Technologist Time Research Articles

Reducing unnecessary outpatient group and screen testing at a regional cancer center.

Unnecessary group and screens (G&S) can lead to unnecessary antibody investigations, use of technologist time, and laboratory resources. A baseline audit at our institution identified that 25% of G&S from the cancer center were unnecessary. We aimed to reduce the ratio of monthly G&S to CBC samples processed from the cancer center by 10% (from 0.034 to 0.031) by January 2024. This represents an interrupted time series design from November 2022 to January 2024. Using Plan Do Study Act (PDSA) cycles, we aimed to increase the use of an existing reflex testing system, termed "do not test." When this option is selected, the blood bank will only process the G&S sample if specific CBC criteria are met (e.g., hemoglobin <9.0 g/dL). Educational sessions increased awareness of this feature and sought feedback from end-users on its usability. With feedback, the design was updated to include a modifiable hemoglobin threshold for G&S testing, automatic re-selection of the "do not test" feature for future G&S orders, and aesthetic changes to make the feature more visible. The percentage of samples with "do not test" selected increased from 7.2% to 63.0% (p < .0001) and the ratio of G&S to CBC specimens improved from 0.034 to 0.028, exceeding the target of 0.031. We noted an improvement in the appropriateness of G&S orders from 75% at baseline (n = 20) to 97.5% (n = 80) post intervention (p = .003). We describe an effective strategy to improve G&S utilization at our institution's cancer center using a reflex testing system.

Analytical Performance Evaluation of BioRad’s Unassayed Multiqual, Immunoassay Plus and Assayed Multiqual InteliQ Tube-Based Quality Control Materials

Abstract Introduction Quality control (QC) practices commonly require aliquoting of liquid material into sample cups prior to analysis. Recently, newer tube-based QC has become available that can be scanned directly onto the analyzer without additional aliquoting. In this study, we evaluate the performance of the BioRad’s Unassayed Multiqual (Mutiqual), Immunoassay (IA) Plus and Assayed InteliQ Muliqual (InteliQ) tube-based QC material. Materials and Methods The analytical performance of Multiqual, IA Plus and InteliQ materials were compared over 14 days at three concentrations on an Abbott Alinity ci analyzer system. The analysis included 20 unique clinical chemistry and 4 immunoassay analytes. For an applied comparison, all QC materials were analyzed using the same lot on multiple days, times, and by various laboratory team members (n=10). The means, standard deviations (SD) and coefficient of variation (CV) were calculated for each analyte. Minimum acceptable allowable imprecision (I) specifications were set using the biological variation (BV) database from European Federation for Laboratory Medicine (EFLM), which was calculated for each analyte using the equation I = 0.75*CV within-subject. Sample cups used for Multiqual and IA plus were also calculated to determine consumable waste for these materials over the study period and extrapolated for a year. Results Multiqual, IA Plus and InteliQ CVs for each analyte were compared to the EFLM BV database and showed comparable results for most analytes studied. Most analytes demonstrated &amp;lt; 5% CV over the 14-day period for InteliQ except alkaline phosphatase, bicarbonate, total bilirubin, and triiodothyronine for either 1, 2 or 3 levels. Total bilirubin and free thyroxine were outside this CV for Multiqual and IA Plus. In addition, minimum acceptable allowable imprecision goals from EFLM were not met for several analytes that were included in InteliQ such as albumin, alkaline phosphatase, aspartate aminotransferase, calcium, bicarbonate, chloride, and sodium. Multiqual and IA plus analytes that did not meet imprecision goals were bicarbonate, chloride, sodium, and free thyroxine, respectively. A total of 84 sample cups were needed to perform Multiqual and IA plus QC analysis over the study period or approximately 2184 over a year. Conclusion Multiqual, IA Plus and InteliQ QC materials provide similar analytical performance although each material had some analytes that did not meet acceptable imprecision limits defined by EFLM. Implementation of new tube-based QC materials can reduce sample cup consumables and may reduce technologist time required to aliquot Multiqual and IA Plus.

