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
There’s been a lot of paranoia about influenza, much of it justified. The 1918 pandemic killed as many as 30-50 million people worldwide, and 675,000 in the US. We don’t know for sure. But in an average non-pandemic year influenza kills between 3-49 thousand in the US. The figure I keep in mind is 35,000 a year, about the population of Bangor, our nearest city. So if that fear makes you get a flu shot, good.
Respiratory syncytial virus (RSV) season runs from approximately November through late February in this region and typically overlaps influenza. I was surprised recently to learn that RSV is deadly in adults, for many of the same reasons as influenza. According to the CDC, while infants and children are the most frequent concern, each year there are 177,000 hospitalizations and 14,000 deaths among adults older than 65.
Nearly half as many as flu? I find that surprising, but it seems plausible for a virus that targets the lower respiratory tract. Why isn’t this on the radar for these patients? Why don’t we routinely test older patients for RSV?
I talked to one of our hospitalists about this, and at first he was skeptical. “I don’t believe those numbers,” he said. “First of all, we don’t test for RSV. How does the CDC know?”
That’s a good point. The CDC admits on their website that it is difficult to estimate, since influenza and other viral agents are not often listed as a cause of death on death certificates. Laboratories don’t routinely test for RSV for a number of reasons. Most (if not all) of the rapid kits are insensitive to adult populations and have only been approved for pediatric patients. And there is no RSV vaccine, which may be another reason we don’t test. Treatment options for RSV are limited compared to influenza.
A local microbiologist working in a lab that routinely tests RSV as part of a respiratory panel shared numbers that suggest RSV is prevalent in older patients, along with influenza. In his opinion, the CDC figures are believable.
NEXT: Populations and Pathogens
Your laboratory is probably a mix of old and new technology. You may have refrigerators decades old, small centrifuges that were purchased used and still run strong, a coagulation analyzer at the end of its five year contract, and a chemistry analyzer you just installed a month ago. Ideally, each new piece of hardware represents a new service, cheaper cost, or faster and better testing ability. When should you upgrade?
It’s not an easy question to answer. Some factors to consider:
- Is there a demand for new technology? Immunochemical fecal occult blood (iFOB), for example, is better in many ways than a guaiac test, but will it be supported by your medical staff? Can you sell it?
- Is it really an upgrade? Any new technology should be a big enough leap to market as a true improvement. A more sensitive troponin, a 6-part CBC differential, and a rapid culture identification are good examples that can improve your service and sell extra expense to administration.
- When will the status quo fail? In general major instrumentation lasts five to seven years. If you start looking for an upgrade a year or two early it gives you plenty of time to decide, strategize, and find support for new technology.
- Does it save money? It’s rare that new technology reduces cost, but it happens. Look for new contracts, year-end deals, zero percent interest rates, and rebate incentives that sweeten the pot. Competition is always fierce by definition. And bean counters are convinced by numbers.
- Is it the only option? Your organization may have a policy to get several quotes on purchases, but it’s a good idea anyway. You can always pit one vendor against another. Simply saying, “I’m considering other vendors” is often enough, since everyone knows who the players are. And who knows? You might be pleasantly surprised.
Finally, you should consider the state of the competition. If all the labs around you have hematology analyzers that report a 6-part differential, it may be time to seriously consider an upgrade, for example. Your lab needs to stay current to be competitive.
NEXT: RSV Season
When I was a teenager a local businessman ran a company called ABC Rubbish, I suppose so it would be listed first in the telephone book. We always called it “Already Been Chewed.” To this day that’s the main reason I remember that company. Mnemonics (from the Greek word for “memory”) are definitely handy.
A common “ABC” that you may not think about is one you see every day. It’s in your workplace, grocery store, department store, corner market, and probably your home. It’s what describes a type of fire extinguisher.
Not all fire extinguishers are the same. Different types fight different types of fire. OSHA has a handy “etool” that explains this. The most common types are:
- A (water, usually a large metal canister with a hose) - used for paper, wood, linens, and other ordinary combustibles; anything that leaves an “A”sh.
- BC (CO2, the kind with a horn nozzle) - used for flammable liquids, greases, and paints (anything that “B”oils or “B”ubbles) and for electrical fires (anything carrying a live electrical “C”urrent).
- ABC (dry chemical, usually a small or medium red canister with a hose attached) - suitable for all fires (A, B, or C).
The most common type of extinguisher you’ll see is ABC. Usually a label on the extinguisher says “ABC” but may also contain universal symbols denoting the type of fire: a burning trash can for A, gasoline can for B, and electric plug for C. Since the dry chemical is released under pressure, these extinguishers have a gauge with a needle that should be in the green. There should also be a tag attached denoting monthly checks.
It’s common in laboratories, IT departments, and other places with a lot of electronics to have a BC type extinguisher. But an ABC is also needed for any general type of fire. The dry chemical, which is intended to smother the fuel source, can be used on an electrical fire, but it effectively ruins the equipment. It’s something to think about when selecting a fire extinguisher, and a good reason to know your ABCs.
NEXT: When Should You Upgrade?
