ASCLS Today Volume 32 Number 5

ASCLSToday Masthead 680

Volume 32, Number 5

Pre-Analytical Assessment: You Best Be Aware (of its Importance)

Jennifer Hawkins Randle, MSHA, CLC(AMT)

The pre-analytical phase is viable in every aspect of a healthcare professional career. As laboratorians, we depend on phlebotomists for most of our preanalytical phase. It is not just the phlebotomists that the lab depends on for quality specimens. We depend on physicians and nurses to follow protocols and provide a “good” specimen. Most of all, we depend on other laboratorians that we collaborate with to provide a quality sample when follow-up testing must be performed by another laboratory.

The purpose of this article is to bring increased awareness to the vital seriousness of a QUALITY specimen collection and timely submission when results are used for patient assessment, diagnosis, treatment, and/or monitoring.

This is the events of what happened when our lab received a sample for BRUCELLA Rule–Out(R/O), on or about the fourth week after initial subculture. The specimen was received on a blood agar plate (BAP), but at first look, it was thought to be a chocolate plate (CHOC) due to the age of the plate. Now, Brucella is a fastidious, aerobic, small gram-negative coccobacillus that is neither motile nor spore forming. Brucella is considered an overlap select agent because it not only has the potential to pose a threat to public health and safety, but it also poses a threat to animal and animal products.

Polymerase chain reaction (PCR) is a time-consuming process and the suspected organism is easily airborne, so we eliminated having to go into the sample multiple times. Therefore, we performed PCR simultaneously with the Gram stain. The lead Medical Laboratory Scientist (MLS) on this case re-subbed and performed biochemical tests and made a Gram stain. The biochemical tests correlated with the suspected organism. It was not until the Gram stain was performed that we noticed a problem. The lab supervisor re-stained and viewed the slide and concluded with the lead MLS that the Gram stain showed Gram-positive cocci clusters, which is not consistent with Brucella species. However, PCR results indicated Brucella species.

The initial Gram stain threw the whole case off! From this, it is evident that Staphylococcus overgrowth contamination masked the ability to get a pure culture of the Brucella that was detected by PCR. This catalyst made me finally decide to focus on the importance of the pre-analytical stage of clinical laboratory testing. Once again, this confirms results are only as good as the specimen submitted.

An article published in a 2012 report by Bonini and his colleague supports these findings. They found that preanalytical errors predominated in the laboratory, ranging from 31.6% to 75%.1 Out of the three stages of medical testing, current studies show the pre-analytical phase accounts for 46% to 68.2% of errors observed during the total testing process.2 Any error during the laboratory testing process can affect patient care, including delay in reporting, unnecessary redraws, misdiagnosis, and improper treatment. Sometimes these errors can be fatal (e.g. acute hemolytic reaction after incompatible blood transfusion caused by an error in patient identification).3 While there are many published protocols written to minimize errors, along with how to measure those protocols; a practical solution would be to do “random” monthly direct inspections. In short, inspect what you expect. 

Until the science of error prevention catches up with the need that exists, the best we can do is adopt common-sense steps that address the most common and important factors known to contribute to diagnostic error and harm,2 which are preanalytical errors.

In conclusion, the MLS “not” immediately recognizing the “original” collection dates, caused more hands-on than what was needed. Quality of the submitted specimen was poor and overgrown. A four-week-old sub-culture plate should not have been submitted. The receiving laboratory should have noticed the “original” date. However, it was reasonable for the receiving lab to think the specimen was suitable for testing.

With the variation in percentage of errors remaining close in proximity over a 2-year period (32%-75% vs 46%–68%), it is so important for laboratorians to recognize our integrity and our profession must be pledged to the absolute reliability of quality work. We must conduct ourselves at all times in a manner appropriate to the dignity and standards of our profession. In short, we must be the gatekeepers of accurate and precise patient results. Furthermore, this case demonstrates the importance of effective communication and cooperation between laboratorians.

