Laboratory Request Forms Research Articles

Demand management and test request rationalization

Demand for laboratory testing is increasing disproportionately to medical activity, and the tests involved are becoming increasingly complex. When this phenomenon is seen in parallel with declining teaching of laboratory medicine in the medical curriculum, a need emerges to manage demand to avoid unnecessary expenditure and improve the use of laboratory services: 'the right test in the right patient at the right time.' Various methods have been tried to manage demand, with success depending on the medical context, type of health service and preintervention situation. Because many factors contribute to demand, and the different settings in which these exist, it is not realistic to meta-analyse the studies and we are limited to trying to identify trends in results in particular situations. The studies suggest that education combined with facilitating interventions, such as feedback, prompts and changes to laboratory request forms are the most successful. From the perspective of a whole health service, it is important that results are not exaggerated by assessing benefits in terms of total rather than marginal cost. It would be desirable, although difficult, to include the impact on downstream clinical activity caused or avoided by the interventions. Advances in information and web technology may make the elusive goal of achieving substantial demand control more achievable.

Effect of remedial measures on inadequacies in the completion of laboratory request forms by clinicians

Effect of remedial measures on inadequacies in the completion of laboratory request forms by clinicians Igwebuike V Onyiaorah,1 Cornelius O Ukah,1 Daniel CD Anyiam,1 Maxy AC Odike,1 Ikewelugo CA Oyeka21Department of Histopathology, Nnamdi Azikiwe University/Teaching Hospital, Nnewi, Anambra State, Nigeria; 2Department of Statistics, Nnamdi Azikiwe University, Awka, Anambra State, NigeriaAims: This study sought to analyze the effect of three remedial measures, namely, hiring more pathologists, increasing the frequency of clinicopathologic conferences, and stepwise increase in the level of rejection criteria, on the adequacy of laboratory request form completion by clinicians. Based on the findings, recommendations were made that may reduce rejection rate of specimens and facilitate histopathology investigations.Methods: This is a retrospective study covering a period of 7 years (2004–2010). Data were retrieved from histopathology laboratory request forms submitted to three laboratories in Eastern Nigeria. These data were entered in SPSS statistical software and were analyzed using simple linear regression analysis.Results: A total of 8573 completed and submitted forms were analyzed, out of which 74.7% were found to be inadequately completed. The effect of increasing the number of pathologists in the employ on the adequacy of laboratory request form completion was found not to be statistically significant. Similarly, change in the frequency of clinicopathologic conferences was also found not to significantly affect the adequacy of laboratory form completion. However, change in the aggregated level of rejection criteria used by the laboratories was found to significantly affect the clinician's compliance to laboratory request form completion. For every 1 unit increase (or decrease) in the level of rejection criteria used there was, on the average, a 4.7% increase (or decrease) in the proportion of adequately completed laboratory request forms submitted.Conclusion: The findings highlight the need to enforce and implement policies that would possibly enhance compliance with the requirements of laboratory request form completion.Keywords: clinicopathologic conference, rejection criteria

Can Redesigning a Laboratory Request form Reduce the Number of Inappropriate PSA Requests without Compromising Clinical Outcome

Introduction: Unnecessary laboratory utilization due to inappropriate test-ordering behaviour among hospital clinicians and community general practitioners is an ongoing problem in many hospitals and primary care trusts throughout the UK and abroad. In January 2007, our hospital removed the ‘tick box’ for PSA from its laboratory tests request form, in a managed way, with the intention of reducing unnecessary requests for this test. Here we address the impact this action had on the number of PSA tests being requested and its downstream effects on prostate cancer diagnosis. Methods: Using our laboratory database we compared the number of hospital and local GP requests for PSA, before and after modification of our laboratory form (requests from 2004 to 2006 were compared to 2007). We then correlated this data with the number of fast-track target referrals (2 week wait) from primary care for suspected prostate cancer, the results of prostate biopsies, and the number of prostate cancers being diagnosed, over the same time period. Results: Mann—Whitney non-parametric testing demonstrated a 17% reduction in the median number of PSA requests since the change was introduced ( p = 0.001). Subset analysis revealed an 18% reduction in GP requests ( p = 0.002). However no change was found in the number of prostate cancer diagnoses being made ( p = 0.86) and the number of target referrals for suspected prostate cancer ( p = 0.59) in the months of April, May, June, July, August and September of 2004–2006 as compared to the same months in 2007. The rate of patients undergoing biopsy increased in the post intervention period from 15.5 to 18.5 patients per month. The rate of negative biopsies remained stable, changing from 7.2 to 7.3 per month, and the rate of positive biopsies increased from 8.3 to 11.2 per month. This change reduced the false negative rate (suspected cancer, negative biopsy) from 46% to 40% in the period following the intervention. The rate of target referrals leading on to cancer showed a small increase after the intervention from 2.9 to 3.3 per month. Conclusions: Our study shows that with this simple modification to the design of our laboratory request form, whereby the doctor must make an active written decision to order a PSA test, there was a significant reduction in the number of PSA requests, both in the hospital and in the community, without patient safety being compromised as measured by maintaining the number of fast-track target referrals for suspected prostate cancer and the number of prostate cancers diagnosed.

