Total laboratory automation: Do stat tests still matter?

Blood over-testing: impact, ethical issues and mitigating actions

Plenty of studies demonstrate that hospital-acquired anemia (HAA) can increase transfusion rates, mortality, morbidity and cause unnecessary patient burden, including additional length of hospital stay, sleep disruption and venipuncture harms resulting from blood samples unlikely to change clinical management. Beyond patient costs, community costs should also be considered, such as laboratory time and resources waste, environmental impact, increasing pressure on labs and fewer tests available on time for patients who can benefit from them most. Blood over-testing does not support the principles of non-maleficence, justice and respect for patient autonomy, at the expense dubious beneficence. Reducing the number and frequency of orders is possible, to a certain extent, by adopting nudge strategies and raising awareness among prescribing doctors. However, reducing the orders may appear unsafe to doctors and patients. Therefore, reducing blood volume from each order is a better alternative, which is worth implementing through technological, purchasing and organizational arrangements, possibly combined according to need (smaller tubes, adequate analytic platforms, blind dilution, blood conservative devices, aggregating tests and laboratory units).

Laboratory testing consolidation and total laboratory automation improves service efficiency and effectiveness: a study of a medical center in Taiwan

BACKGROUND

Test consolidation and total laboratory automation (TLA) were implemented in a core laboratory with a high volume of specimens in a medical center in Taiwan to reduce the costs of laboratory services and improve laboratory workflow and performance.

METHODS

Using a retrospective research approach, 5 stat and 7 routine tests were used to analyze the in-laboratory to report turnaround time (IR-TAT). Mean, SD, medium, 90th percentile, outlier percentage of IR-TAT, full-time equivalents, productivity, tube touch moment (TTM), and financial impact were determined and compared pre- and post-TLA.

RESULTS

The mean IR-TAT of overall stat chemical tests for inpatient and outpatient were 32.8% and 11.9% reductions, respectively. The productivity of each medical technologist increased by 32.4% per month, and there was a reduction of 5 medical technologists compared with the number required to complete the same tests before consolidation. The TTM of staff per year post-TLA decreased by 74.1% tube touches.

CONCLUSION

The efficiency of laboratory services was improved by consolidation to the core laboratory along with TLA implementation coupled with logic rules such as delta-check and autoverification. Effectiveness was improved as measured by an increase in productivity, labor reduction, staff safety, and cost reduction.

Evaluation of the Comparability of Wantai Wan200+ Instrument with Routine Laboratory Assays for 21 Different Analytes

Background: We compared the performance of 21 different assays performed by the Wantai Wan200+ (Wantai BioPharm, Beijing, China) with respect to other methods in use at the University Hospital of Padova (AOPD), Italy. Methods: The plasma (P) or serum (S) of 5027 leftover samples, collected from May to Sept 2023, was either analyzed or frozen at -20 °C. Beckman DXI800 (DXI), Roche Cobas 8000 e801 (RC), Snibe Maglumi 4000 plus (SM), DiaSorin Liaison XL (DL) and Binding Site Optilite (BS) equipment were used at the AOPD. P-procalcitonin (PCT), DXI; P-Troponin I (TnI), DXI; S-CA125, DXI; S-free PSA (f-PSA), DXI; S-total PSA (t-PSA), DXI; S-IL6, SM; P-Troponin T (TnT), RC; P-NT-proBNP, RC; P-Neuron-Specific Enolase (NSE), RC; S-CA15-3, DL; S-CA19-9, DL; S-AFP, DL; and S-CEA, DL were tested in fresh samples. P-Myoglobin (Myo), DXI; P-Cyfra21-1, RC; S-β2 microglobulin (B2MIC), BS; S-HE4, SM; S-PGI, SM; S-PGII, SM; S-CA72-4, SM; and S-CA50, SM were analyzed in frozen and thawed samples. Bland-Altman (BA), Passing-Bablok (PB) and Cohen's Kappa (CKa) metrics were used as statistics. Results: An excellent comparability profile was found for 11 analytes. For example, the t-PSA CKa was 0.94 (95%CI: 0.90 to 0.98), and the PB slope and intercept were 1.02 (95%CI: 0.99 to 1.03) and 0.02 (95%CI: 0.01 to 0.03), respectively; the BA bias was 2.25 (95%CI: -0.43 to 4.93). Ten tested measurands demonstrated a suboptimal comparability profile. Biological variation in EFLM (EuBIVAS) performance specifications was evaluated to assess the clinical relevance of measured biases. Conclusions: Evaluation of the Wantai Wan200+'s performance suggests that between-method differences did not exceed the calculated bias. Metrological traceability may influence the comparisons obtained for some measurands.