References

  1. Hammerling Julie A. A Review of Medical Errors in Laboratory Diagnostics and Where We Are Today; Laboratory Medicine 2012; 43(2): pp 41-44
  2. National Patient Safety Foundation Reducing Diagnostic Error | Patients and Families.http://www.npsf.org/October 2014
  3. Kaushik, N and Green, S. Pre-analytical errors: their impact and how to minimize them. MLO 2014 http://www.mlo-online.com

Legislative Symposium: A First Timer's Perspective

Cherika Robertson, MEd, MLS(ASCP)CM

Excited. Nervous. Intimidated. Those were my initial feelings upon first arriving in Washington, D.C., for the 2018 Legislative Symposium. I had never thought of myself as being interested in politics, or much less as a lobbyist. But, I did know that I love the profession of medical laboratory science. And, this profession I love faces many challenges. I wanted to use my knowledge and experience to make a difference. I was fortunate to receive the New Professional New Member Forum (NPNMF) Legislative Symposium Travel Grant. And now I am hopeful to be a Legislative Symposium attendee for life!

The event kicked off Sunday, March 18, with a NPNMF and Student Forum mixer. This mixer included dinner at the Hard Times Cafe and a visit to Escape Quest. We divided into two groups and each group used its problem-solving skills to try to solve the case in to “escape.” Both groups were able to successfully escape! This experience allowed me to reconnect with some members I had previously met at other events while also allowing the opportunity to establish new relationships. I am thankful for this opportunity to interact with other new professionals and new members because it made me realize I was not alone in my initial feelings.

Another concern I had pertaining to attending Legislative Symposium was commuting. I was unfamiliar with transportation in D.C. Have no fear, the D.C. Metro is easy to navigate. There’s even a D.C. Metro app that details the location of each train stop, the different color coded trains that travel to these locations, and expected arrival times at these specific locations.

Most of our scheduled meetings with legislators were completed as a group, comprised of all of the constituents from Arkansas. However, I did have a meeting with the representative from my state district by myself! Let me tell you, I was nervous. And I know when I get nervous, I talk fast. I just kept remembering the advice Stephanie Noblit and Karen Williams gave me: speak what you know. And adding a personal story or experience will further leave a lasting impression on legislators. I am not knowledgeable about political processes or legislative terminology, but I do have personal experience in the laboratory, seeing effects of legislation trickle down and have an impact on laboratories and patient care. That experience will leave the most impact. That is what I remained focused on.

One thing I realized from my first experience at the Legislative Symposium is I can use my voice, knowledge, and experience to make a difference. If you are nervous about how to approach a legislator or exactly what to say, do not worry. The educational sessions will guide you through all those details. I highly encourage all laboratory professionals to pay attention to important legislative issues that will have an impact on our profession, the healthcare system, and ultimately patient care. One way to do this is to not only become a member of ASCLS, but to be active and informed. If we don’t advocate for ourselves, who will do it?

Amazed. Proud. Those were feelings when leaving Washington, D.C., after our scheduled meetings with our legislators. Never had I felt prouder to be a medical laboratory scientist. Never had I felt more like I made an impact; that maybe, just maybe, what I discussed with legislators would cause change and have an effect.

As Patrick Cooney, ASCLS Legislative Lobbyist, stated, “what a great country we live in to be able to voice what we want.” This was my first legislative experience, but this experience taught me the value of using my voice to speak up and make a difference. My experience at the Legislative Symposium was both empowering and rewarding. I am already looking forward to attending the 2019 Legislative Symposium, March 18-19. Learn more at www.ascls.org/education-meetings/legislativesymposium.

Application of Case Studies: An Effective Tool to Improve Distance Learning in Clinical Laboratory Sciences

Payman Nasr, PhD, MT(ASCP)

Distance learning is the result of progressive steps in the evolution of correspondence courses which had become popular in the first half of the 20th century. Over decades, as new technologies became commonplace, the correspondence courses adapted to the new technologies, until the 1990s at which time the internet became a regular feature of everyday life and propelled the prospect of distance learning to a whole new level. The recent advances in computer and internet technologies have broadened the prospect of the academic landscape, and today, one can be in remote parts of the world and access information about any topic through a cellphone. Indeed, online academic degrees and universities have become commonplace, and most secondary academic institutions offer online courses. This phenomenon has altered the concept of teaching throughout the academic scene and the clinical laboratory field is no different.