Evaluation of request forms submitted to the haematology laboratory in a Ghanaian tertiary hospital

Laboratory request forms provide information about the laboratory test being requested for. They carry demographic data and other information such as location of patient, laboratory number, doctor's name, signature of the doctor, telephone number of the requesting doctor. Omission of information on the forms may lead to laboratory errors. The aim of this study was to evaluate the level of completion of laboratory request forms at the haematology department of a Ghanaian tertiary hospital. Three thousand request forms submitted to the haematology department between January and April 2010 were retrieved and studied. The information provided on each request form was recorded in a spread sheet and analyzed. The patient's age and sex were missing in 25.6% and 32.7% of the forms respectively. About half of the request forms did not have the patient's location. No clinical detail was provided on 22.7% of the forms. Doctors were more likely to sign their request forms and provide a name but they all failed to provide an address or a contact telephone number. This study demonstrates that, the standard of completion of request forms was poor. Essential information required on the forms was often missing. This can lead to limited advice given by laboratory physicians and may increase the potential for errors. Conversely, provision of all the information needed on the forms will aid laboratory diagnosis and enhance patient care and save time and resources. There should be closer interaction between clinicians and laboratory personnel to improve quality of services.

Laboratory malaria diagnostic capacity in health facilities in five administrative zones of Oromia Regional State, Ethiopia

Quality laboratory services are a requisite to guide rational case management of malaria. Using a pre-tested, standardized assessment tool, we assessed laboratory diagnostic capacity in 69 primary, secondary and tertiary health facilities as well as specialized laboratories in five administrative zones in Oromia Regional State, Ethiopia, during February and March 2009. There was marked variability in laboratory diagnostic capacity among the facilities assessed. Of 69 facilities surveyed, 53 provided both comprehensive malaria laboratory diagnosis and outpatient treatment services, five provided malaria microscopy services (referring elsewhere for treatment), and 11 primary care health posts provided rapid diagnostic testing and outpatient malaria treatment. The facilities' median catchment population was 39, 562 and 3581 people for secondary/tertiary and primary health facilities, respectively. Depending on facility type, facilities provided services 24 hrs a day, had inpatient capacity, and access to water and electricity. Facilities were staffed by general practitioners, health officers, nurses or health extension workers. Of the 58 facilities providing laboratory services, 24% of the 159 laboratory staff had received malaria microscopy training in the year prior to this survey, and 72% of the facilities had at least one functional electric binocular microscope. Facilities had variable levels of equipment, materials and biosafety procedures necessary for laboratory diagnosis of malaria. The mean monthly number of malaria blood films processed at secondary/tertiary facilities was 225, with a mean monthly 56 confirmed parasitologically. In primary facilities, the mean monthly number of clinical malaria cases seen was 75, of which 57 were tested by rapid diagnostic test (RDTs). None of the surveyed laboratory facilities had formal quality assurance/quality control protocols for either microscopy or RDTs. This is the first published report on malaria diagnostic capacity in Ethiopia. While our assessment indicated that malaria laboratory diagnosis was available in most facilities surveyed, we observed significant gaps in laboratory services which could significantly impact quality and accessibility of malaria diagnosis, including laboratory infrastructure, equipment, laboratory supplies and human resources.