Characterization of add-on testing before and after automation at a core laboratory

Objectives

Add-on testing refers to the process that occurs in clinical laboratories when clinicians request that additional tests be performed on a previously analysed specimen. This is a common but inefficient procedure, highly time-consuming, especially at core laboratories and could be optimised by automating these procedures. The aims of this study are: 1) To describe patterns of add-on testing at a core laboratory at a tertiary hospital, 2) To evaluate turnaround time (TAT) before and after automation of the pre-, post- and analytical phases.

Methods

Retrospective, observational study conducted at the biochemistry area of a core laboratory of all add-on orders received in two different months (pre-automation and post-automation).

Results

A total of 2464 add-on orders were analysed, representing around 5 % of total requests. Most orders were for either one (>50 %) or two (≈20 %) tests. Most orders were received during the week (from Monday to Friday), particularly during the morning shift (>50 %). More than 50 % of requests were made by the Emergency Department. The two most common add-on parameters were C-reactive protein and N-terminal pro-brain natriuretic peptide. After automation, the median TAT decreased by 42.3 % (from 52 to 22 min). The largest decreases in TAT were observed for routine samples (58.89 %) and fully automated analyses (56.86 %).

Conclusions

Automation of our core laboratory substantially reduced turnaround time for add-on testing, indicating an increase in efficiency. Automation eliminated several manual steps in the process, leading to a mean reduction of 15 work hours per day (more than 2 full-time equivalents).

Automation in the Thrombosis and Hemostasis Laboratory

Automation continues to advance into hemostasis and thrombosis laboratories. Integration of hemostasis testing into an existing chemistry track systems and adoption of a separate hemostasis track systems are important considerations. Unique issues must be addressed to maintain quality and efficiency when automation is introduced. Among other challenges, this chapter discusses centrifugation protocols, incorporation of specimen-check modules in the workflow, and inclusion of tests amenable to automation.

Effectiveness of a Mobile App (PIMPmyHospital) in Reducing Therapeutic Turnaround Times in an Emergency Department: Protocol for a Pre-Post Study (Preprint)

BACKGROUND

Delays in reviewing issued laboratory results in emergency departments (EDs) can adversely affect efficiency and quality of care. One opportunity to improve therapeutic turnaround time could be to provide real-time access to laboratory results on mobile devices available to every caregiver. We developed a mobile app named "Patients In My Pocket in my Hospital" (PIMPmyHospital) to help ED caregivers automatically obtain and share relevant information about the patients they care for including laboratory results.

OBJECTIVE

This pre- and posttest study aims to explore whether the implementation of the PIMPmyHospital app impacts the timeliness with which ED physicians and nurses remotely access laboratory results while actively working in their real-world environment, including ED length of stay, technology acceptance and usability among users, and how specific in-app alerts impact on its effectiveness.

METHODS

This single-center study of nonequivalent pre- and posttest comparison group design will be conducted before and after the implementation of the app in a tertiary pediatric ED in Switzerland. The retrospective period will cover the previous 12 months, and the prospective period will cover the following 6 months. Participants will be postgraduate residents pursuing a ≤6-year residency in pediatrics, pediatric emergency medicine fellows, and registered nurses from the pediatric ED. The primary outcome will be the mean elapsed time in minutes from delivery of laboratory results to caregivers' consideration by accessing them either through the hospital's electronic medical records or through the app before and after the implementation of the app, respectively. As secondary outcomes, participants will be queried about the acceptance and usability of the app using the Unified Theory of Acceptance and Use of Technology model and the System Usability Scale. ED length of stay will be compared before and after the implementation of the app for patients with laboratory results. The impact of specific alerts on the app, such as a flashing icon or sound for reported pathological values, will be reported.