A multicenter evaluation of Copan's Colibrí™, an automated instrument for MALDI TOF MS target application for bacterial identification

The Colibrí™ is a new instrument that automates picking and placement of colonies on target plates for MALDI identification. This study compared the performance of the Colibrí™ to standard manual spotting using the VITEK® MS for bacterial identification. Colonies were selected from cultures of urine, wound, respiratory, and positive blood cultures. The Colibrí™ sampled the colonies, transferred them to a MALDI target slide, and overlayed each spot with matrix. Manual spotting was then performed using the same or similar colonies. A total of 444 bacteria were compared. Identification was achieved with both methods for 432 organisms with only 2 discrepant results, overall agreement of 99.54%. Twelve organisms (2.70%) gave no identification using Colibrí™. The Colibrí™ provides automation to a manual process with a high accuracy. Use of the Colibrí™ instrumentation provides an opportunity to reallocate technologist time to more complicated tasks and provides complete traceability from plating to organism identification.

A-186 Enabling Laboratories to Do More With Less: Assessment of Workflow Efficiencies Through Instrument Consolidation in an Immunology Lab

Abstract Background As today’s laboratories adjust to the ever-changing landscape of growing demands while continuing to provide quality diagnostic testing, the need to evaluate and improve workflow, productivity and efficiency has never been more important. One way to ensure current processes and technology are fully optimized is to perform a Workflow Analysis Study. Geisinger Medical Center (GMC) recognized an opportunity to consolidate their immunology laboratory for allergy and autoimmune testing with annual volume of approximately 138 000. A consolidation solution can result in many improvements for the laboratory, such as: improved turnaround times, decreased manual labor, reduced reagent waste, increased employee morale, enhanced space utilization. Maximizing operational efficiencies is and will always be a good business model. We aimed to assess pre- and post- workflow changes to determine impact to laboratory resources. Methods To measure the impact of the instrument consolidation and integration of Phadia250TM systems, operational data was collected through direct workflow observations, time and motion studies, and targeted interviews of testing personnel at GMC’s Immunology Laboratory. The initial/baseline study was conducted in May 2022 and the follow-up/post study occurred in October 2022. The baseline study encompassed seven separate platforms that GMC utilized for autoimmune and allergy testing. The following systems were included: two DYNEX DSX®, two Werfen BIO-FLASH®, two Siemens IMMULITE® 2000, one ZEUS IFA™. Results The workflow assessment resulted in GMC consolidating down to three platforms for autoimmune and allergy testing: two Phadia250, one ZEUS IFA™. The major benefit of the change was the reduction in technology from three types of technology to one type of technology, resulting in standardization of practices. The decrease in number of testing systems simplified overall test management (reduced LIS interface, process steps, instrument maintenance, reagent management, contract management) and reduced system footprints. A total of 361 square feet of laboratory space was saved equating to a 57% improvement over the baseline metric. After consolidating most of the testing to the two Phadia250 systems, the total daily manual time went from 4.2 h to just over 2.5 h. The combined workflow assessment resulted in saving a total of one full time employee (FTE). Conclusion To keep up with growing testing demands, laboratories must continue to produce high-quality results in an efficient manner. Test assay quality and utilization should also be evaluated when determining test consolidation options. Instrument consolidation is a viable strategy to save on technologist time, space and costs.This can result in not only economic savings to the laboratory, but also allows medical technologist to be funneled to other more needed areas of the laboratory, while saved space can be used for test expansion. In the climate of major medical technologist shortage nationwide, efficient workflows and productivity are important considerations to ensure the continued success of any laboratory.

