Laboratory Information System Research Articles

The digital health landscape at children’s hospitals in Canada

ABSTRACT Objectives Canadian hospitals have historically lagged behind peer nations in terms of adoption of digital health tools. The aim of this study was to assess the current state of adoption of digital health tools at children’s hospitals in Canada. Methods We conducted an online survey of Canadian pediatric tertiary-care hospitals between January and July 2023. The 35-item questionnaire was administered in English and French. Hospital characteristics, informatics infrastructure data and electronic health record (EHR) functionality data were summarized using descriptive statistics. Results The survey was completed by 15 of the 17 (88.2%) pediatric hospitals in Canada. All institutions had an EHR with 10 (66.6%) being fully digitized and five (33.3%) being partially digitized. Funding and availability of clinicians with expertise in clinical informatics were cited as barriers to implementing digital health tools. The availability of core EHR functionalities ranged from 53.3% for medication to 100% for the presence of a laboratory and radiology information system. Only five (33.3%) institutions reported that they had a patient portal. Discussion While all hospitals in this study had an EHR, functionalities varied greatly between centers. Canada lags behind the United States in terms of adoption of digital health tools such as patient portals likely due to governmental mandates and incentives, and a focus on cultivating a physician informatics workforce. Conclusion Canadian pediatric hospitals lag behind peer institutions in digital maturity. This study highlights the perceived need from hospitals for policies, funding, and resources from the Canadian government to help increase the uptake of comprehensive EHRs.

Epidemiological survey of 32,786 culture-positive dermatophytosis cases in Hangzhou from 2018 to 2023.

With the rapid development of the economy and changes in lifestyle in recent years, the epidemiological pattern of dermatophytosis has changed. We analyzed the epidemiological features of dermatophytosis in a hospital in Hangzhou from 2018 to 2023. Data from patients with culture-positive dermatophytosis were obtained from the Laboratory Information System of the Mycology Laboratory of our hospital. Dermatophyte isolates were mainly identified by macroscopic and microscopic features of the colonies. There were 32,786 patients with culture-positive dermatophytosis during the 6-year period, including 16,789 male patients and 15,990 female patients. Patients' ages ranged from 1month to 97years. Tinea unguium accounted for the largest proportion (14,879, 45.38%), which was mainly prevalent among females (8946, 60.13%). Significant gender differences were observed in all clinical types of dermatophytosis, except for tinea pedis. In total, 15,486 (47.73%) patients aged 21-40years. The median age of patients with tinea manum and tinea capitis was the highest (49years) and the lowest (5years), respectively. Nine species of isolated dermatophytes were identified, of which Trichophyton rubrum accounted for 90.20% (29,573 cases). M. canis accounted for 66.80% of isolated dermatophytes from tinea capitis. The isolation rates of zoophilic species were 43.41% in tinea faciei and 18.90% in tinea corporis. T. rubrum was absolutely predominant agent of dermatophytosis except tinea capitis in which M. canis was the most common organism. The prevalence of zoophilic dermatophytes has increased in tinea faciei and tinea corporis. Tinea unguium was the major clinical form of dermatophytosis, and it was more prevalent among females. The onset peak of dermatophytosis was in the age group of 21-40years, except for tinea capitis.

Influence of Blood Sampling Service Process Reengineering on Medical Services Supply: Quasi-Experimental Study.