Anatomical pathology errors and the classic laboratory test cycle at Muhimbili National Hospital, Dar es Salaam, Tanzania

Backbround: Due to its complex nature, anatomical pathology practice is inherently error prone. Currently, there is a tendency towards an increase in errors in pathology which stems out from medical practices of other medical disciplines at Muhimbili National Hospital and thus there is a need to have error reduction strategies combined with an attempt to apply these strategies. Objective: To determine errors in anatomic pathology in relation to the classic laboratory test cycle and discuss factors contributing to these errors. Study design: The study was a descriptive cross-sectional one in which the information analyzed was obtained from pre-analytic,analytic and pot-analytic phases of the anatomical pathology laboratory test cycle. Study setting: Muhimbili National Hospital in Dar es Salaam, Tanzania. Methodology: During the pre-analytic phase of the laboratory test cycle, request forms and specimen containers containing information of patients for histological analysis of the biopsy specimens were analyzed for important parameters which had a bearing in the diagnosis. Also parameters in the analytic phase of the laboratory test cycle were analyzed for errors. The parameters analyzed here were mainly those which occurred during the histologic specimen processing, in the taking-in room, at the microscope and by clerical personnel in the laboratory. Errors which were analyzed in postanalytic phase of testing related mainly to those which resulted from delivery of the reports or information to the clinician, untimely delivery of the reports and failure of the caregiver to see the reports at all. Results: In the pre-analytic phase of laboratory testing, errors were derived and analyzed from request forms for investigation fromclinicians and from information on the containers containing biopsy specimens. Out of 13 variables analyzed from the request forms, 11(84.6 %) had errors which differed in magnitude. The highest errorswere those which arose from misleading clinical information (90%),and missing of relevant clinical information of patients (90%). However, 8 variables were also analyzed from containers and the errors which ranked highest included mislabeling on the container (85%) followed by illegibly labeling of the container (75%) and others. On the part of the analytic phase of laboratory test cycle, there were 11 variables analyzed for analytic errors and 9 (81.8 %) variables had errors, among them typographic errors had the highest frequency (45%) followed by block mislabeling (35%). In the post-analytic phase of laboratory testing, there were 3 variableswhich were analyzed for errors. The variables analyzed and the errors which were found included; delivery of the report or information to wrong clinician (10%), untimely delivery of report to the clinician (35%) and failure of the caregiver to see the report at all was (15%). Conclusion and recommendations: The numerous errors amounted in the pre-analytic, analytic and post-analytic phases of laboratory test cycles in Anatomical pathology reinforces the need for effective quality control and quality assurance at all steps in laboratory test cycle. This will be possible only and only if factors that contribute to errors be reduced to an absolute minimum through error reduction strategies combined with an attempt to apply these strategies. Additionally, incremental adoption of information technology and automation along with improved training in patient safety and quality management can help reduce errors.Key words: Anatomical pathology, Pre-analytic, Analytic, Post-analytic, Errors, Laboratory test cycle

MP-21.04: Can Redesigning a Laboratory Request Form Reduce the Number of Inappropriate PSA Requests without Compromising Clinical Outcome

MP-21.04: Can Redesigning a Laboratory Request Form Reduce the Number of Inappropriate PSA Requests without Compromising Clinical Outcome

Liver function tests

The term ‘liver function tests’, used typically to describe the liver profile on a laboratory request form, is in fact a misnomer as several of the tests involved are not tests of liver function, but of hepatic enzyme release either as a result of induction or damage. This article will refer to liver profile tests except when specifically referring to liver function. As the body's hepatic reserve is considerable, liver function generally only begins to decline in the face of advanced or severe acute disease, and the liver profile is used to detect abnormalities that may indicate disease. They rarely diagnose the cause of the liver disease in question but can throw light on the category of disease, i.e. obstructive or hepatic.