RESULTS

Retrospective data collection gathered from the institutional data set will span a 12-month period from October 2021 to October 2022, while the 6-month prospective collection will begin with the implementation of the app in November 2022 and is expected to cease at the end of April 2023. We expect the results of the study to be published in a peer-reviewed journal in late 2023.

CONCLUSIONS

This study will show the potential reach, effectiveness, acceptance, and use of the PIMPmyHospital app among ED caregivers. The findings of this study will serve as the basis for future research on the app and any further development to improve its effectiveness. Trial Registration: ClinicalTrials.gov NCT05557331; https://clinicaltrials.gov/ct2/show/NCT05557331.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05557331; https://clinicaltrials.gov/ct2/show/NCT05557331.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43695.

Pursuing appropriateness of laboratory tests: a 15-year experience in an academic medical institution

Appropriateness in Laboratory Medicine has been the object of various types of interventions. From published experiences, it is now clear that to effectively manage the laboratory test demand it is recommended to activate evidence-based preventative strategies stopping inappropriate requests before they can reach the laboratory. To guarantee appropriate laboratory test utilization, healthcare institutions should implement and optimize a computerized provider order entry (CPOE), exploiting the potential of electronic requesting as "enabling factor" for reinforcing appropriateness and sustaining its effects over time. In our academic institution, over the last 15 years, our medical laboratory has enforced various interventions to improve test appropriateness, all directly or indirectly based on CPOE use. The following types of intervention were implemented: (1) applying specific recommendations supported by monitoring by CPOE as well as a continuous consultation with clinicians (tumour markers); (2) removing outdated tests and avoiding redundant duplications (cardiac markers, pancreatic enzymes); (3) order restraints to selected wards and gating policy (procalcitonin, B-type natriuretic peptide, homocysteine); (4) reflex testing (bilirubin fractions, free prostate-specific antigen, aminotransferases, magnesium in hypocalcemia); and (5) minimum retesting interval (D-Dimer, vitamin B₁₂, C-reactive protein, γ-glutamyltranspeptidase). In this paper, we reviewed these interventions and summarized their outcomes primarily related to the changes in total test volumes and cost savings, without neglecting patient safety. Our experience confirmed that laboratory professionals have an irreplaceable role as "stewards" in designing, implementing, evaluating, and maintaining interventions focused to improving test appropriateness.

Digital Morphology Analyzer Sysmex DI-60 vs. Manual Counting for White Blood Cell Differentials in Leukopenic Samples: A Comparative Assessment of Risk and Turnaround Time

Background

Digital morphology (DM) analyzers are increasingly being used for white blood cell (WBC) differentials. We assessed the laboratory efficiency of the Sysmex DI-60 system (DI-60; Sysmex, Kobe, Japan) in comparison with manual counting in leukopenic samples.

Methods

In total, 40 peripheral blood smear samples were divided into normal, mild leukopenia, moderate leukopenia, and severe leukopenia groups based on WBC count. In each group, the risk and turnaround time (TAT) were compared between DI-60 and manual counting. Risk was determined by failure mode and effect analysis using the risk priority number (RPN) score, and TAT was recorded for the analytical phase.

Results

Overall, DI-60 showed a five-fold lower risk (70 vs. 350 RPN) and longer TAT than manual counting. In severe leukopenic samples, DI-60 showed a shorter TAT/slide and a remarkably lower cell count/slide than manual counting. In all samples, the TAT/cell for DI-60 was substantially longer than that for manual counting (DI-60 vs. manual total, 1.8 vs. 1.0 sec; normal, 1.5 vs. 0.7 sec; mild leukopenia, 1.9 vs. 0.9 sec; moderate leukopenia, 1.8 vs. 1.0 sec; severe leukopenia, 28.8 vs. 19.0 sec).