Tertiary hospitals in China are confronted with significant challenges due to limited spatial capacity and workforce constraints, leading to saturated allocation of medical resources and restricted growth in medical service provision. The incorporation of digital health into medical service process reengineering (MSPR) marks a pivotal transformation and restructuring of conventional health service delivery models. Specifically, the application of MSPR to blood sampling services processes reengineering (BSSPR) holds promise for substantially enhancing the efficiency and quality of medical services through streamlining and optimizing these procedures. However, the comprehensive impact of BSSPR has been infrequently quantified in existing research. This study aims to investigate the influence of BSSPR on the efficiency and quality of medical services and to elucidate the key informative technological support points underpinning BSSPR. Data were collected from both the new and old laboratory information systems from August 1, 2019, to December 31, 2021. A combination of statistical description, chi-square test, and t test was used to compare check-in time and waiting time of outpatients before and after the implementation of BSSPR. An interrupted time-series design was used to analyze the impact of BSSPR on medical service efficiency and quality, enabling the control of confounding variables, including changes in medical human resources and both long- and short-term temporal trends. BSSPR had an impact on the efficiency and quality of medical services. Notably, there was a significant increase in the number of patients receiving blood sampling services, with a daily service volume increase of ~150 individuals (P=.04). The average waiting time for patients decreased substantially from 29 (SD 36) to 11 (SD 11) minutes, indicating a marked improvement in patient experience. During the peak period, the number of patients receiving blood sampling services per working hour statistically increased from 9.56 to 16.77 (P<.001). The interrupted time-series model results demonstrated a reduction in patients' waiting time by an average of 26.1 (SD 3.8; 95% CI -33.64 to -18.57) minutes. Although there was an initial decline in the number of outpatients admitted following BSSPR implementation, an upward trend was observed over time (β=1.13, 95% CI 0.91-1.36). BSSPR implementation for outpatients not only reduced waiting time and improved patients' experience but also augmented the hospital's capacity to provide medical services. This study's findings offer valuable insights into the potential advantages of BSSPR and underscore the significance of harnessing digital technologies to optimize medical service processes. This research serves as a foundational basis and provides scientific support for the promotion and application of BSSPR in other health care contexts. By continuing to explore and refine the integration of digital technologies in health care, we can further enhance patient outcomes and elevate the overall quality of medical services.

Characterization of Thrombocytopenia in Pediatric Patients in Noncritical Hospital Setting: An Institutional Review From Pakistan

Pediatric thrombocytopenia is frequently observed in critical care and oncology settings with an increased risk of bleeding and platelet transfusions. However, little is known about low platelets in childhood during seasonal influence. This study aimed to evaluate the frequency and severity of pediatric thrombocytopenia in the postflood period. The patients aged 1 to 18 years with thrombocytopenia (platelet count &lt;150×109/L) were studied from August to December 2022 after institutional ethical approval (ERC-Path-2022-8044-23395). Data was collected from electronic health records and laboratory information systems. Of 2318 admitted patients, 192 (8.3%) including 128 males and 64 females had thrombocytopenia. The median (IQR) age was 12 (8 to 15) years. Mild, moderate, and severe thrombocytopenia were seen in 109 (56.8%), 76 (39.5%), and 7 (3.6%) patients, respectively. Concomitant leucopenia was observed in 77 of 192 patients (40.1%). Infection was the predominant cause of low platelets (N=175 or 91.1%). Only 15 patients (7.8%) had grade 1/2 bleeding. Overall, 176 patients (92%) were discharged in stable conditions and no mortality was observed. The frequency of pediatric thrombocytopenia in the noncritical and nononcological care settings was &lt;10% and mostly observed in association with underlying infections. The frequency of bleeding manifestation and platelet transfusions was minimal in this group.

Characteristics and eye disease distribution of HIV-infected or AIDS patients: a single-center study

Objective: To explore the characteristics and eye disease distribution of human immunodeficiency virus (HIV)-infected or acquired immune deficiency syndrome (AIDS) patients reported by Beijing Tongren Hospital, Capital Medical University. Methods: A retrospective case series study was conducted. Data of HIV-infected or AIDS patients who were reported for the first time in the Chinese Center for Disease Control and Prevention Information System by Beijing Tongren Hospital, Capital Medical University from January 1, 2012 to December 31, 2021 were collected. Epidemiological data such as the patient's gender and age were recorded, and information such as the patient's clinical diagnosis, department classification, and laboratory test results were retrieved from the hospital's outpatient and emergency system and laboratory information system. Results: A total of 191 HIV-infected or AIDS patients were included, with an average age of (36.71±13.52) years, including 177 males and 14 females. The proportion of male and female patients showed no statistically significant change over the years (P>0.05). Most cases were initially diagnosed in the department of ophthalmology (75 cases, 38.22%), followed by the department of dermatology (49 cases, 25.65%). There were 42 cases (56.00%) reported in the fundus group, 10 cases (13.33%) in the cataract group, 8 cases (10.67%) in the refractive center, and other cases in the glaucoma, cornea, and ocular tumor groups. The ophthalmological diagnoses included uveitis (21 cases, 28.00%), retinopathy (13 cases, 17.33%), cataract (11 cases, 14.67%), refractive error (7 cases, 9.33%), glaucoma (4 cases, 5.33%), retinal detachment (3 cases, 4.00%), vitreous hemorrhage (3 cases, 4.00%), cytomegalovirus retinitis (2 cases, 2.67%), ocular tumor (2 cases, 2.67%), optic neuropathy (2 cases, 2.67%), conjunctivitis (2 cases, 2.67%), keratoconus (1 case, 1.33%), chronic dacryocystitis (1 case, 1.33%), lacrimal duct obstruction (1 case, 1.33%), corneal endothelial decompensation (1 case, 1.33%), and ectropion (1 case, 1.33%). Some patients had co-infections with syphilis, hepatitis B, and hepatitis C. Conclusions: There are undiagnosed HIV-infected or AIDS patients in some departments of non-infectious general hospitals, and the ophthalmological manifestations are mostly uveitis and retinopathy. Ophthalmologists should pay attention to the HIV infection or AIDS infection status of patients with eye diseases such as uveitis and retinopathy to reduce the risk of occupational exposure.