Cardiac Troponin in Cerebral Injury: Understanding your Laboratory Reports

Cardiac troponin (cTn) is now the ‘gold standard’ biochemical test for the diagnosis of acute coronary syndrome (ACS). This clinical spectrum of ischemic heart disease includes stable and unstable angina through to acute myocardial infarction (AMI). The growing evidence base for the diagnostic and prognostic use of cTn in ACS has resulted in the redefinition of AMI [1]. With increasing popularity owing to ease of measurement, the presence of a tick box on a laboratory request form and a reduction in test price, cTn is a common request in many clinical scenarios outside the remit of ACS. This has resulted in the identification of a plethora of elevated cTn in other conditions, often creating clinical confusion. With the redefinition of AMI, many emergency physicians could not adequately distinguish between a primary acute coronary syndrome and secondary ischemic or nonischemic disease states [2], plainly from ignoring the clinical history. A common misconception is that elevated cTn indicates AMI. It does not. All cTn elevations indicate myocardial cell necrosis [3] but not the pathological mechanism of release. Anecdotal data from a London teaching hospital demonstrate as many as 30% of all medical noncardiac admissions with elevated serum cTn do not have a final diagnosis of ACS [2]. Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) are expressed in the cardiac myocyte. A small circulating pool exists in the cytosol, but greater than 90% is bound to the thin filament of the contractile apparatus. The cardiac isoforms are distinctly different in amino acid sequence from those expressed in skeletal muscle. Monoclonal antibodies have been raised against cTnT and cTnI and form the basis of immunoassay tests that have been in commercial use since the early 1990s [4]. Patients presenting to the emergency department with an acute cerebral injury may be cognitively impaired or exhibit severe speech

Interactive workshops increase chlamydia testing in primary care--a controlled study

Primary care clinicians suggest that staff education is needed to increase chlamydia testing appropriately. To determine if interactive workshops and modified laboratory request forms could increase testing and case detection. Prospective cluster randomized controlled study, using modified Zelen's design, examining the effect of workshops and modified request forms on primary care clinicians' chlamydia specimen submission and case positivity rate. 82 general practices in six geographical clusters within five primary care trusts (PCTs) in Gloucestershire and County Durham and Darlington. Practices within geographical clusters were randomly assigned to workshops on chlamydia or a control consisting of comparable workshops on the management of urinary symptoms, held in PCT-protected learning time. Half the practices were randomized to receive modified laboratory request forms. Staff were unaware that they were part of a study. Interactive workshops increased chlamydia testing in 16- to 24-year-old women by 33% in intervention practices compared to controls with effect persisting at 10 months (P = 0.003). No associated rise in the number of chlamydia infections was detected (P = 0.91), suggesting that increased testing may have occurred in a lower risk population. Modified forms did not change test submission (P = 0.75). Interactive workshops for general practices can be used to successfully increase chlamydia-testing rates. Chlamydia detection rates will need to be monitored as this type of educational programme may not increase absolute numbers of chlamydia infections detected, if patients at lower risk of infection are inappropriately tested. Other interventions may need to be combined with the workshops, to reach sufficiently high chlamydia screening rates to significantly reduce prevalence of chlamydial infection.

Do we need lipid clinics? Shifting the balance between secondary and primary care

Increasing activity in cholesterol lowering is placing increasing demands on lipid clinics to be able to cope with the increase in demand. A combination of interventions has been used to improve laboratory testing, focus interpretative results and provide educational and advisory facilities for general practitioners in order to increase shared care of many potential clinic patients. Retrospective study of clinic waiting times, results in patients managed on a shared care basis, and overall clinical activity over a three-and-a-half-year intervention period between March 2001 and August 2004 in a single-consultant, single-centre secondary care clinic serving three primary care trusts, covering a population of approximately 270,000 people. The interventions involved a change to the laboratory request form, outreach educational meetings and promotion of use of "written advice only" for certain patients as an alternative to direct clinic referral. The main outcome measures were percentages of patients followed up in primary care, change in cholesterol and triglyceride results after advice, and clinic waiting time. A total of 520 patients were referred over three and a half years, either to be seen or for written advice only. About 291 of these were handled by advisory letters. In all, 90% of these patients were already receiving or had received lipid-lowering therapy at the time of referral. 98% of patients were followed up by their general practice post-advice. Cholesterol and triglyceride concentrations fell by 23% and 39%, respectively, post-advice. Waiting times fell from a peak of 35 weeks before the interventions to an average of three weeks after. This fall has been maintained over the three-and-a-half years the intervention has run. The interventions have resulted in a large fall in clinic waiting times, improvement in lipid results, and high rate of general practice follow-up, all of which have been sustained in the long term.

