ASCLS Today Volume 34, Number 1

Barbara Snyderman, MLS(ASCP)^CM, DLM, ASCLS E&R Fund Vice Chair

What student couldn’t use some additional cash to fund his or her education, graduate studies, or research? The ASCLS Education & Research Fund, Inc., (E&R Fund) provides scholarships and grants available for students enrolled in programs in medical laboratory technology, medical laboratory science, and graduate degrees related to our profession. The E&R Fund also provides scholarship opportunities to students studying for the doctorate in clinical laboratory science.

Established in 1953, ASCLS E&R Fund provides dollars that assist in the growth of the clinical/medical laboratory science profession and enhance the essential services provided by laboratory professionals. The fund is supported by endowments and by contributions from members and the public.

In 2011, the E&R Fund began providing Memorial Scholarships that are intended for those who wish to honor or memorialize a friend, colleague, or family member with a gift.

Funding Opportunities

The fund offers a $1,500 Memorial Undergraduate Scholarship annually to a qualifying MLS student and a $1,000 scholarship to a qualifying MLT student in the final year of study. Other undergraduate scholarships are available to honor Dan Southern ($2,000) and in memory of Edward C. Dolbey, Michelle Kanuth, and Bernadette Rodak ($1,500 each). A $3,000 Edward C. Dolbey graduate scholarship is offered to graduate students in clinical/medical laboratory science or in a related graduate field.

The E&R Fund also offers research grants of $3,000-$5,000 supporting members’ investigations of issues critical to laboratory medicine and health care.

The ASCLS awards program recognizes outstanding achievements, contributions, and service to the profession and celebrates the value of professional ability and commitment. Grants, scholarships, and professional achievement awards are presented at the ASCLS-AGT Joint Annual Meeting.

Eligibility for E&R Fund Scholarships

• Member of ASCLS
• Citizen or permanent resident of the United States
• Undergraduate applicants may apply during their final year
• Undergraduate applicants must be enrolled in a NAACLS-accredited program

Donations
The E&R Fund depends on your donations! Money is raised through silent auctions at the Joint Annual Meeting Presidents’ Reception and at the Clinical Laboratory Educators Conference but that is just a part of what is given to students each year. Donations are welcome at any time of the year. Please go to ASCLS.org and use the DONATE button to make your contribution to the E&R Fund, or simply mail your check to the ASCLS national office, c/o James Flanigan, American Society for Clinical Laboratory Science, 1861 International Drive, Suite 200, McLean VA 22102.

Your contribution is officially a tax-deductible donation to our 501c3 fund. There is no minimum contribution—all donations are appreciated. If you want to donate to a specific scholarship, simply provide the name and affiliation of the person you wish to honor or memorialize. The trustees of the E&R Fund thank you in advance for your contributions.

Barbara Snyderman is senior laboratory specialist at Ortho Clinical Diagnostics in Philadelphia.

Brandy Gunsolus, DCLS, MLS(ASCP)^CM, ASCLS Patient Safety Committee Vice Chair, ASCLS Representative to the Coalition to Improve Diagnosis

The Coalition to Improve Diagnosis hosted an annual in-person meeting November 10-13 in Washington, D.C., where coalition representatives met to discuss what their organizations have been doing to improve diagnosis and to collaborate with other coalition members.

Coalition representatives voted on eight potential priorities for the organization, with the top four priorities being the final focus.

For those of you that may not be aware, this past year ASCLS joined the Coalition to Improve Diagnosis, a coalition of more than 80 societies, organizations, and facilities that have one common goal: to improve patient diagnosis. The ASCLS representative is chosen by the ASCLS Board of Directors from the active members of the Patient Safety Committee, and I am honored to have been chosen.

While the coalition does have several conference calls throughout the year, and has recently launched a MemberCentric community app very much like our own at ASCLS, it hosts an annual in-person meeting where coalition representatives are able to meet and discuss what their organizations have been doing to improve diagnosis, as well as develop opportunities to collaborate with other coalition members. This year’s coalition annual meeting was during the Diagnostic Error in Medicine Conference, November 10-13 in Washington, D.C. ASCLS was not the only new organization represented at the coalition meeting; there were 12 total new members, including COLA and The Joint Commission.