Conclusions

This is the first comparative assessment of risk and TAT between DI-60 and manual counting in leukopenic samples. DI-60 decreases the laboratory risk and improves patient safety, but requires more time to count fewer cells, especially in severe leukopenic samples. DM analyzers should be applied selectively depending on the WBC count to optimize laboratory efficiency.

Total Laboratory Automation for Rapid Detection and Identification of Microorganisms and Their Antimicrobial Resistance Profiles

At a time when diagnostic bacteriological testing procedures have become more complex and their associated costs are steadily increasing, the expected benefits of Total laboratory automation (TLA) cannot just be a simple transposition of the traditional manual procedures used to process clinical specimens. In contrast, automation should drive a fundamental change in the laboratory workflow and prompt users to reconsider all the approaches currently used in the diagnostic work-up including the accurate identification of pathogens and the antimicrobial susceptibility testing methods. This review describes the impact of TLA in the laboratory efficiency improvement, as well as a new fully automated solution for AST by disk diffusion testing, and summarizes the evidence that implementing these methods can impact clinical outcomes.

A step towards optimal efficiency of HbA1c measurement as a first-line laboratory test: the TOP-HOLE (Towards OPtimal glycoHemOgLobin tEsting) project

OBJECTIVES

The TOP-HOLE (Towards OPtimal glycoHemOgLobin tEsting) project aimed to validate the HbA_1c enzymatic method on the Abbott Alinity c platform and to implement the HbA_1c testing process on the total laboratory automation (TLA) system of our institution.

METHODS

Three different measuring systems were employed: Architect c4000 stand-alone (s-a), Alinity c s-a, and Alinity c TLA. Eight frozen whole blood samples, IFCC value-assigned, were used for checking trueness. A comparison study testing transferability of HbA_1c results from Architect to Alinity was also performed. The alignment of Alinity TLA vs. s-a was verified and the measurement uncertainty (MU) estimated according to ISO 20914:2019. Turnaround time (TAT) and full time equivalent (FTE) were used as efficiency indicators.

RESULTS

For HbA_1c concentrations covering cut-offs adopted in clinical setting, the bias for both Architect and Alinity s-a was negligible. When compared with Architect, Alinity showed a mean positive bias of 0.54 mmol/mol, corresponding to a mean difference of 0.87%. A perfect alignment of Alinity TLA to the Alinity s-a was shown, and a MU of 1.58% was obtained, widely fulfilling the desirable 3.0% goal. After the full automation of HbA_1c testing, 90% of results were released with a maximum TAT of 1 h, 0.30 FTE resource was also saved.

CONCLUSIONS

The traceability of Alinity HbA_1c enzymatic assay to the IFCC reference system was correctly implemented. We successfully completed the integration of the HbA_1c testing on our TLA system, without worsening the optimal analytical performance. The shift of HbA_1c testing from s-a mode to TLA significantly decreased TAT.

Sample Preparation and Diagnostic Methods for a Variety of Settings: A Comprehensive Review

Sample preparation is an essential step for nearly every type of biochemical analysis in use today. Among the most important of these analyses is the diagnosis of diseases, since their treatment may rely greatly on time and, in the case of infectious diseases, containing their spread within a population to prevent outbreaks. To address this, many different methods have been developed for use in the wide variety of settings for which they are needed. In this work, we have reviewed the literature and report on a broad range of methods that have been developed in recent years and their applications to point-of-care (POC), high-throughput screening, and low-resource and traditional clinical settings for diagnosis, including some of those that were developed in response to the coronavirus disease 2019 (COVID-19) pandemic. In addition to covering alternative approaches and improvements to traditional sample preparation techniques such as extractions and separations, techniques that have been developed with focuses on integration with smart devices, laboratory automation, and biosensors are also discussed.

