Enhancing Communication of Potentially Compromised Test Results

With  so many priorities competing for their time, clinical laboratorians often must  make deliberate, painful choices about which quality improvement (QI) projects  offer the best return on scarce resources. Other times patient safety problems  appear so quickly that they thwart careful plans for QI projects already in the  queue. At our lab, such was the case with a QI project that tackled canceled  specimens.

It  started with several phone calls from clinicians about tests that had been  canceled due to “specimen  contamination” without  further information. In some instances, the clinical team wanted the test  results released for documentation even though they were clearly compromised by  intravenous (IV) fluid, as was apparent by the number and pattern of abnormal  test results. In other instances, we discovered that the lab had canceled test  orders inappropriately: What initially appeared as a contaminated specimen  represented accurate, but highly abnormal, test results for patients who were  rapidly deteriorating. After investigating the issue, an array of problem cases  surfaced, each more eye-opening than the last, revealing specimen contamination  as a significant patient safety issue. 

It  became clear to us that clinical laboratory scientists should not be making  unilateral decisions to cancel results for samples suspected of being  contaminated. We needed a joint decision-making strategy that included both  clinical laboratorians and healthcare providers to increase communication,  documentation, and overall satisfaction for everyone involved in making these  tough decisions.

Incorrectly  canceling testing on a specimen that is not truly contaminated may lead to  delayed results. Conversely, releasing erroneous, contaminated results could  result in inappropriate diagnosis and treatment. Both scenarios have the  potential to harm patients, leaving little room for doubt about our need for a  multidisciplinary group of experts.

EASY  AS CTRL + P

We  started the QI project by asking the lab staff to simply print the screen of  results in our laboratory information system (LIS) for the samples they believed  were contaminated and for which they planned to cancel the test order per lab  policy. This was a minor change to their workflow, but this data collection was  critical to the project’s  success.

After  collecting and reviewing 3 months of data, we found that, on average, the lab  suspected contamination in 125 specimens per month. Pathology residents audited  the cancellations by perform-ing chart reviews.

The  chart reviews revealed that some of the more seasoned clinical laboratory  scientists were better at catching the less obviously contaminated specimens  while the overtly contaminated specimens were accurately identified by both new  and seasoned staff. The data also provided insight into who could benefit from  targeted education. Overall, the data demonstrated that for 90% of the  cancellations due to specimen contamination, clinical lab personnel had the same  interpretation as the residents.

One  of the goals defined early in the QI process was to increase the concordance  rate between the behavior of the lab personnel and the clinical results  collected by the residents. This led us to improve our test cancellation  procedure by adding a section that highlights common contaminants, such as  normal saline and heparin, and provides general examples of how they can affect  lab results (1, 2). By providing more specific criteria for evaluating specimen  contamination, we were able to help the lab staff more accurately identify  suspicious samples.

Soliciting  feedback following the procedural change yielded several ideas for additional  educa-tional tools, including a notebook with examples of compromised patient  test results to illustrate typical patterns. We also implemented safeguards such  as encouraging staff to contact the resident on call or their medical director  if they had questions about whether a sample is contaminated since, in general,  lowering the threshold for escalating concerns improves patient  safety.

BOOSTING  QUALITY AND CLARITY OF COMMUNICATION

Although  it is important to properly identify a compromised sample to prevent treatment  errors, it is equally as important to communicate clearly about any compromised  sample. We updated our test cancellation procedure to provide guidance on how to  communicate suspicion of specimen contamination to other sections within the lab  as well as to patient care providers.

To  improve communication internally, the clinical laboratory scientists must now  query the LIS to take several required actions. These include: investigating  other results on the same order that may be adversely affected; reviewing  previous orders to see if there was a recent cancellation due to contamination  and escalating to a medical director if warranted; determining if the patient  specimen was collected in the inpatient setting; and notifying the phlebotomy  supervisor if the contaminated specimen was collected in-house by a  phlebotomist.

Having  this information available prior to calling the clinical team means the lab  often can make a single, more productive phone call. This procedure also helps  the lab escalate problems more quickly through the appropriate  channels.

We  also recognized that clinicians need to know why the lab suspects sample  contamination so that they can be involved in making the decision to cancel  testing. Clinicians have specialized knowledge about the patient and their  departmental practices, just as clinical laboratory scientists have specialized  knowledge of the assays and instruments.

The  new protocol requires clinical laboratory scientists to explain to the patient  care provider why contamination is suspected based on the test results  generated. They are also instructed to inquire about how the specimen was  collected to determine if contamination is likely due to drawing through a  peripheral IV catheter. If this investigation confirms that a sample has been  contaminated, we can-cel the affected tests and re-draw the patient at the  physician’s  discretion.

We  also require that staff use a new cancellation comment to document that the  order was canceled specifically due to suspected contamination, including the  clinician’s name who approved  the cancellation. If the care provider cannot confirm or does not agree that  contamination is likely, then we release the results with a comment documenting  that the ordering physician was notified about the suspected specimen  contamination and to repeat testing if clinically indicated. We also use this  comment when a physician wants the contaminated results released into the  medical record for documentation.

SMALL  VICTORIES ARE WORTH THE EFFORT

Gaining  traction with this QI project was challenging but worth the effort. Ultimately,  implementing the workflow changes described above improved communication both in  and out of the lab, enhanced documentation of suspected contaminated results,  and most importantly, improved patient safety.

A  post-intervention data review demonstrated that approximately 50% of our test  cancellations were due to specimen integrity issues such as insufficient  quantity for testing, hemolysis, or detection of an interfering substance  (Figure 1). With the new cancellation comment, we identified that approximately  10% of these specimens were cancelled due to contamination. This translates to a  total of 5% of all test cancellation in our lab for which the enhanced procedure  improved communication and documentation, approximately 1,500 specimens a  year.

This  small QI victory provided the confidence and momentum needed to tackle larger  issues with the same persistence. It also fostered better inter-departmental  relationships with caregivers. Without these relationships, other QI initiatives  down the road would not have been possible.

Jaime  Noguez, PhD, DABCC, is the associate director of clinical chemistry and  toxicology at University Hospitals Cleveland Medical Center and assistant  professor of pathology at Case Western Re-serve University in Cleveland,  Ohio.