Survival of Severe Acute Respiratory Syndrome Coronavirus

Background. The primary modes of transmission of severe acute respiratory syndrome (SARS) coronavirus (SARS-CoV) appear to be direct mucus membrane contact with infectious droplets and through exposure to formites. Knowledge of the survival characteristics of the virus is essential for formulating appropriate infection-control measures. Methods. Survival of SARS-CoV strain GVU6109 was studied in stool and respiratory specimens. Survival of the virus on different environmental surfaces, including a laboratory request form, an impervious disposable gown, and a cotton nondisposable gown, was investigated. The virucidal effects of sodium hypochlorite, house detergent, and a peroxygen compound (Virkon S; Antec International) on the virus were also studied. Results. SARS-CoV GVU6109 can survive for 4 days in diarrheal stool samples with an alkaline pH, and it can remain infectious in respiratory specimens for >7 days at room temperature. Even at a relatively high concentration (104 tissue culture infective doses/mL), the virus could not be recovered after drying of a paper request form, and its infectivity was shown to last longer on the disposable gown than on the cotton gown. All disinfectants tested were shown to be able to reduce the virus load by >3 log within 5 min. Conclusions. Fecal and respiratory samples can remain infectious for a long period of time at room temperature. The risk of infection via contact with droplet-contaminated paper is small. Absorbent material, such as cotton, is preferred to nonabsorptive material for personal protective clothing for routine patient care where risk of large spillage is unlikely. The virus is easily inactivated by commonly used disinfectants.

Appropriateness of physicians' requests of laboratory examinations in primary health care: an over- and under-ulilisation study.

The aim of this work is to study the appropriateness of the laboratory measurement for quantities that may be conditioned by the result of another quantity, estimating the proportions of inappropriate requests due to over- or under-utilisation. We refer to over-utilisation when a quantity was requested and measured when it was not needed, and we refer to under-utilisation when a quantity was not requested and not measured when it was needed. In our centre, the laboratory staff together with the primary health care physicians of the region designed a new laboratory request form. This request form incorporated an agreed requesting protocol for the most common diagnoses in primary health care. Protocols included, according to each case, one or several of 11 pairs of quantities depending on each case. Second quantity in each pair was measured or not, conditional on the result of the first quantity of the pair, the age, the sex and the diagnosis corresponding to the requested protocol. Following recommendations from scientific societies, we decided what should be the results of the first quantity in the pair so to measure the second quantity in the pair. When recommendations were not available, we reviewed the data contained in the laboratory information system, and we established as non-conditioning values, the levels of the first quantities that were associated with the results of second quantities within their reference intervals in 99.95% of cases. The study was done retrospectively using 46091 old laboratory request forms received in our laboratory over two years. Among the 46091 request forms, the first quantities included in the present forms that incorporate agreed requesting protocols were requested 66434 times. The 66434 corresponding second quantities were measured and should not have been measured in 14225 cases (21.4%) and were not measured and should have been measured in 16137 cases (24.3%). Using the request forms according to the conditioning protocols changes the number of quantities by a mean of 0.66 in every request form. This change would have increased the number of quantities measured by 0.04 quantities per form, but would also have improved the appropriate use of the laboratory.

Division of labour in clinical microbiology. Co-operation and fragmentation.

The aim of this study was to describe clinical microbiological practices in a hospital setting. A grounded theory was developed from qualitative data in two steps: initial participant observation to describe the clinical work-flow, and a main case study based in depth interviews and analyses of work practices using a video-based stimulated recall technique. Six physicians, 2 senior medical laboratory technologists and one head nurse were interviewed in depth based on their organizational positions. Stimulated recall interviews were conducted with 11 nurses, 6 secretaries, 6 medical laboratory technologists, and 3 physicians. An informal clinical microbiological 'workgroup' was found to co-operate around two physical objects: the microbiological sample and the laboratory request form. Work organization was divided into planning, based on science and legislations, and performance based on tradition and local supervision. None of the practitioners had a total overview of an analysis cycle, all being occupied with a discrete part of planning, practical work and information management. The conclusion of the study is that fragmentation in the division of labour may be a critical hindrance to development in clinical microbiology. If a common strategy is not shared between specialties and professions, even minor changes in routines by individual practitioners may influence patient outcome.

Antenatal testing for HIV antibody: problems of documentation and record.