Stat Laboratory Interventions to Improve Patient Management in the Emergency Department and Resource Expenditure: A 10-Year Study

OBJECTIVE

To illustrate the changes in stat laboratory procedures over a 10 year period.

MATERIALS AND METHODS

We implemented 5 different interventions: reporting total bilirubin through the icteric index, replacing total proteins for albumin, reporting albumin-adjusted calcium in hyper- or hypocalcemia, using lipase as a first marker and amylase-selected scenario, and measuring magnesium in hypocalcemia, hypokalemia, or high lipase values.

RESULTS

Only 9.9% of total bilirubin that was requested was measured, which resulted in savings of $22,492.83. There were 30,036 albumin tests measured, and $15,625.18 was saved replacing total protein. There was $41,374.38 spent to measure lipase and amylase; the difference in costs from the lipase establishment was $16,929.62. Finally, $382.30 was spent for magnesium: 717 magnesium levels were measured given hypocalcemia or hypokalemia (42.8% hypomagnesemia), and 123 tests were added because of high lipase (35% hypomagnesemia). Overall, $53,374.15 was saved.

CONCLUSION

Progressive changes in stat laboratory procedures resulted in more efficient resources expenditures.

Laboratory-related issues in the measurement of cardiac troponins with highly sensitive assays

A number of assay-related issues can affect the performance of cardiac troponin (cTn) measurement in everyday practice. In this respect, it is vital that all information on cTn assays is known and that the performance characteristics of assays are objectively assessed and adequately described. The advent of the latest generation of more sensitive cTn assays has heralded a new wave of information about low concentrations of cTn in blood. These recent generation assays have improved analytical sensitivity and corresponding performance at low cTn concentrations when compared to their predecessors, providing a convincing goal for laboratory medicine in helping clinicians in the diagnosis of acute myocardial infarction. Crucial to the clinical utility of highly sensitive cTn assays is the laboratorians' role in closely scrutinizing proposed assays and defining their value in relation to available evidence. Analytical, as well as pre-analytical and post-analytical, aspects must be documented. In this review, we describe what laboratory professionals should know about their cTn assay performance characteristics and the pre-analytical prerequisites for robustness to ensure optimal post-analytical reporting.

Improving the laboratory result release process in the light of ISO 15189:2012 standard

The ISO 15189:2012 standard section 5.9.1 requires laboratories to review results before release, considering quality control, previous results, and clinical information, if any, and to issue documented procedures about it. While laboratory result reporting is generally regarded as part of the post-analytical phase, the result release process requires a general view of the total examination process. Reviewing test results may follow with troubleshooting and test repetition, including reanalyzing an individual sample or resampling. A systematic understanding of the result release may help laboratory professionals carry out appropriate test repetition and ensure the plausibility of laboratory results. In this paper, we addressed the crucial steps in the result release process, including evaluation of sample quality, critical result notification, result reporting, and recommendations for the management of the result release, considering quality control alerts, instrument flags, warning messages, and interference indexes. Error detection tools and plausibility checks mentioned in the present paper can support the daily practice of results release.

Prospective validation of an automatic reflex test for identifying spurious elevations of mean corpuscular haemoglobin concentration due to the presence of cold agglutinins

Cold agglutinins (CA) in blood may cause false reduction in red blood cell (RBC) count and false increases of RBC indices, such as mean corpuscular haemoglobin concentration (MCHC). Preheating at 37 °C for 2 h is used to overcome this problem. We previously proposed the integration in a total laboratory automation (TLA) setting of a customized reflex test in the presence of MCHC >385 g/L for identifying spurious elevations due to CA. Here, we prospectively evaluate this approach after its introduction in our clinical practice. We evaluated 73 consecutive blood samples from 34 adult patients. Short heating (<1 min) at 41 °C using the reticulocyte channel of Sysmex XN-9000 platform was followed by calculation of optical parameters by the instrument software to ensure quick solution of the CA-dependent problems. After the reflex test in the reticulocyte channel, MCHC dropped below 385 g/L in 50 samples. The reflex markedly corrected the RBC number in eight samples obtained from three patients with CA condition. Two samples from markedly anaemic patients had low blood haemoglobin and RBC count before and after reflex. The remaining 13 samples were obtained from 12 patients, most of whom were on antiretroviral therapy or suffered severe electrolyte disorders, known conditions associated to increased MCHC. The implementation of the proposed automatic reflex by reticulocyte channel on the Sysmex XN-9000 platform in a TLA setting may solve the problem of spuriously high MCHC due to RBC agglutination for CA in a few minutes instead of waiting hours for sample preheating.