A-108 Validation of Plasma Oxalate Measurement on the Roche Cobas c501

Abstract Background Measurement of plasma oxalate is important in patients with renal failure as oxalate may build up due to impaired excretion and lead to organ damage due to precipitation of calcium oxalate crystals. However, the measurement of plasma oxalate is challenging due to the low concentrations present in individuals with healthy kidney function and the pre-analytical steps needed to prevent erroneous oxalate results due to conversion from ascorbate. In order to provide improved turn-around-time for plasma oxalate testing, our objective was to develop and validate a method to measure plasma oxalate on the Roche cobas c501. Methods Samples used in the validation study included both fresh collections and residual plasma from specimens collected in lithium heparin, no-gel tubes. Samples from fresh collections were kept on ice prior to centrifugation, and then frozen if not analyzed immediately. Thawed plasma was acidified by addition of 12.1 M HCl to a pH between 2 and 3 and mixed thoroughly by vortexing. One milliliter of the acidified plasma was added to a Centrifree filter (Millipore). The samples were then centrifuged for 90 min at 1500 × g 20°C in a fixed angle rotor to remove plasma proteins. The resulting filtrate was assayed on the Roche cobas c501. The assay (Trinity Biotech) uses oxalate oxidase to produce an indamine dye through the production of hydrogen peroxide from oxalate in the sample, which is measured spectrophotometrically at 600 nm at a single time point. The analytical measuring range (AMR) was evaluated by performing serial dilutions of a high sample. Interferences from hemolysis, icterus, and lipemia were assessed at both low and high oxalate concentrations. Precision was evaluated using two QC concentrations, and patient samples with low and high concentrations of oxalate. Samples were tested ten times in a single day, or twice per day for ten days to estimate intra- and inter-precision, respectively. Spike recovery studies were used to assess method accuracy. Lastly, reference intervals were verified by assaying samples from twenty healthy volunteers. Total allowable error was ±30% or 2 µmol/L with a maximum 15%CV. Results The assay was validated to be linear across an AMR of 2 to 30 µmol/L, with an average recovery of 105% across five concentrations. The total assay imprecision was &amp;lt;15%. Initial spike recovery studies across the AMR showed an average recovery of 99.4% (n = 12), with a range of 76.6 to 132.4%. In a mixing study, hemolyzed and lipemic sample recovery was on average 82.1% and 76.1% respectively, which was low, but acceptable. Samples mixed with icteric specimens demonstrated unacceptably low recovery (average of 64.1%). The reference interval of &amp;lt;2 µmol/L was successfully verified as all twenty healthy volunteers had results &amp;lt;2 µmol/L. Conclusion Initial validation studies support the clinical utility of the newly developed method. Plasma oxalate methods are documented to have significant inter-method variability and variable recovery, which is hypothesized to be due to variation at the filtration step. This semi-automated assay will require less technologist time and will reduce the possibility for human error affecting the result.

Consumable Material Waste and Workflow Efficiency Comparison Between Multi-use Syringeless and Single-use Syringe-Based Injectors in Computed Tomography

Syringeless power injectors obviate the need for reloading iodinated contrast media (ICM) and plastic consumable pistons between exams. This study evaluates the potential time and material waste (ICM, plastic, saline, and total) saved using a multi-use syringeless injector (MUSI)compared to a single-use syringe-based injector(SUSI). Two observers recorded technologist time spent using a SUSIand a MUSIover three clinical workdays. CT technologists (n=15) were polled on their experience between the systems using a 5-point Likert scale survey. ICM, plastic, and saline waste data from each system were collected. A mathematical model was created to estimate total and categorical waste from each injector system over a 16-week period. On average, CT technologists spent 40.5seconds less per exam with MUSI compared to SUSI (p<.001). Technologists rated MUSI work efficiency, user-friendliness, and overall satisfaction (strongly or somewhat improved) higher relative to SUSI (p<.05). Iodine waste was 31.3L and 0.0L for SUSI and MUSI, respectively. Plastic waste was 467.7kg and 71.9kg for SUSI and MUSI, respectively. Saline waste was 43.3L and 52.5L for SUSI and MUSI, respectively. Total waste was 555.0kg and 124.4kg for SUSI and MUSI respectively. Switching from SUSI to MUSI resulted in a 100%, 84.6%, and 77.6% reduction in ICM, plastic, and total waste. This system may fortify institutional endeavors toward green radiology initiatives. The potential time saved administering contrast using MUSI may improve CT technologist efficiency.

Extraction-free clinical detection of SARS-CoV-2 virus from saline gargle samples using Hamilton STARlet liquid handler

As part of the COVID-19 pandemic, clinical laboratories have been faced with massive increases in testing, resulting in sample collection systems, reagent, and staff shortages. We utilized self-collected saline gargle samples to optimize high throughput SARS-CoV-2 multiplex polymerase chain reaction (PCR) testing in order to minimize cost and technologist time. This was achieved through elimination of nucleic acid extraction and automation of sample handling on a widely available robotic liquid handler, Hamilton STARlet. A customized barcode scanning script for reading the sample ID by the Hamilton STARlet’s software system was developed to allow primary tube sampling. Use of pre-frozen SARS-CoV-2 assay reaction mixtures reduced assay setup time. In both validation and live testing, the assay produced no false positive or false negative results. Of the 1060 samples tested during validation, 3.6% (39/1060) of samples required retesting as they were either single gene positive, had internal control failure or liquid aspiration error. Although the overall turnaround time was only slightly faster in the automated workflow (185 min vs 200 min), there was a 76% reduction in hands-on time, potentially reducing staff fatigue and burnout. This described process from sample self-collection to automated direct PCR testing significantly reduces the total burden on healthcare systems in terms of human resources and reagent requirements.