The objective of this study was to audit an ante-natal HIV screening programme by observing the congruence of documentation of consent between case notes and request forms; correlation of testing with prior agreement to be tested; and recording documentation that the test had been offered but declined in women who were not tested. The design was one of retrospective case note review of 538 women drawn from an inner city teaching hospital. There was documentation of invitation to undergo HIV testing in 415 (77%) cases. Test documentation was absent in 123 (23%) cases which represent 37% of those for whom a test was not performed. HIV testing was performed in 205 (38%) cases. There was discrepancy between documentation of consent to testing on the laboratory request form and in the notes. Some blood specimens of women agreeing to be tested were apparently never received in the laboratory. Incomplete documentation and a low test uptake suggests a low acceptance. However, without adequate documentation it cannot be determined in those not tested whether the test was declined or whether the invitation was either never extended, or not implemented after acceptance. Audit of implementation and staff compliance should be established at the outset of any universal testing programme.

Decision Support Based on Laboratory Data

SummaryMedical decision support systems dealing with multiple diseases are presently in a phase of development or revision and, in the immediate future, are likely to be utilized only as part of ongoing research projects or in the field of medical education. Those decision support systems (DSS) which are in routine use have one major factor in common. They are applied in a single narrow domain or series of overlapping narrow domains. Blois and Wagner predicted this, suggesting that computer-based medical decision aids were inherently limited in their ability to assist clinicians in reaching decisions about undifferentiated patients, i. e., those for whom an initial high level general classification had not already been made. To be useful, the domain should be narrowed by the clinical acumen of the physician. A thoughtful working diagnosis on a laboratory request form provides a good example of this process.

Laboratory request forms (menus) that guide and teach

Laboratory request forms (menus) that guide and teach

Ordering of Laboratory Tests in a Teaching Hospital

A review of ordering patterns for thyroid function tests and for measurements of creatine kinase (CK) isoenzyme and lactate dehydrogenase (LDH) isoenzyme levels indicated considerable misuse. We employed an educational program for both types of tests, but changed the request form only for ordering the thyroid function tests. No changes were made in the forms for ordering CK and LDH isoenzyme tests. The effect was a prompt decrease in ordering triiodothyronine radioimmunoassay and thyrotropin tests to 38% and 61%, respectively, of baseline rates. There was no effect on rates of ordering CK and LDH isoenzyme tests, which were 102% and 96%, respectively, of baseline rates. The improved use of thyroid function tests was likely because of the change in the laboratory request form, since the educational strategy by itself had no effect on the ordering of CK and LDH isoenzyme tests.

Computer-aided procedures in a multi-centre co-operative controlled clinical trial in pulmonary tuberculosis

The management of a large-scale controlled clinical trial in the treatment of pulmonary tuberculosis includes the maintenance of accurate clerical procedures over a long period of time, both in the co-ordinating group and in the central laboratory responsible for the bacteriological investigations. Clerical procedures which are tedious and time-consuming, but nevertheless well defined, are, however, ideally suited to being transferred to a computer.In a current multi-centre co-operative controlled clinical trial of the treatment of tuberculosis in Britain computer methods are being applied in two main fields. First, the progress reports and the laboratory request forms which have to be completed in the treatment centres are being headed up specifically for each patient for each month using a Flexowriter (tape editing set). The report forms are sent from the co-ordinating group to the appropriate treatment centre with the following information already completed, the name and serial number of the patient, the treatment regimen, the date of start of treatment, the date of the next monthly appointment, and a detailed list of investigations to be undertaken at the attendance for the month in question. The necessary information is punched on paper tape computer output in a suitable format for printing on continuous forms by the Flexowriter. The second main computer application is in the central bacteriology laboratory. Each patient's basic data are stored in a magnetic tape file when the patient is admitted to the study, and results of all bacteriological examinations are also stored as soon as they become available. Thus all the information required to produce bacteriological reports for the treatment centres is readily accessible and reports are produced automatically as paper tape output ready for printing on the Flexowriter. The calculations associated with the interpretation of tests of sensitivity of the tubercle bacilli to the antituberculosis drugs are also being done by computer.The use of the computer has led to the more accurate performance of the set clerical procedures. It has also effected a considerable saving of the laboratory's technical staff time and of clerical staff time, and a lesser saving of medical, statistical and secretarial staff time in the co-ordinating group.