The most attractive advantages of online learning are location and time flexibilities, giving an opportunity to those in remote geographical regions or with busy schedules, to earn college credits. Compared to traditional teaching styles, such flexibilities are the primary advantage of online learning since other technological advancements may simply augment the traditional teaching styles and effectively enhance the students’ learning experience. New technologies are here to stay, and we should harness the power of new technology to improve our teaching rather than inadvertently replacing it.

Careers in Medical Laboratory Science (MLS) are dynamic, high-tech, and versatile, and require exceptional problem solving and critical thinking skills. In the MLS field, certain facts must be learned; however, it is not the knowledge of facts alone which makes a successful Medical Laboratory Scientist, but the ability to apply the acquired knowledge to real life situations. This is an important missing component in many online courses which fail to distinguish between “teaching” and “instructing” students. Simply providing the information for students in various online platforms does not constitute a comprehensive MLS education, and often results in unqualified graduates who struggle in the workplace to uphold the standards expected from well-trained MLS graduates.

One successful strategy to improve online learning is the application of case studies that are content driven and designed to serve specific learning objectives. Case studies strengthen the effectiveness of teaching by applying what is learned in course material to real life situations. By placing the students in a decision-making position as the primary investigators, students are encouraged to analyze the situation in greater depth to rationalize their decisions before reaching any conclusions. For MLS students, learning to think like a Medical Laboratory Scientist means learning to do both analysis and synthesis individually and with a group of co-workers. Hence, learning by means of group discussions to solve case studies encourages students to be active listeners and to incorporate their classmates’ ideas into their own before reaching conclusions. This fosters active participation of students in their own education and gives students a chance to acquire knowledge through facilitated dialogue. The applic tion of case studies is a practical strategy in online MLS courses, but of course, the role of the faculty is of utmost importance to have a successful integration of case studies in an online course. To integrate a successful application of case studies, the faculty should adhere to four simple principles: clarity, brevity, constructiveness, and diligence.

Clarity: The diversity of technologically savvy students in an online setting should be taken into consideration. At the beginning of each course, faculty should make clear what is expected from the students in discussion forums, how the students should participate in case analysis, and where to find meaningful resources to solve the cases. The faculty should be actively monitoring the discussion trends and intervene if there is inadequate participation by students.

Brevity: Lengthy explanations are often not as helpful as short but precise comments. While monitoring the discussion boards, frequent, specific, and punctual comments may be time consuming for the faculty but are the most essential component of a successful application of case studies in an online format.

Constructiveness: Faculty comments should not directly provide answers to students’ questions but act as a bridge to build upon what students have learned in the course and arrive at something they do not know. The faculty feedback should encourage students to analyze the cases through proper research and facilitated dialogue with other classmates.

Diligence: To succeed in case study application in an online format, one cannot overemphasize the importance of faculty diligence. Continuous monitoring of discussion boards keeps the students actively engaged in discussions. If the faculty is not engaged, the students will not effectively engage.

While there is no single method of teaching an effective online course, the rapidly changing nature of healthcare professionals’ education substantiate the application of effective teaching strategies as case studies, which regardless of the students’ backgrounds and level of experience, improves their level of comprehension and interest in the subject matter. In MLS, the application of case studies will be particularly beneficial for the students’ transition from an academic setting into the clinical setting and ultimately patient management. Hence, the MLS community needs to develop basic standards for MLS online education that combines the strength of the available technology with the traditional principles and standards of MLS to ensure the education of well-qualified MLS graduates.

Laboratory Educator Institute

Kyleigh Ellis, 2017-18 Region VII Student Representative

Achieve teaching and academic excellence with the new ASCLS Laboratory Educator Institute. This online institute assists with professional development in critical areas that include education/teaching, administration/leadership, clinical practice, and research. The institute includes training for educators in all medical laboratory programs or settings - community college, university-based, hospital-based or at the clinical site, including courses for program directors.

The institute will:

  • Provide educators with skills and knowledge to effectively develop and implement courses and provide assessments.
  • Develop more effective laboratory science educators and program administrators.

Each session is approximately 60 minutes and has been developed by ASCLS education experts. P.A.C.E.® credit is available upon successful course completion.