Each coalition representative provided a brief report of activities his or her organization has been working on toward improving patient diagnosis. Activities reported on behalf of ASCLS included:

• Develop patient safety brochures for both patients/caregivers and providers. These products are customizable for individual facilities to use and distribute to their own patients and providers to help both groups improve laboratory testing.
• Write patient safety articles for COLA’s Lab Testing Matters website.
• Volunteer for LabTestsOnline Consumer Response Team, answering questions of both patients and clinicians regarding laboratory testing.
• Oversee and support the Doctorate in Clinical Laboratory Science programs and practitioners.
• Develop podcasts and webinars, accessible to both laboratory and non-laboratory healthcare professionals, on a variety of topics, including topics related to improving patient safety.

Coalition Member Highlights

Interesting updates from other coalition members include (not a comprehensive list; only some pertinent highlights):

• American Health Quality Association – Currently working with Centers for Medicare & Medicaid Services (CMS) to identify and eliminate quality measures that have not produced quality healthcare improvements that were intended, as well as implement diagnostic quality measures.
• Centers for Disease Control and Prevention – Part of its project ECHO is a demo project to link laboratory professionals to clinicians through telemedicine to help eliminate the gap between physicians and the laboratory.
• ECRI Institute – Sent a survey to all National Provider Identifier (NPI) registered providers asking about various concerns in daily patient management; diagnostic error was the biggest concern identified in the survey. It has also established a database of genetic tests with evidence for what is clinically valid and clinically useful, which is currently used by both physicians and insurance payors.
• Geisinger – Developed a toolkit for clinical service directors to show them how to use diagnostic errors as learning tools in a non-threatening manner.
• MedStar – Implemented a review death within their health system by an interdisciplinary team to identify diagnostic errors and then identify where the diagnostic process can be improved to prevent such deaths in the future.
• Society to Improve Diagnosis in Medicine – Australia now has its own coalition with 50 members. Improving Diagnosis in Medicine Act of 2019, H.R.5014, was introduced in the House of Representatives by Representative Lujan and Representative Ray on November 8 before the coalition annual meeting. More information regarding this act will be forthcoming.
• Veterans Health Administration – Developing an algorithm to measure timeliness of test result follow-up by clinicians and plans to improve targets for improvement based on baseline measurements.

Grant Opportunity

The coalition is also tasked with developing guidance for Diagnosis Quality Improvement (DxQI) grants that will be awarded by the Gordon and Betty Moore Foundation, a coalition sponsor. These one-year renewable grants will be open to anyone who has an innovative and/or educational idea to improve diagnostic quality. Grants will be capped at $50,000 per proposal with a total of $3 million being awarded over the next three years.

At least 50 percent of awarded proposals must be directed towards improving diagnosis of cancer, infection, or acute vascular events. There was much talk about community, rural, and critical access perhaps having some preference for a percentage of grants as well. This will be an excellent opportunity for project funding for anyone who has a great idea. If you need help with grant writing, we have ASCLS members with grant writing knowledge who can help organize and edit any member wishing to submit.

Coalition Priorities

The last task for the coalition was to determine priority areas for coalition societies to focus on, and potentially partner together. There were eight potential priorities and each coalition representative was allowed to vote for three of these priorities, with the top four being the final focus. The themes that were up to a vote were:

• Measuring when and where misdiagnosis occurs
  • Standardize event reporting and taxonomy
• Supporting clinical decision-making at the bedside
  • Interdisciplinary workflows for diagnostic screening and follow-up
• Increasing care team collaboration and communication*
  • Lead provider identified to decrease segmentation of care
• Influencing organization leadership to make diagnostic quality and safety a priority*
  • To get to ROI/cost analysis on improving diagnostic quality
• Improving clinician education/training surrounding the diagnostic process*
• Influencing payment and regulatory policy changes
• Reducing disparities in diagnostic error
• Improving patient-provider communications

The bolded priorities were the priorities that won the vote with asterisked (*) priorities being the three priorities that I voted for as representative of ASCLS. Coalition members can, and should, continue to work on non-voted areas; however, the coalition’s big push for the next year will be on the top four voted priorities.

The coalition is looking for working group members from coalition organization members for each of these four priorities. These working group members do not have to be the organization’s coalition representative but should be someone who is very active at the top or national level of the organization. If anyone is interested in joining one of the coalition’s workgroups on the bolded priorities above, please contact me at brandy.gunsolus@gmail.com.