Histopathological assessment of AIDS-defining malignancies in the gastrointestinal tract presenting with acute abdomen: Improving diagnostic timeliness and patient care.

While a large number of cases in an HIV setting may be attributed to infections, there has also been a rise in HIV- associated malignancies such as Kaposi sarcoma and aggressive B-cell lymphoma. To describe the clinicopathological features of cases with acute abdomen secondary to AIDS-defining malignancy in the gatrointestinal tract. This is a retrospective analysis of all cases presenting with acute abdomen and histologically diagnosed AIDS-defining malignancies of the gastrointestinal tract over a period of 8 years in our centre. Clinicopathological characteristics were retrieved from the laboratory information system. Archived haematoxylin and eosin-stained sections and immunohistochemical stains were reap- praised. A total of 13 cases, which consisted of 5 males and 8 females, with an average age of 35 years formed the study sample. All the patients were HIV-positive on antiretroviral therapy, and presented with acute abdomen. Intraoperatively, there were five intussusceptions, three strictures, three perforated tumours and two luminal occlusions. Histopathology confirmed five cases of Kaposi sarcoma and eight cases of high-grade B-cell lymphomas. Two patients with high-grade B-cell lymphomas died after surgical intervention. Expedited histopathological assessment of bowel resection in HIV-infected patients could improve clinical outcomes with early treatment.

Estimating Reference Change Values Using Routine Patient Data: A Novel Pathology Database Approach.

The reference change value (RCV) is calculated by combining the within-subject biological variation (CVI) and local analytical variation (CVA). These calculations do not account for the variation seen in preanalytical conditions in routine practice or CVI in patients presenting for treatment. As a result, the RCVs may not reflect routine practice or align with clinicians' experiences. We propose a novel RCV approach based on routine patient data that is potentially more clinically relevant. This study used the refineR algorithm to determine RCVs using serial patient data extracted from a local Laboratory Information System (LIS). The model was applied to biomarkers with a range of result ratio distributions varying from normal to log-normal. Results were compared against conventional formula-based RCVs using CVI estimates from a state-of-the-art biological variation study. Monte Carlo simulations were also used to validate the LIS data approach. The RCVs estimated from LIS data were: 11-deoxycortisol (men): -70%/+196%, 17-hydroxyprogesterone (men): -49%/+100%, albumin: -10%/+11%, androstenedione (men): -47%/+96%, cortisol (men): -54%/+51%, cortisone (men): -32%/+51%, creatinine: -16%/+14%, phosphate (women): -23%/+29%, phosphate (men): -27%/+29%, testosterone (men): -38%/+60%. The formula-based RCV estimates showed similar but slightly lower results, and the Monte Carlo simulations confirmed the applicability of the new approach. RCVs may be estimated from patient results without prior assumptions about the shape of the ratios between serial results. Laboratories can determine RCVs based on local practice and population.

Serum megalin levels in type-2 diabetes mellitus with and without cardiovascular disease