The institute was developed due to changes in the education environment. Over the last eight to ten years, attendance at the ASCLS Clinical Laboratory Educators’ Conference (CLEC) has shown a turnover as long-time educators retire and younger laboratory professionals step in to new educator roles. During the review and update of the Entry Level Curriculum (ELC), it was discovered that while many new educators have the content expertise for teaching within Medical Laboratory Technician and Medical Laboratory Science programs, many of them need instruction on educational theories and techniques.

New medical laboratory educators expressed interest in receiving training on basic and advanced instruction on writing educational objectives, creating learning activities, and designing high-quality examinations and assessments. The institute will supplement the annual CLEC and the ELC with readily available education modules.

The Committee on Education Programs and Initiatives (CEPI), a subcommittee of the Education Scientific Assembly (ESA) of ASCLS, is taking the lead in the development of Laboratory Educator Institute with the assistance of the Product Development Committee (PDC).

Currently available courses include:

  • Writing Instructional Objectives - Part 1: The Quick Start Guide
  • The Affective Domain in Laboratory Education

Courses coming soon:

  • Writing Instructional Objectives – Part 2: Advanced
  • How to Write Multiple Choice Exam Questions
  • Creating and Using Rubrics
  • The Nuts and Bolts of Assessment and Evaluation: It’s Not Just about the Outcomes

To purchase courses, visit www.ascls.org/EducatorResources. If you have questions or suggestions for additional courses, contact Joan Polancic, CEPI member, at joan.polancic@dhha.org.

A Not-So-Warm Welcome

Rebecca Matthews, MLS(ASCP)CM

Imagine being a new graduate, fresh out of school and hungry for your first real job in the professional world. You have passed your certification exam and you begin searching for a generalist position in an effort to remain competent in all the disciplines. You are offered a position to work the night shift at a 300 bed hospital 45 minutes from your house. While not ideal, you know that there are few generalist positions in your area so you happily take it. You receive 3 weeks of training in each department, enough time to learn the laboratory information system, basic protocols, and maybe a few odd-ball things here and there. Mind you, this is on day shift where there are two other technologists on the bench to help you.

Nine weeks after your hire date, you are sent to your first night shift with no other trained blood banker available to assist you, neither in person nor on call. It’s 3 o’clock in the morning. Over the intercom, you suddenly hear “Double Alpha Trauma, Male, E.T.A. Now.” As the operator echoes the alert, every muscle in your body tenses up as you realize that not only have you never dealt with a single Alpha trauma by yourself, you most certainly have never dealt with two at the same time. Deep breaths. Think about what you know. Male – okay, so we are going to get the four O positive emergency release units in the fridge. Take the pink slip out, run them over to the ER, come back, set up four more. Got it. Go! Within 10 minutes, eight emergency release units are over in the ER fridge and four more are set up to keep ahead. Everything is fine, you did great!

3:30 a.m. The phone rings; you see it’s the ER, but you are confident that they are just calling to tell you the trauma is over; that’s what always happens on day shift after all. You calmly answer the phone only to hear the charge nurse say, “The doctor wants to activate the Massive Transfusion Protocol. NOW.” Your heart stops. Your hands are shaking, you stutter to gain more information, then hang up. There is a man 100 yards from where you are standing that is expected to lose his entire blood volume, approximately 6 liters, in the next 24 hours or less. What do you do?

Over the course of the next 12 hours, I released over 25 products to support this patient, including packed RBCs, Platelets, Fresh Frozen Plasma (FFP), and Cryoprecipitate (which I initially thawed by accident instead of FFP). I ended up calling 3 different supervisors and no one answered. I was fully convinced that this young man was going to die because I wasn’t getting the blood out fast enough. Eventually I was able to reach my supervisor who rushed over at 4:30 a.m. and spent the next 6 hours alongside me issuing blood, processing STAT orders from the American Red Cross, filling out work cards, completing all the computer work, and communicating with the floor. For 12 hours straight I worked in blood bank. For 12 hours straight, I took no bathroom breaks, no food breaks, no water breaks.