In summary, the work ASCLS has done toward improving patient safety and reducing diagnostic error has been great and well appreciated, but there is still much to do. We are just chipping at the top of the iceberg of diagnostic error. We have positioned ourselves by joining this amazing coalition to make a bigger impact than we ever could have imagined … it’s our responsibility to our profession and patients to do it.

Brandy Gunsolus is doctor of clinical laboratory science at Augusta University Medical Center in Augusta, Georgia.

Kristen Croom, MLS(ASCP)^CMMB^CM, ASCLS Region X Director

ASCLS-Hawaii participates in the University of Hawaii John A. Burns School of Medicine’s Joint Health Opportunities Conference.

Members of ASCLS-Hawaii volunteer at a Girl Scouts STEM Fest.

Typically, advocacy is thought of as lobbying our congressional representatives at a state or national level. This can be done by visiting these leaders to discuss your specific concerns. Or you can donate to a Political Action Committee (PAC) for a professional lobbyist to work with these representatives to create bills addressing your concerns.

ASCLS does an amazing job at organizing the membership for national lobbying efforts. The constituent societies also work at the state level to organize lobbying efforts. ASCLS-Hawaii does not have many official lobbying efforts regarding laboratory services, because we have a strong licensure for our laboratory professionals. This has led Hawaii to take a different approach to advocacy efforts. For the last few years the board has focused on advocating for our profession to students and non-laboratory science college students.

ASCLS-Hawaii chose to focus on promoting the clinical laboratory profession to different age groups in the state. The board made a dedicated effort to become involved in community activities that involve students with an interest in science. They use these activities to share their passion for laboratory medicine and how each laboratorian is an important member of the healthcare team.

“ASCLS-Hawaii realizes that students are the future of laboratories and our professional organization. This is one way they are using advocacy to promote the profession.”

Some of the activities include participating in STEM fairs for girls and working with the medical school on a health careers day. ASCLS-Hawaii realizes the importance of encouraging students to investigate clinical laboratory science, and by participating in these events more students can learn about our field and our critical role in healthcare.

ASCLS-Hawaii also participates in the CLS program at University of Hawaii. They attend the welcome fair for new students and attend one of the class sessions to discuss the importance of professional associations. This provides the opportunity for students to see ASCLS and hear about the different ways we help laboratorians and our patients.

The annual Hawaii Clinical Laboratory Conference recently changed its meeting location to the local community college. This change allowed ASCLS-Hawaii to interact with the MLT students and other non-laboratory science students. The participants were able to attend a job fair and provided an opportunity for non-MLT students to gain some understanding of the program.

The ASCLS-Hawaii board feels strongly about working with the different programs to grow future laboratorians. They realize the importance of participating in community and university events. They can use these events to boost engagement with ASCLS members who want to participate and give back to the students. ASCLS-Hawaii realizes that students are the future of laboratories and our professional organization. This is one way they are using advocacy to promote the profession.

Kristen Croom is director of Pathology and Molecular Services at Queen’s Medical Center in Honolulu, Hawaii.

Minh Kosfeld, PhD, MLT(ASCP)^CM

As a working medical laboratory scientist and educator, I have found blood gas testing a challenging concept for many, coworkers and students alike. In this brief case I will provide a basic example of blood gas analysis to illustrate its use in the diagnosis of a blood gas disorder.

A child was found unconscious in a smoke-filled apartment and brought to the ED. Results of the initial blood tests (venous blood gases, CO-oximetry, whole blood electrolytes, and lactic acid) are shown in the table below. The blood gas analyzer used was a Radiometer ABL800 Flex, which uses selective electrodes to measure pH, pCO₂, pO₂, electrolytes, and glucose, and CO-oximetry to determine the relative concentrations of carboxyhemoglobin (CO-Hb), methemoglobin (Met-Hb), oxyhemoglobin (O₂-Hb), and hemoglobin (H-Hb).

RADIOMETER ABL800 FLEX

Blood gas testing helps to assess the function of the respiratory, cardiovascular, and renal systems by determining the acid-base balance and oxygen status of the blood. Usually, arterial blood is preferred for blood gas measurement. However, correlation between COHb levels and pH in venous and arterial blood is good,¹ and the easy and rapid availability of a venous draw made it the sample of choice in the ER, given the criticality of the presentation.