ABSTRACT Background: Low-density lipoprotein receptor-related protein-2 (LRP2), also called megalin, is a multi-ligand receptor of the LDL receptor gene family mediating reabsorption of ligands like Apo-A1. Type 2 diabetes mellitus (T2DM) may possibly disrupt megalin functions as it is found to be regulated by insulin. This might cause cardiovascular complications due to derangement in lipoprotein metabolism. The current study was carried out to assess the serum megalin levels among T2DM individuals with cardiovascular complications in the Indian population. Methods: This was a cross-sectional study involving 80 patients with T2DM. 40 T2DM patients with known cardiovascular disease were selected as cases and 40 of those without evidence of cardiovascular disease were selected as controls. Demographic details, DM duration and class of oral hypoglycemic agents (OHA) used were collected from medical records while details of lipid profile, fasting glucose, serum creatinine and urea were collected from laboratory information system. Serum megalin levels were estimated using left-over samples by ELISA. Results: The study groups showed no statistical significance in baseline laboratory parameters except for serum creatinine and low density lipoprotein cholesterol (LDL-c). Mean serum megalin levels were statistically insignificant between cases and controls (0.91 ± 0.78 ng/mL vs. 0.85 ± 0.69 ng/mL, P 0.74).The subgroup analysis of serum megalin levels based on OHA consumption among cases was also statistically insignificant (P 0.056). Pearson’s correlational analysis was statistically insignificant between serum megalin and lipid profile parameters among cases (P &gt; 0.05). Conclusion: Serum megalin alone may not serve as a biomarker for cardiovascular disease.

Temporal and spatial trends of fentanyl co-occurrence in the illicit drug supply in the United States: a serial cross-sectional analysis

BackgroundFentanyl and its analogs contribute substantially to drug overdose deaths in the United States. There is concern that people using drugs are being unknowingly exposed to fentanyl, increasing their risk of overdose death. This study examines temporal trends and spatial variations in the co-occurrence of fentanyl with other seized drugs. MethodsWe identified fentanyl co-occurrence (the proportion of samples of non-fentanyl substances that also contain fentanyl) among 9 substances or substance classes of interest: methamphetamine, cannabis, cocaine, heroin, club drugs, hallucinogens, and prescription opioids, stimulants, and benzodiazepines. We used serial cross-sectional data on drug reports across 50 states and the District of Columbia from the National Forensic Laboratory Information System, the largest available database on the U.S. illicit drug supply, from January 2013 to December 2023. FindingsWe analyzed data from 11,940,207 samples. Fentanyl co-occurrence with all examined substances increased monotonically over time (Mann-Kendall p<0.0001). Nationally, fentanyl co-occurrence was highest among heroin samples (approx. 50%), but relatively low among methamphetamine (≤1%), cocaine (≤4%), and other drug samples. However, co-occurrence rates have grown to over 10% for cocaine and methamphetamine in several Northeast states in 2017-2023. InterpretationFentanyl co-occurs most commonly with heroin, but its presence in stimulant supplies is increasing in some areas, where it may pose a disproportionately high risk of overdose. FundingThis work was partly supported by FDA grant U01FD00745501. This article reflects the views of the authors and does not represent the views or policies of the FDA or US Department of Health and Human Services.

Association of serum bilirubin levels and glycemic measurements in Type 2 diabetic patients

Introduction: Bilirubin, a waste product of the heme catabolic pathway, has proven to be a natural antioxidant associated with a lower prevalence of oxidative stress-mediated diseases. This study evaluates the association of serum bilirubin levels with Glycated Hemoglobin (HbA1c), Fasting Blood Sugar (FBS) and Post Prandial Blood Sugar (PPBS) in diabetic patients. Methods: A retrospective analytical study was conducted at the Department of Haematology of the Sri Jayewardenepura General Hospital. Data was obtained through a laboratory information system of randomly selected 201 adult patients diagnosed with T2DM and grouped as poorly and well controlled using HbA1c values over and below 7%, respectively. Normal ranges for serum bilirubin, FBS, and PPBS were (0.3-1.2) mg/dL, (75-110) mg/dL and (80-140) mg/dL, respectively. Data were analyzed using (SPSS) version 20, descriptive statistical methods, Pearson’s Correlation test and independent sample t-test. P&lt;0.05 was considered significant. Results: A negative correlation between total bilirubin and HbA1c (r = -0.234, p=0.001) was observed. There was no statistically significant correlation between total bilirubin level and FBS (p=0.131), PPBS (p=0.408), and age (p=0147). However, the mean values of total bilirubin (p=0.001), FBS (p&lt;0.001) and PPBS (p&lt;0.001) were significant between diabetes well controlled and poorly controlled groups. A statistically positive correlation was observed between HbA1c and FBS (p&lt;0.001) and PPBS (p&lt;0.001), but not with age (p=0.887). Conclusion: There was a significant relationship between total bilirubin with FBS, and PPBS in both groups. A significant negative correlation was found between total bilirubin and HbA1c, suggesting a potential protective or modulatory role of bilirubin in glycemic control. No significant correlation was observed between total bilirubin levels and FBS, PPBS, or age in the total population.Keywords: T2DM, HbA1c, bilirubin, FBS, PPBS

Diagnostic Performance of Red Blood Cell Indices in the Differential Diagnosis of Iron Deficiency Anemia and the Thalassemia Trait in Chile: A Retrospective Study.