A Cost Comparison Modeling Analysis for Healthcare Access and Equity: Cost of COVID-19 Test Screening by Point of Care (POC) Versus Rapid Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)

Abstract Introduction/Objective Testing platforms to detect COVID-19 infection include antigen-based point of care (POC) testing and reverse transcriptase polymerase chain reaction (RT-PCR) to detect viral ribonucleic acid (RNA). RT-PCR, generally considered the gold standard for diagnosis of COVID-19 infection, is capable of being used for mass population screening but may be more expensive. Alternatively, antigen based POC testing can not only produce results rapidly (15 minutes on some assays) but also may be less expensive. This reduced cost provides an argument that it may be economical to use POC testing for mass surveillance in asymptomatic or mildly symptomatic patients while reserving the more expensive gold standard RT-PCR testing for sensitivity for hospitalized and more significantly at risk or ill patients. However, cost modeling between the two modalities for mass screening is sparse, particularly for studies including the Veteran Affairs system that may have different costs from the general community retail pricing. Methods/Case Report Cost information reviewed at the regional VAMC included costs for the Alinity-m SARS-CoV-2 RT-PCR assay (Abbott, Chicago IL), the Cepheid Xpert-Xpress-CoV-2-Flu-RSV-Plus RT-PCR assay (Cepheid, Sunnyvale CA), and the BinaxNOW POC antigen-based assay (Abbott, Chicago IL). The median cost of RT-PCR testing in the community was obtained from the Peterson-KFF Health System Tracker. Publicly available quoted prices for selected POC assays in the community were reviewed for comparison. Results (if a Case Study enter NA) Test costs at the regional VAMC was $28.34 (Alinity-m), $68 (Cepheid), and $5 (BinaxNOW). These costs did not include technologist time or standard laboratory consumables that would be part of the standard overhead costs of running the laboratory. The median community RT-PCR assay price per the Peterson- KFF Health System Tracker was $148, and the Abbott’s quoted BinaxNOW price was $25. POC testing cost was 82% less than the cheapest RT-PCR assay available at the regional VAMC. This trend in being significantly cheaper holds true in the community whereby BinaxNOW testing was 83% cheaper. Publicly available quoted prices from other selected POC assays confirm this trend. Conclusion For a mass surveillance screening program, the use of POC assays would result in significant cost savings.

Validation Study of a Direct Real-Time PCR Protocol for Detection of Monkeypox Virus

Monkeypox has recently been described as a public health emergency of international concern by the World Health Organization and a public health emergency by the United States. If the outbreak continues to grow, rapid scalability of laboratory testing will be imperative. During the early days of the coronavirus disease 2019 (COVID-19) pandemic, laboratories improved the scalability of testing by using a direct-to-PCR approach. To improve the scalability of monkeypox testing, a direct real-time PCR protocol for the detection of monkeypox virus was validated. The assay retains the sensitivity and accuracy of the indirect assay while eliminating the need for nucleic acid extraction kits, reducing laboratory technologist time per sample and decreasing exposure to an infectious agent. The direct method will make it easier for laboratories across the world to rapidly develop, validate, and scale testing for monkeypox virus.

Customized middleware experience in a tertiary care hospital hematology laboratory