Healthcare is hazardous to your health. A 2010 Bureau of Labor Statistics report lists the highest number of workplace injuries in healthcare (176,380), followed by manufacturing (127,410) and construction (74,950). Nearly half of lost workdays caused by injury happen in the healthcare sector, four times the national average. Back injuries alone cost over $7 billion per year. And as dangerous as our work environments are, OSHA carries out few inspections.
It seems hard to believe, at first. After all, we work in enclosed, climate-controlled environments. We aren’t monitoring enormous machines in plants or moving steel girders hundreds of feet in the air. We don’t have to wear hard hats, respirators, hazmat suits, or face shields every day.
But in 2011 nurses ranked highest among occupations for numbers of musculoskeletal disorders resulting in lost work days. The wear and tear of patient handling is a major contributing factor. The workforce is getting older and the patients heavier. The reality of modern nursing accounts for many injuries.
Lab techs may not lift patients, although many items are heavy, such as large cubes of saline. Laboratory equipment, instruments, and tasks routinely involve exposure to high speed rotors, moving parts, heating elements, needles, and other sharps around fingers and hands. The degree of fine motor control required can cause repetitive motion injuries. We deal with harsh chemicals such as corrosive acids. And blood and body fluid exposures are a constant occupational risk.
Often, it’s ambient factors that go unnoticed. These include temperature and humidity, ventilation, cleanliness, clutter, and ergonomics. A laboratory that is too cold, too hot, too stuffy, or too dirty can be a difficult, hazardous, and stressful environment to work in. Clutter and poor arrangement of workstations can sap productivity. (There’s no such thing as being “organized under the surface.”) Poorly designed chairs, counter surfaces, and floor mats also cause musculoskeletal wear and tear. And labs are incredibly noisy, too, with all the bells, buzzers, high speed motors, and telephones. It all adds up.
So the next time you arrive at work, look around. How safe is your lab?
NEXT: Know Your ABCs
Interviewing for a job is stressful, especially if you don’t have a job and need one. It’s easy to forget that you’re not just buying what an employer is selling - working conditions, pay rate, benefits, culture, etc. - but shopping. What should you be shopping for?
Like most shopping, we want value.
The Guardian reports that, at least in the UK, work-life balance is number one. Location and job stability rank second and third. The interview is your best chance to ask about work factors important to your “real” life: shift times, rotations, holiday schedules, staffing levels, etc. It’s also a chance to ask about the financial health of the organization and its strategic plan.
There are other factors included in “value” that will vary from person to person. Here are two that have made a difference to me:
- Commute time - it amazes me that people will choose to drive an hour or more to a job. An hour commute is two hours (depending on seasonal traffic) out of your day. If you consider this as time worked (it’s not play, that’s for sure) it dilutes your take home pay, along with gasoline expense. I’ve worked most jobs with a two to five mile drive, which is great. Most days I can go home for lunch, too.
- Please and Thank You - a lot of fuss is made about “corporate culture,” but it all boils down to “Is it a nice place to work?” Unless you have experience at a workplace as a customer, the best way to tell is by walking around and observing employees. If they smile, say please and thank you, and get along that’s a good sign. The only thing worse than working at a place where people dislike each other is being one of their customers.
I rarely interview candidates who ask me about the above, and no one has ever asked me about the future plans of the hospital. But this kind of value is important in a place where you hope to spend a lot of your time and creative energy.
NEXT: How Safe Is Your Lab?
Hospital acquired anemia can be an issue if multiple tubes are collected several times a day. Over time, small amounts of blood (5 mL is a teaspoon) add up. I’ve developed a “short draw” protocol to use low volume tubes and chart the amount drawn for patients if a physician has a concern.
However, it’s common to draw a rainbow - one of every color - when time is a factor. This has been common practice in the ED and with EMS personnel. Before the doc sees the patient and while the nurse is starting an IV, a rainbow is drawn just in case on some patients.
Pros: when the ED doc orders a test, blood is in the lab and in many cases spun, reducing delays. We can anticipate an order in some cases e.g. chest pain and have a test running.
Cons: Extra tubes sitting around without laboratory barcodes are a problem that needs to be constantly checked. If information in an account is corrected, tubes are labeled incorrectly, or a test is ordered that needs a special tube e.g. lactate, delays happen. Tracking tubes without orders is a distracting process variation.
Indeed, I’ve toyed with the notion of not accepting any specimens without an order. But specimens sitting in the ED could cause bigger problems.
What if the ED stopped drawing a rainbow? What if they drew only the tubes needed for the tests ordered?
Pros: tubes are more likely to be received with orders already in the system. Less blood is collected from the patient. Cost is reduced.
Cons: it’s harder for ED and EMS to fit a draw time in at the doc’s discretion, so the lab is more likely to be called to draw the patient, causing delays. There is a predictable delay in processing samples if the draw waits for an order. Untrained or hurrying personnel can forget which tube goes with which test, resulting in redraws and further delays.
It’s lab meets nursing meets cost containment and efficiency.
What about your lab? Do you draw rainbows? Why or why not?
NEXT: When Choosing a Job, Shop for Value