Iron deficiency anemia (IDA) and the β-thalassemia trait (BTT) are two main causes of hypochromic-microcytic anemia worldwide. Researchers have described many red blood cell (RBC) indices as screening tests for presumptive differentiation, based on differences observed in complete blood count (CBC) data for each condition. There are few BTT reports in Chile, and neither laboratories nor clinical staff have widely used these indices. The objective of this study was to evaluate the diagnostic performance of 29 RBC indices in 182 patients (51 BTT and 131 IDA) and compare CBC results in both groups. A retrospective search was carried out in the Laboratory Information System between January 2021 and February 2024 to collect results from CBC, and 29 RBC indices were calculated for each patient. Then, sensitivity, specificity, positive predictive value, negative predictive value, Youden's index, positive likelihood ratio, negative likelihood ratio, and diagnostic accuracy were calculated using MedCalc©. The Green and King, Wongprachum, and Keikhaei indices showed the best discriminatory power with Youden index values of 0.923, 0.908, and 0.896, respectively, and significant differences were observed in all CBC parameters between BTT and IDA patients (p < 0.001). The Green and King, Wongprachum, and Keikhaei indices showed the best performance; therefore, they can be used as screening for the differential diagnosis between BTT and IDA in order to improve diagnosis given the important therapeutic and epidemiological implications. In this way, clinical laboratories could have a main role in the investigation of these patients.

Update on Vaccine-Derived Poliovirus Outbreaks - Worldwide, January 2023-June 2024.

Circulating vaccine-derived polioviruses (cVDPVs) can emerge and lead to outbreaks of paralytic polio as well as asymptomatic transmission in communities with a high percentage of undervaccinated children. Using data from the World Health Organization Polio Information System and Global Polio Laboratory Network, this report describes global polio outbreaks due to cVDPVs during January 2023-June 2024 and updates previous reports. During the reporting period, 74 cVDPV outbreaks were detected in 39 countries or areas (countries), predominantly in Africa. Among these 74 cVDPV outbreaks, 47 (64%) were new outbreaks, detected in 30 (77%) of the 39 countries. Three countries reported cVDPV type 1 (cVDPV1) outbreaks and 38 countries reported cVDPV type 2 (cVDPV2) outbreaks; two of these countries reported cocirculating cVDPV1 and cVDPV2. In the 38 countries with cVDPV2 transmission, 70 distinct outbreaks were reported. In 15 countries, cVDPV transmission has lasted >1 year into 2024. In Nigeria and Somalia, both countries with security-compromised areas, persistent cVDPV2 transmission has spread to neighboring countries. Delayed implementation of outbreak response campaigns and low-quality campaigns have resulted in further international spread. Countries can control cVDPV outbreaks with timely allocation of resources to implement prompt, high-quality responses after outbreak confirmation. Stopping all cVDPV transmission requires effectively increasing population immunity by overcoming barriers to reaching children.

A Descriptive Study: Evaluation of Delayed Laboratory Testing in Emergency Room

Precision, accuracy, and short turnaround time (TAT) are important to improve the quality and effectiveness of laboratory services in the Emergency Room (ER). Several studies reported an average of 60% the ratio of anticoagulant to sample is not appropriate, lysis, and clotted samples occurred in the pre-analytical part. This part consisted of the request/registration of laboratory tests, patient preparation, specimen collection, and transportation to the central laboratory. The aim of this research is to evaluate the cause of the long TAT for laboratory research so as to obtain problem solving based on the target. This observational study was conducted in 2021 at the ER laboratory outlet. Observations were made started from the workload carried out by the laboratory technician, sample registration, and data collection from the Laboratory Information System (LIS). The study obtained 14.709 samples from the LIS at the Clinical Pathology Department, Cipto Mangunkusumo Hospital. The highest sample rejection rate was from the ER laboratory outlet due to specimen lysis (2.79%). The average time required for re-collecting specimens was around 2-2.5 hours. This rejection was below the minimum quality standards based on the International Federation of Clinical Chemistry (IFCC). Other problems include the limited number of medical laboratory experts compared to the workload also inefficient Computerized Physician Order Entry (CPOE) registration methods. The main problem of delayed laboratory testing in the emergency department is the pre-analytical part including sample registration and rejection specimens. That rejection mostly comes from lysis specimens, which caused invalid laboratory result.

