brother or outsourced in a way that doesn’t sacrifice quality.
The laboratory has always been driven by bigger and better technology, but it comes at a price that is increasingly scrutinized. As a pathologist told me recently, “There is nothing unique in what we do.”
Bench techs have a different story. The value of the generalist in a small laboratory is in the details of care: faster turnaround times, multitasking across departments, and a personal relationship with team members that spans disciplines. I’ve worked in medical centers where I have arrived at work in the dark, worked a double, left in the dark, and never seen a soul outside the laboratory. That almost never happens in a small hospital. Local, personalized care has a unique quality impossible with “economies of scale.”
Next, I’ll consider how to make “what we do” unique.
NEXT: Get Out of the Basement
All the labs I’ve been in have a radio on. A surveyer once commented on this in a lab, saying in her experience they were usually by a sink. In our lab there is a radio directly outside my office, which is the only place we get reception. All day, every day it plays country western music. Not all the techs - myself included - prefer this genre, and most don’t complain. But does it help? Can music at work improve productivity?
The New York Times reports that melodious sounds help release dopamine in the reward area of the brain. One study showed that workers listening to music completed their tasks sooner and came up with better ideas, because music improved their sense of focus and their mood.
CBS Money Watch reports the same, adding that music makes you feel calmer at work. Listening to music lowers your perception of tension, which is even true for energetic music. Music can also have positive effects on people who suffer from adult ADD, again by increasing the dopamine levels in the brain.
Dopamine is a neurotransmitter with a number of functions, including mediating pleasure in the brain. It is released during pleasurable activities and stimulates one to seek pleasure. But it’s also associated with attention and cognition. Science Daily reports that dopamine also helps with difficult cognitive tasks: “Our key cognitive center, the prefrontal cortex, which we use for abstract thought, rule-based decisions and logical conclusions, is intensively supplied with dopamine.”
Bench work is filled with rules-based decisions and simple math, such as verifying results, troubleshooting quality control, and unit conversions. The above suggests that music not only improves our mood but our ability to do lab work, as well.
Sometime last year I started listening to music while writing, and to my amazement I wrote faster, more clearly, and with more focus. Usually, this involves headphones, Grooveshark, and power pop tunes. Beats me why upbeat, energetic music improves writing, but it does. I can easily imagine it helping at work, too. And who knows? It might keep people awake at meetings.
NEXT: Economies of Scale
The American Academy of Microbiology website states, “The human microbiome, the collection of trillions of microbes living in and on the human body, is not random, and scientists believe that it plays a role in many basic life processes.” Our gut flora is increasingly being seen as communities of microbes that work with us to influence our health. This is a startling change from the pathogen/species focus of clinical microbiology.
This suggests that our gut flora is not just essential but has to be cared for in terms of lifestyle, habits, diet, etc. And indiscriminate use of antibiotics that can destroy entire populations in the gut may have unknown or negative consequences. The most obvious example of the latter is hospital acquired C. difficile infection, an opportunistic colitis.
These populations don’t just keep us from being overrun with pathogens - a focus of laboratories - but help us digest food. A 2013 study in Nature indicates that changes in the microbiome occur rapidly in response to changes in diet. Ten participants switched to either a plant- or animal-based diet. In the latter group there was an increase in Bilophila wadsworthia, a bacteria linked to inflammatory bowel disease in mice.
The changes occur rapidly, too. Rather than days or weeks, the microbiome seems to respond within hours. This suggests an evolutionary advantage for early hunter-gatherers whose food supply could change from day to day, helping these humans achieve maximum absorption of nutrients.
The Nature article states, “Microbial activity mirrored differences between herbivorous and carnivorous mammals, reflecting trade-offs between carbohydrate and protein fermentation.” I suppose, it also shows difference between vegetarian, typical Western, and other diets. It’s something I have never thought about when choosing what to eat. I’m not sure I’d know where to start. But the study suggests that bile-tolerant species such as Alistipes, Bilophila, and Bacteroides that contribute to colitis are linked to animal-based products.
As laboratories will we eventually being reporting percentages of populations from stool cultures to give a snapshot of this activity? I wonder. It would be a change to look at populations and not pathogens.
NEXT: Music Improves Your Work