BackgroundIn the clinical laboratory, middleware is a software application that sits between the analyzer and the laboratory information system (LIS). One of the more common uses of middleware is to perform more efficient result autoverification than can be achieved by the LIS or analyzer alone. In addition to autoverification, middleware can support highly customized rules to handle samples and results from specific patient locations. The objective of this study was to review the impact of customized middleware rules that were designed and implemented in the hematology laboratory of a 1000-bed tertiary care adult academic center hospital. MethodsThree novel initiatives using middleware rules to achieve workflow efficiencies were retrospectively reviewed over different audit periods: preliminary neutrophil resulting for oncology patients, microcytosis interpretive comments, and 1 white blood cell differential (WBCD) reported per day. In addition, autoverification rates for complete blood count and differential (CBCD) and coagulation tests were calculated. ResultsA preliminary neutrophil count was released from middleware on average 64 min before the final CBCD for Leukemia/Bone Marrow Transplant (L/BMT) outpatients, and on average 59 min earlier for oncology patients. Reflexing interpretive comments for select instances of microcytosis removed on average 500 slides per month from technologist review with an estimated cost savings of approximately $3383.33 CAD per month. The 1 WBCD per day rule resulted in a 5.1% cancelation rate, resulting in an estimated monthly cost savings of $943.46 CAD in reagents and technologist time. Finally, middleware rules achieved very high autoverification rates of 97.2% and 88.3% for CBC and CBCD results, respectively. ConclusionsImplementation of customized middleware hematology rules in our institution resulted in multiple positive impacts on workflow, achieving high autoverification rates, reduced slide reviews, cost savings, and improved standardization.

Meeting clinical needs for and sidestepping supply chain threats to COVID-19 testing through continuous process improvement

Abstract Introduction/Objective The first human case of SARS-CoV-2 infection was reported in December of 2019. By late February 2020 evidence of community transmission in the United States was documented and soon it developed into a global pandemic. On March 11, 2020, the Mayo Clinic Arizona’s Microbiology Laboratory introduced a PCR test for diagnosis of SARS-CoV-2 infection. Even as testing demands exponentially increased, the hospital relied on timely results to assist in directing patient care. In order to provide timely results in the face of continuously emerging supply chain threats, we needed to increase our capacity for SARS-CoV-2 PCR testing by reducing technologist time and reagent waste, without impacting turnaround time or other quality metrics such as repeat rate. Methods/Case Report Technologist time was measured in hands-on time per specimen. Reagent use was defined by the volume of lysis buffer (the primary rate limiting reagent due to supply chain constraints) used per sample. Turnaround time was measured from receipt in lab until result verification and the rerun rate is the percent of specimens with an internal control (IC) failure, an indicator of specimen or process quality. Unnecessary steps were determined using a process map, spaghetti diagram and waste walk. Improvements included simplifying steps, changes to protocols and lab design. Impacts of the improvements were measured for 5 months post-implementation. Results (if a Case Study enter NA) Process improvements reduced technologist time per sample by 30.8 seconds and decreased critical reagent needs by 23.6%. Improvements led to $104,000 in just reagent savings over 5 months. Turnaround time and rerun rates were not negatively impacted. Conclusion By creating the leanest possible workflow, we were able to meet the demands for accurate and timely SARS-CoV-2 results. In future workflows, we will continue to implement lean processes and ensure the most efficient use of limited resources.

Sustainable Laboratory-Driven Method to Decrease Repeat, Same-Day WBC Differentials at a Tertiary Care Center.

A CBC with WBC differential is often ordered when a CBC alone would be sufficient for patient care. Performing unnecessary WBC differentials adds to costs in the laboratory. Our objective was to implement a laboratory middleware algorithm to cancel repeat, same-day WBC differentials to achieve lasting improvements in laboratory resource allocation. Repeat same-day WBC differentials were first canceled only on intensive care unit samples; after a successful trial period, the algorithm was applied hospital-wide. We retrospectively reviewed CBC with differential orders from pre- and postimplementation periods to estimate the reduction in WBC differentials and potential cost savings. The algorithm led to a monthly WBC differential cancellation rate of 5.40% for a total of 10,195 canceled WBC differentials during the cumulative postimplementation period (September 25, 2019, to December 31, 2020). Nearly all (99.94%) differentials remained canceled. Most patients only had one WBC differential canceled (range, 1-38). Savings estimates showed savings of $0.99 CAD per canceled differential and 1,060 minutes (17.7 hours) of technologist time. A middleware algorithm to cancel repeat, same-day WBC differentials is a simple and sustainable way to achieve lasting improvements in laboratory utilization.