Antibiotic Susceptibility among Infective Endocarditis Population: Syndromic Antibiogram Evaluation at Indonesian National Cardiovascular Center

Infective Endocarditis (IE) is a life-threatening disease with a high mortality rate (25%). Laboratory approaches to support the diagnosis of IE especially blood and/or cardiac vegetation culture, are crucial for providing definitive therapy. However, negative culture is frequently observed, therefore empirical use of antibiotics seems unavoidable and may lead to increasing antimicrobial resistance. This study aims to observe the prevalence of antibiotic susceptibility among the IE population using the WISCA approach. This retrospective study observed medical record data of all inpatients diagnosed with IE according to ICD-10 at Cardiovascular Center Harapan Kita Hospital (NCCHK) between January 2018 and December 2022. Patient data were combined with bacterial identification and antibiotic susceptibility test data from the laboratory information system, and evaluated based on period (year). A total of 67,858 inpatients and 1.1% (n=772) were diagnosed with IE. Successful culture growth (blood and/or cardiac vegetation specimen) was between 36.8% and 70% annually. Streptococcus viridans group (82/237, 34.6%) and Coagulase-negative Staphylococci (57/237, 24.1%) were dominantly observed among the IE population. Low susceptibility among Penicillin (34.3%) towards Gram-positive bacteria, as first-line treatment option in IE. Meanwhile, high susceptibility range was observed in Ceftriaxone (95.7%), Gentamicin (80.4%), Rifampicin (84.4%), and Vancomycin (98.7%) as second-line treatment in IE. Despite the low prevalence, the occurrence of antimicrobial resistance in IE has become a priority concern. Continuing the syndromic antibiogram is mandatory to assist the trend of empirical antibiotic usage and refine the established local treatment guidelines.

The Correlation between Interleukin-6 and D-dimer in Severe and Critical COVID-19 Patients

Severe and critical COVID-19 patients are known to experience hyperinflammatory conditions and endothelial damage primarily characterized by increased levels of IL-6 and D-dimer. This group of patients is also considered at risk of experiencing hemostasis disorders including decreased platelet counts, prolonged PT and APTT, as well as increased fibrinogen. Therefore, this study aimed to determine the correlation between IL-6 and D-dimer in severe and critical COVID-19 patients. The relationship between IL-6 and other hemostasis parameters such as platelet count, PT, APTT, and fibrinogen were also analyzed. A descriptive-correlative observational design was used with a retrospective cross-sectional approach. The subjects were severe and critical COVID-19 patients at Hasan Sadikin Hospital, Bandung treated between January to December 2021 and met the inclusion and exclusion criteria. Secondary data were taken from medical records and the Laboratory Information System (LIS). Correlation analysis between IL-6 and D-dimer as well as hemostasis parameters was carried out using the Spearman test. The results showed that among the total 167 subjects, the median age was 60 years. The number of male subjects was 110 (65.86%), while the most common comorbidity was hypertension (45.51%). The analysis showed a very weak and insignificant correlation between IL-6 and platelets (r= -0.044; p=0.571), IL-6 and PT (r=0.115; p=0.137), IL-6 and APTT (r=0.109; p=0.159), as well as IL-6 and fibrinogen (r= -0.087; p=0.264). However, the correlation between IL-6 and D-dimer was significant (r= 0.199; p=0.010). Interleukin-6 did not correlate with hemostasis parameters but correlated with D-dimer. This means that IL-6 and D-dimer may provide information about the inflammatory response in COVID-19 patients and help monitor disease progression.