The pH reflects the acid-base status of a patient’s blood, and the Henderson-Hasselbalch equation makes clear its dependence on the concentration of bicarbonate (HCO₃^-) and the partial pressure
of CO₂ (pCO₂): pH = 6.1 + log ([HCO₃^-]/0.03 x pCO₂).

Blood pCO₂ levels are dependent on the balance between the rate of production of CO₂ by metabolic processes and the rate at which it is removed by the lungs. Blood HCO₃^- levels are maintained by the kidneys as a means of buffering acids added to the blood by metabolism or ingestion and as a means of transporting carbon dioxide from the tissues to the lungs where it can be discharged.

As is apparent from the equation above, pH will fall as HCO₃^- falls and/or as pCO₂ rises, and pH rises if these changes are reversed. pCO₂ can be directly assessed, but HCO₃^- is more of a challenge, as it acutely changes in the same direction as any change in pCO₂ since they are in equilibrium with one another through carbonic acid (unrelated to compensation by the kidney, which takes longer). So, to easily assess HCO₃^-, a parameter called the base excess (BE) is calculated, and it tells whether there is an excess of HCO₃^- (metabolic alkalosis when BE is +), or a deficit (metabolic acidosis when BE is –).

The present case reflects a mixed acidosis with both a respiratory component (elevated pCO₂) and a metabolic component (diminished HCO₃^- as reflected by the extremely negative BE). The elevated pCO₂ is consistent with hypoventilation resulting from smoke inhalation causing loss of consciousness and diminished respiratory drive. The diminished HCO₃^- is likely related to hypoxia. Several factors can cause a reduction in the partial pressure of oxygen (pO₂) in the blood following smoke inhalation, including the reduced rate of ventilation (as suggested by the elevated pCO₂), a decrease in pO₂ in the environment, and a reduction in the efficiency of gas exchange in the lungs (due to the toxic effects of smoke)². Our patient’s pO₂ was not low upon arrival, likely due to prior administration of O₂, but there is evidence of hypoxia, nonetheless.

What is important for the delivery of oxygen to the tissues is the blood’s oxygen content (ctO₂), which is the product of the fraction of total hemoglobin that is oxygenated (FO₂Hb), the hemoglobin (Hb) level and the O₂ carrying capacity of Hb. In this case it is very low (6.2 Vol%), because of a low Hb (unknown whether there was a preexisting anemia or whether it was the result of fluid resuscitation), but more importantly, because of a low FO₂Hb. The latter is because CO binds Hb at least 200x as avidly as O₂ and so displaces O₂ from Hb. In addition, CO reduces the release to the tissues of whatever O₂ that is bound, so that tissue hypoxia is compounded. The resulting tissue hypoxia leads to anaerobic metabolism and the production of high levels of lactic acid, causing the high anion gap metabolic acidosis present in this case.

It should be noted that sO₂ and FO₂Hb both represent the percentage of total Hb saturated by O₂ but define total Hb differently. FO₂Hb calculation includes all types of Hb in total Hb, while sO₂ estimation (from the measured pO₂ and a standard oxyhemoglobin dissociation curve) excludes dyshemoglobins like COHb. So, if COHb is present, as in this case, FO₂Hb will be smaller than sO₂.

References

1. Gerald F. O’Malley, DO, Rika O’Malley, MD, Carbon Monoxide Poisoning, October 2017 https://www.merckmanuals.com/professional/injuries-poisoning/poisoning/carbon-monoxide-poisoning
2. Karen L. Wood , MD, Measurement of Gas Exchange, October 2017 https://www.merckmanuals.com/professional/pulmonary-disorders/tests-of-pulmonary-function-pft/measurement-of-gas-exchange
3. Bishop M, Fody E, Schoeff L, eds. Clinical Chemistry: Principles, Procedures, and Correlations. 8th ed. Philadelphia, Pennsylvania: Wolters Kluwer; 2018.
4. Keith A Lafferty, MD; Chief Editor: Joe Alcock, MD, MS. Smoke Inhalation Injury Workup; Nov 06, 2018 https://emedicine.medscape.com/article/771194-workup
5. NSW Agency for Clinical Innovation. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/220675/ABG_poster_large.pdf

Minh Kosfeld is program director of IMS and assistant professor of Clinical Health Sciences at Saint Louis University in St. Louis, Missouri.