After returning to work a mere 12 hours later, I found both young men were stable enough to be sent to a larger hospital in the big city with the resources more equipped to monitor their treatment and recovery. A part of me was proud that, despite feeling anxious, scared, and unprepared, I was still able to provide an adequate level of service that contributed to saving the lives of these two young men. On the other hand, I began to think, “This was a really close call. What if I am put in another situation where I am really not prepared and there’s no one there to help me?” So, I wrote an e-mail to the laboratory manager detailing my concerns. I didn’t feel experienced enough, not only as a new employee but as a new professional, to be left with an entire blood bank on my shoulders. In an effort to help, I offered to sit down and discuss solutions: maybe a staggered shift or an on-call system, scanning the protocols into a shared drive for easy access, providing minimal blood bank training to the other night shift workers. I made it clear that I was more than willing to take on extra projects to improve this situation.

Six weeks went by with not so much as a response acknowledging my concerns in any way, shape, or form. Feeling the stress closing in again, I decided to take my concern a step further and file a formal complaint with Human Resources. I told them of the working conditions I felt were unsafe for both me and the patients. They said they would investigate and get back to me. I heard nothing. Another 3 weeks went by; then it happened again. This time a cardiac catheterization had gone wrong and a 56 year old woman was rushed to open heart surgery. For 9 hours I did nothing but thaw plasma, tube crossmatch red blood cells, fill coolers with products for the Operating Room (OR), scan components so I could perform the modifications, and computer work after the fact. Again, no bathroom break, no food, no water, no relief. I had to order 2 STAT deliveries of donor units because the O POS inventory was depleted twice. I issued over 45 blood products by myself. I didn’t have time to think about calling for help, I just jumped into survival mode.

Unfortunately, this case didn’t have a happy ending. There was nothing else I could have done on my end; the OR ended up returning the last 15 products I had issued out. This was the last straw. I had managed to escape a potentially devastating liability suit for a second time now. I could no longer justify working in a facility where I felt I was not given the resources to succeed, where progress was not welcome, my voice was not heard, and where I really didn’t feel like I was helping people anymore. I finally quit. I was able to accept a position at a larger facility in a new city and start over.

I share my experience as a new professional with you for several reasons. First, I think as a new professional, it is easy to feel like you don’t have any status. You have a lot of knowledge but little experience to back it up; meanwhile, some of your new co-workers have been in the field for more than 40 years. It is easy to feel intimidated and that your voice has not been “earned”; but it’s not true! If you don’t understand something, ask. If one person may be reluctant to answer or even make you feel silly for asking, ask someone else. If you don’t feel comfortable or confident enough to work on your own just yet, ask for more time and be patient with yourself. Know that you will get there, but on the timeline that is right for you. The work we do is important and even though we may rarely get to see the patients, we still have their lives in our hands. That’s no small responsibility, nor is it one you want to carry before you are ready.

Secondly, don’t be afraid to be an advocate for yourself and for your patients. If something doesn’t sound right or makes you uneasy, bring it to someone’s attention: talk it out, bounce ideas off of your co-workers, and get other perspectives on the matter. Our number one goal as health care professionals is to provide the highest quality of patient care we possibly can. This entails voicing concerns, being open to new ideas, continuing to search for ways to make workflow more efficient, and maximizing patient safety. As new professionals, we are a tremendous asset to laboratories. We have a wealth of knowledge in all the disciplines that is fresh in our minds, including the newest theories and practices. We have little experience in the lab which means we haven’t had time to become entrenched in one particular mindset or pick up bad habits. Furthermore, we are a fresh set of eyes that can add a new perspective. The clinical laboratory is a beautifully dynamic field that is ever evolving; but progress can’t happen without people willing to question and speak up.

Finally, don’t be discouraged if you don’t immediately find the place that you want to spend the next 40 years of your career. Another beautiful thing about our profession is that there is no shortage of jobs. If you are in a situation where you have done everything you can to share your ideas and concerns, tried to connect with your co-workers and create a community dedicated to evolving laboratory practices and patient safety, and tried to provide the best patient care you can but are not provided adequate resources – give yourself permission to let go. I was in a situation where as much as I was willing to facilitate change, there weren’t enough people with me or behind me to make it happen. That doesn’t mean I’m a failure. It means I pick myself up, move on, and try again.

For all of you new professionals out there who are still trying to find your way, know that you are not alone. There are so many different environments in which we can use our knowledge and our skill sets to provide a service to those in need. If the first one isn’t right for you, keep looking, keep trying. Be patient with yourself and remember why you chose this field in the first place. Keep working hard my fellow lab rats, and keep advocating for yourself, your patients, and your profession!

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