Implementation of CPOE, ERBI, and ePPID in Critical Care Operating Rooms at a Tertiary Care Academic Center

Abstract Introduction/Objective Blood transfusion in operating rooms (ORs) is a critical and complex process, often complicated by issues such as paper-based orders, lack of guidelines, and delays in blood delivery. In response, a multidisciplinary task force developed a quality improvement plan. This study assesses the impact of implementing an electronic positive patient identification (ePPID) system, standardized computer provider order entry (CPOE), and electronic remote blood issue (ERBI) process in a critical care OR setting at our institution. Methods/Case Report The team initially implemented ePPID in cardiac surgery ORs before expanding hospital-wide. CPOE was developed in collaboration with the laboratory information systems (LIS) and hospital information technology (IT). ERBI required cross-departmental coordination to establish a bi-directional interface between LIS and ERBI software. Staff received training through a train-the-trainer approach, interactive sessions, videos, and surveys. CPOE focused on order set development and creating the Maximum Surgical Blood Order Schedule (MSBOS). ePPID began with a pilot program and expanded with training sessions. Data collection tracked blood ordering, ERBI workflow, and transfusion data for compliance and utilization rates. Results (if a Case Study enter NA) The implementation of ePPID saw a rise in compliance rates from 71% to 98%, with 60 completed cases and 233 blood products transfused by 24 clinicians. ePPID’s utilization for blood products increased from 60% to 98% within 90 days. ERBI lowered RBC return rates from 30% to 15% and plasma return rates from 45% to 35% over a 2.5 year span. ERBI utilization rates reached 81% at 24 months post-implementation. Conclusion The implementation of ePPID, CPOE, and ERBI in critical care ORs was well-received among clinicians. Significant improvements in compliance and utilization rates for blood products following ePPID implementation were evident. ERBI implementation also led to substantial reductions in return rates of blood products allocated to ORs. The steady increase in ERBI utilization indicates successful integration into OR workflows.

Lack of Diagnostic Value from Fungal and Mycobacterial Cultures in Cases of Suspected Prosthetic Joint Infection

Abstract Introduction/Objective Infections of prosthetic joints cause significant morbidity and often result in removal of the infected joint. In many cases, an infectious etiology can be difficult to definitively identify. As a result, providers suspecting prosthetic joint infections (PJI) often place large order sets of microbiology tests, including fungal and mycobacterial cultures. Fungal and mycobacterial cultures are labor-intensive for the laboratory taking up to 28 days and 42 days, respectively, to complete. As a potential area for a diagnostic stewardship intervention, we wanted to evaluate how often a fungal or mycobacterial culture produced actionable information in cases of suspected PJI. Methods/Case Report Data reports were retrieved from both the Electronic Health Record (EHR) and the Laboratory Information System (LIS) from May 2022 to May 2023. As sources submitted by the provider often do not specify that the joint is prosthetic, data from LIS was evaluated to identify microbiology culture test sets ordered on joint sources, while data from EHR was examined to isolate patients with implanted joints. Using Microsoft Excel, data from both systems was compared in order to match microbiology culture test sets to the known implanted joints. LIS data from implanted joint sources was assessed to record negative (no growth) and positive (growth) cultures, and to register all organisms isolated. Results (if a Case Study enter NA) Of 794 order sets for cultures collected from prosthetic joint sources, 430 included requests for fungal culture and 79 included requests for mycobacterial culture. Of these 79 requests for mycobacterial culture, 0 organisms were isolated (0%). Of these 430 requests for fungal culture, 7 grew yeast (1.6%) and 7 out of 7 (100%) of these yeasts were also isolated on general (aerobic bacterial) culture. No molds were isolated. Conclusion Discontinuing the routine practice of ordering fungal and mycobacterial culture for prosthetic joint sources would have no negative impact on patient care but would reduce unnecessary work in the microbiology laboratory and potentially avoid additional costs to the patient. Education to the orthopedic provider group as well as best practice alerts in the EHR will be pursued, based on the findings from this study, in order to reduce unnecessary culture orders.

Relocating a highly complex 5 million test per year hospital based laboratory - what you should know and what you should avoid