Development and validation of a multiplex reverse transcriptase-PCR assay for simultaneous testing of influenza A, influenza B and SARS-CoV-2

In the current pandemic of coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the co-circulation of SARS-CoV-2 and other respiratory viruses during the upcoming fall and winter seasons may present an unprecedented burden of respiratory disease in the population. Important respiratory viruses that will need to be closely monitored during this time include SARS-CoV-2, influenza A and influenza B. The epidemiology of these viruses is very similar in terms of susceptible populations, mode of transmission, and the clinical syndromes, thus the etiological agent will be difficult to differentiate without target specific assays. The availability of a sensitive and specific multiplex assay that can simultaneously detect all these targets will be valuable. Here we report the validation of a real-time reverse transciptase-PCR assay for the simultaneous detection of SARS-CoV-2, influenza A and influenza B. This multiplex assay is comparable to its singleplex counterparts with a limit-of-detection being less than 5 copies/reaction, 100 % specificity, over seven logs of dynamic range, less than 1 % coefficientof variation showing high precision, and equivalent accuracy using patient samples. It also offers the added benefits of savings in reagents and technologist time while improving testing efficiency and turn-around-times in order to respond effectively to the ongoing pandemic.

2152. Detection of Uropathogens Using BD Kiestra™ Total Laboratory Automation with Urine Culture Application

BackgroundUrine is the most frequently cultured specimen type for the majority of clinical microbiology laboratories. Typically, around 30% of cultures are positive for uropathogens with 70% yielding insignificant or mixed growth. BD is developing a software Urine Culture Application (UCA) for the BD Kiestra Total Laboratory Automation (TLA) system to screen images of urine culture plates, sort them based on growth vs. insignificant growth and also allow for presumptive pathogen identification.MethodsDe-identified urine specimens were inoculated onto BD BBL™ CHROMagar™ Orientation Media (CHROM; BD, Sparks, MD), CHROM/Trypticase™ Soy Agar II with 5% Sheep Blood (TSA) biplate, BD BBL MacConkey II agar, and TSA using the BD Kiestra TLA system. Plates were imaged at 24 hours using the BD Kiestra™ ReadA Compact imaging acquisition software and an algorithm was applied to the images using the UCA (Version 2.0). Semi-quantitative measurements of <100, 100–1,000, 1,000–10,000, 10,000–100,000, and >100,000 cfu/mL growth were determined by UCA for all media types and presumptive ID was determined using CHROM. Manual reading of the images by two technologists was the gold standard for comparison. For discrepant results, a third manual reader was used as an arbitrator.ResultsTesting between 877 and 934 urine specimens on each of five media types using UCA resulted in an exact semi-quantitative agreement with manual reading for 85.5–95.0% of specimens (Table 1). If semi-quantitative values ± one category of agreement are included, the number rises to 98.2–99.4% agreement. Using CHROM for presumptive identification of pure or predominant organisms, UCA was in agreement with manual identification in 251 of 272 cultures (92.3%). Of the 21 discrepant organisms, 19 were classified as “other” by manual reading but were identified as specific organisms by UCA. Definitive organism identification was not performed.ConclusionUCA was able to accurately categorize bacterial growth into five semi-quantitative categories using five media types. Pure and predominant uropathogens were accurately identified from CHROM using UCA. The use of UCA software application may enable laboratories to save time screening urine cultures by allowing more efficient use of technologist time. Disclosures All authors: No reported disclosures.

Monitoring the Use of Extra Images on Chest Radiography Examinations

BackgroundA large number of chest radiography studies in our department include extra images due to incompletely imaged anatomy (eg, extra frontal view to include a truncated costophrenic angle). Negative impacts include: increased radiologist review time due to disruption of search pattern and the need to review additional films in slightly different obliquities, additional radiation exposure, and increased technologist time expenditure. PurposeTo determine the chest radiograph repeat rate, collaborate with technologists on a process to decrease the frequency, and incorporate the process into our quality control program. MethodsData collection was performed by using coded dictation macros to indicate the type of extra view (frontal, lateral) and whether the extra image was necessary due to patient habitus. Twelve weeks after the macro was instituted, baseline data were collected by querying the macro codes with a search engine (MONTAGE Search and Analytics). Intervention consisted of in-person tutorials of basic radiographic positioning principles with x-ray technologists and posting of checklists in all diagnostic radiology exam rooms. Twelve weeks of postintervention data were collected. ResultsBaseline data included 5645 examinations, of which 335 (5.9%) included extra images. Postintervention, 5943 examinations were performed and 295 (5.0%) included extra images. A significant decrease in the frontal view repeat rate was noted, decreasing from 4.6%-3.3% (P = 0.001). The repeat rate of lateral images did not change significantly (3.1%-3.2%). Conclusions and ImplicationsData monitoring and interprofessional collaboration led to a significant decrease in unnecessary extra radiographs. Ongoing monitoring may lead to sustained improvement and further reductions.