Abstract Introduction/Objective A highly complex hospital based laboratory performing 5 million test per year in New York City was commanded to relocate due to a clinical department need to expand. This presented a challenge regarding the obtention of a suitable new space within the existing facility, the architectural design to optimize the performance of both Anatomic and Clinical Pathology, the choice between acquirring brand new instrumentation versus relocation of the existing instruments. At the same time, we had to interact with hospital wide Facilities Management and Information Services/ Electronic Medical records. In addtion, for quality improvement and to alleviate the shortage of licensed technologist in our state, it was decided that a robotic line was to be implemented in the new facility. Methods/Case Report Several space options were assessed. Once the most suitable space was found a decision was made to move in two phases, Anatomic Pathology first, and subsequently Clinical Pathology. New work stations were purchased for Anatomic Pathology. New instruments were obtained for Chemistry, Immunology and Hematology. All instruments were validated.. Our laboratory information system had to be upgraded in order to support the robotic line, which is to be implemented after the Clinical Laboratory move. This will facilitate the expansion of in house provision of laboratory services to outpatient facilities / clinics expandin our outreach. The new space includes room to expand as well as abundant swing space. Our next phase includes the relocation of our Blood Bank and expansion of our Microbiology Services Results (if a Case Study enter NA) Due to delays in the obtention of the State Occupational permit the move was postponed several times. It was decided to move in two phases, once the permit was received. The Laboratory successfully moved in a two week period, and was fully operational overnight. Conclusion The Laboratory successfully moved in a two week period, and one week later we underwent a routine State inspection, in which the rigourous inspectos encountered very few deficiencies. The Laboratory is fully operational to the satisfaction of our clinical departmenst and preparing to the next phase including Blood bank and expanding our outreach program

Effect of Pre-Analytical Line Settings on Artefactually Elevated Anion Gap Results

Abstract Introduction When the core lab at a large tertiary care hospital introduced an automated laboratory system from a major manufacturer, the automated line aliquoted patient serum into open cups for all chemistry testing. It was subsequently discovered that if sample testing was delayed, electrolyte abnormalities could be introduced from evaporation, resulting in an increased anion gap (presumably due to a loss of bicarbonate with evaporation of carbon dioxide). To address this issue, the core lab changed the sample processing protocol in April 2023 from an open cup system to testing primary tubes on the analyzers. The purpose of this study was to evaluate the impact of switching to a primary tube testing system on artefactually elevated anion gap results. Methods Equivalent ten-week blocks of anion gap, creatinine and sample turnaround time (from receipt on the line to analyzer perform time) results from pre- to post-primary tube conversion were collected from the laboratory information system. Data from weekend testing and from repeat samples from the same patient were excluded. Data was cleaned and analyzed using R. Results Multivariable linear regression showed that when adjusted for the turnaround time and creatinine result, the open cup system was significantly associated (p&amp;lt;0.0001) with a 0.95 [95% CI 0.69-1.21] increase in anion gap. There was a positive relationship between turnaround time and anion gap, with a slope of 0.017 (i.e., a 0.017 increase in anion gap per minute delay; p&amp;lt;0.0001). Overall, the proportion of abnormal results (defined as anion gap &amp;gt;=16) decreased from 26% to 10% after switching to a primary tube testing system. Furthermore, there was an association between the times of day in which the lines were overloaded with specimens, turnaround time, and an increase in abnormal anion gap results. Overall, the mean anion gap decreased by 1 with a turnaround time of one hour and 2 after two hours by switching to the primary tube system. This trend in anion gap was largely driven by a corresponding decrease in bicarbonate. Sodium and chloride levels did not show any relationship with turnaround time. Conclusions Using an open cup system for electrolyte testing can cause spuriously elevated anion gap levels, especially with testing delays. Switching to a primary tube testing system largely resolved the issue; however, the data still showed a weakly positive relationship between turnaround time and anion gap for the primary tube testing system, so additional work is needed to identify potential causes of this relationship.

Establishment and application of autoverification system for HbA1c testing.

This study aimed to determine autoverification rules for routine glycated hemoglobin (HbA1c) analysis based on high-performance liquid chromatography (HPLC) principle. Laboratory information system (LIS) and Bio-Rad D-100 Advisor software (Bio-Rad, Hercules, USA) with graphics recognition function were carriers for the autoverification system. A total of 105,126 HbA1c results, including 98,249 HbA1c matching fast plasma glucose (FPG) results of real-world data from May 2019 to June 2020, were collected to determine autoverification rules including flags, delta checks, reporting limits, and logical rules. The validation database was composed of 48,045 HbA1c results and 41,083 matching FPG results. Autoverification passing rate and the reduction of turnaround time (TAT) were evaluated. Four autoverification systems (A, B, C, D) were established by two types of delta check rules, 28 flags, one reporting limits, and two kinds of logical rules. The autoverification passing rates were 80.6%, 78.8%, 83.7%, and 81.3%, and the average time saved in TAT were 117.5 min, 116.7 min, 121.1 min, and 121.7 min, respectively. Autoverification system C was the optimal one. Application of distribution of FPG corresponding to HbA1c groups had better performance as logical rules. Established HbA1c autoverifcation system shortened the auditing report time and improved work efficiency.