9. Integrating clinical microarray analyses in the myeloma diagnostic workup: Rationale for improving patient care with precision medicine while reducing overall cost of testing

Implementation of clinical cancer microarrays (CMA) in plasma cell myeloma carries significant advancement of precision medicine technologies that allow more effective diagnosis and therapeutic decisions, as well as the potential to provide improved patient care in the face of declining reimbursements. Traditionally, cytogenetic testing options for myeloma include both karyotypic analysis and multiple FISH assays to determine disease status. At our institution, ∼75% of total charges per myeloma specimen result from conventional cytogenetics and FISH service codes. A cost analysis of 202 bone marrow specimens determined total charges of ∼$4,000,000 with conventional cytogenetics and FISH charges of ∼$3,100,000 or 78% of total charges. Our laboratory recently validated CMA for neoplastic disorders, including plasma cell myeloma. Microarray analysis provides a high resolution whole-genome view in myeloma, thereby serving as an appropriate substitution for multiple individual enumeration and locus-specific FISH probes. Moreover, cost analyses accounting for reagents, consumables, and technologist time confirm that integration of microarrays into diagnostic testing options, could significantly lower the equivalent costs to the offering laboratory. With projected elimination of fee-for-service remuneration, the number of individual probes or hybridization events for which reimbursements are received may be limited. This, in turn, could result in a reduction in FISH probes ordered, adversely impacting the amount and quality of clinical information available to make disease management decisions. Therefore, integration of microarray analysis for myelomas would provide best patient care via cytogenomic testing, while reducing overall cost of service. Strategies for implementation and buy-in by clinicians and administration will be detailed.

Streamlining a blood center and hospital transfusion service supply chain with an informatics vendor-managed inventory solution: development, implementation, and 3-month follow-up.

The ordering process at Stanford Health Care involved twice-daily shipments predicated upon current stock levels from the blood center to the hospital transfusion service. Manual census determination is time consuming and error prone. We aimed to enhance inventory management by developing an informatics platform to streamline the ordering process and reallocate staff productivity. The general inventory accounts for more than 50 product categories based on characteristics including component, blood type, irradiation status, and cytomegalovirus serology status. Over a 5-month calibration period, inventory levels were determined algorithmically and electronically. An in-house software program was created to determine inventory levels, optimize the electronic ordering process, and reduce labor time. A 3-month pilot period was implemented using this program. This system showed noninferiority while saving labor time. The average weekly transfused:stocked ratios for cryoprecipitate, plasma, and red blood cells, respectively, were 1.03, 1.21, and 1.48 before the pilot period, compared with 0.88, 1.17, and 1.40 during (p = 0.28). There were 27 (before) and 31 (during) average STAT units ordered per week (p = 0.86). The number of monthly wasted products due to expiration was 226 (before) and 196 (during) units, respectively (p = 0.28). An estimated 7 hours per week of technologist time was reallocated to other tasks. An in-house electronic ordering system can enhance information fidelity, reallocate and optimize valuable staff productivity, and further standardize ordering. This system showed noninferiority to the labor-intensive manual system while freeing up over 360 hours of staff time per year.

Financial Implications of Revised ACR Guidelines for Estimated Glomerular Filtration Rate Testing Before Contrast-Enhanced MRI

PurposeTo quantify the financial implications of eliminating the need for renal function screening before contrast-enhanced MRI. MethodsA HIPAA-complaint, institutional review board–exempt retrospective analysis was conducted of all MRI examinations performed at our quaternary care center over a 12-month period (41,336 examinations; 28,970 with contrast). Examination volume–related data, labor costs, and material costs were assessed and applied to a base case model. Univariate sensitivity analyses were conducted to evaluate the impact of individual components on total cost. Bivariate and multivariate sensitivity analyses were then performed. Medicare data were utilized for reimbursement and net cost analysis. ResultsThe annual base case cost estimate for point-of-care estimated glomerular filtration rate testing before contrast-enhanced MRI was $126,058. Assuming 100% Medicare reimbursement for point-of-care testing, the net departmental cost was still $78,330. In univariate sensitivity analyses, MRI technologist time and i-Stat cartridge (Abbott Laboratories, Lake Bluff, Illinois) pricing were the biggest cost drivers for labor and materials costs, respectively. In multivariate sensitivity analyses, the lowest cost estimate was $6,845 and the highest cost estimate was $787,257. ConclusionRecent changes to screening guidelines for group II gadolinium-based contrast agents by the ACR will likely have major financial implications.

The performance of Luminex ARIES® Flu A/B & RSV and Cepheid Xpert® Flu/RSV XC for the detection of influenza A, influenza B, and respiratory syncytial virus in prospective patient samples

BackgroundThe demand for rapid, accurate viral testing has increased the number of assays available for the detection of viral pathogens. One of the newest FDA cleared platforms is the Luminex ARIES® Flu A/B & RSV, which is a fully automated, real-time PCR-based assay used for detection of influenza A, influenza B, and respiratory syncytial virus (RSV). ObjectivesWe sought to compare the performance of Luminex ARIES® Flu A/B & RSV assay to the Cepheid Xpert® Flu/RSV XC assay for rapid Flu and RSV testing. Study designA series of consecutive nasopharyngeal specimens received in the clinical microbiology laboratory during peak influenza season at a major academic center in Chicago, IL, were prospectively tested, using both the ARIES® Flu A/B & RSV and Xpert® Flu/RSV XC assays, side by side. Discrepant results were tested on the BioFire FilmArray® Respiratory Panel for resolution. ResultsA total of 143 consecutive nasopharyngeal specimens, obtained from patients ranging from six months to ninety-three years in age were received between January 1st, 2017 and March 21st, 2017. There was 96.6% agreement between the two assays for detection influenza A, 100% agreement for detection influenza B and RSV, and 98.9% agreement for negative results. The Xpert® Flu/RSV XC performed with an average turn-around time of approximately 60min, compared to the ARIES® Flu A/B & RSV of approximately 120min. Both assays were equally easy to perform, with a similar amount of hands-on technologist time for each platform. ConclusionsOverall, these results indicate that both tests are comparable in terms of result agreement and technical ease-of-use. The Xpert® Flu/RSV XC assay did produce results with less turn-around-time, approximately 60min quicker than the ARIES® Flu A/B & RSV.

P072 Adaptation of NGS technology for engraftment monitoring in hematopoietic cell transplantation

Aim Increasingly, laboratories that support hematopoietic cell transplantation programs are implementing NGS technology for high resolution HLA genotyping. Extension of NGS to other laboratory services can provide efficiency in staffing and equipment usage. We have evaluated NGS of SNP and InDel polymorphisms for engraftment monitoring. Beyond workplace efficiencies, NGS of InDel polymorphism is not subject to stutter artifacts that can compromise results from the STR technology currently in wide use for chimerism analysis. Methods A panel of 49 polymorphisms on 20 chromosomes, comprising 37 SNPs on 18 chromosomes and 12 InDels on 10 chromosomes, was assembled. Initial amplification for the panel was reduced to 2 multiplexed PCRs with 5 ng of sample DNA per reaction. Total time for library preparation is 6 h, followed by a 7 h sequencing run on the MiSeq platform, with 1 h for chimerism analysis. Hands-on technologist time consists of just 3 of the 14 h time frame. Preliminary evaluation involved 4 sets of artificial mixtures of DNA from 2 unrelated individuals, with mixtures ranging from 10% to 0.1%, see Table. Results On average, 30 informative markers were identified between unrelated individuals. NGS achieved 0.5% sensitivity in all 4 sets of mixtures. The table shows the experimental values and standard deviation, SD, compared with the expected ratios among informative the polymorphisms. Informative InDel polymorphisms showed no false positive artifacts in unmixed specimens. Conclusions The results show that NGS technology provides informative, accurate and sensitive detection of a minority species in mixed specimens. With the 6 h library preparation and 7 h sequencing run, NGS offers rapid turnaround for result reporting. Additional testing is underway to assess the NGS technology in low cell count specimens and in mixtures of 3 or more unrelated individuals, intended to simulate retransplant and double cord donor transplant. Download : Download high-res image (233KB) Download : Download full-size image