Clinical laboratory services for primary healthcare centers in urban cities: a pilot ACO model of ten primary healthcare centers

Background

Primary healthcare centers (PHC) ensure that patients receive comprehensive care from promotion and prevention to treatment, rehabilitation, and palliative care in a familiar environment. It is designed to provide first-contact, continuous, comprehensive, and coordinated patient care that will help achieve equity in the specialty healthcare system. The healthcare in Saudi Arabia is undergoing transformation to Accountable Care Organizations (ACO) model. In order for the Kingdom of Saudi Arabia (KSA) to achieve its transformational goals in healthcare, the improvement of PHCs’ quality and utilization is crucial. An integral part of this service is the laboratory services.

Methods

This paper presents a pilot model for the laboratory services of PHC's in urban cities. The method was based on the FOCUS-PDCA quality improvement method focusing on the pre-analytical phase of the laboratory testing as well as the Saudi Central Board for Accreditation of Healthcare Institutes (CBAHI) gap analysis and readiness within the ten piloted primary healthcare centers.

Results

The Gap analysis, revealed in-consistency in the practice, lead to lower the quality of the service, which was seen in the low performance of the chosen key performance indicators (KPI's) (high rejection rates, lower turn-around times (TAT) for test results) and also in the competency of the staff. Following executing the interventions, and by using some of the ACO Laboratory strategies; the KPI rates were improved, and our results exceeded the targets that we have set to reach during the first year. Also introducing the electronic connectivity improved the TAT KPI and made many of the processes leaner.

Conclusions

Our results revealed that the centralization of PHC's laboratory service to an accredited reference laboratory and implementing the national accreditation standards improved the testing process and lowered the cost, for the mass majority of the routine laboratory testing. Moreover, the model shed the light on how crucial the pre-analytical phase for laboratory quality improvement process, its effect on cost reduction, and the importance of staff competency and utilization.

Performance characteristics of the Abbott Alinity m SARS-CoV-2 assay

Mass molecular diagnostic testing for the SARS-CoV-2 pandemic has drawn on laboratory developed tests, commercial assays, and fully-automated platforms to accommodate widespread demand. The Alinity m instrument by Abbott is capable of detecting several clinically relevant pathogens and has recently received FDA emergency use authorization for SARS-CoV-2 molecular testing. The Alinity m performs automatic sample preparation, RT-PCR assembly, amplification, detection, and result calculation in under two hours. Here, we validate the performance characteristics of the Alinity m SARS-CoV-2 assay in comparison with the Roche cobas 6800 and Hologic Panther Fusion platforms. Across 178 positive and 195 negative nasopharyngeal swab specimens (C_T range 14.30–38.84), the Alinity m detected one additional positive specimen that was found to be negative on the Roche cobas 6800 (PPA 100%, NPA 99.5%). Across a separate set of 30 positive and 174 negative nasopharyngeal swab specimens (C_T range 14.1–38.5), the Alinity m had 100% positive and negative agreement with the Hologic Panther Fusion. Using SeraCare SARS-CoV-2 RNA standards, the assay limit of detection was verified to be two-fold more sensitive than the parameters stated by the SARS-CoV-2 AMP kit package insert, at 50 virus copies/mL. Assay specificity was 100% over 20 specimens positive for other respiratory viruses and intraday precision was 100% concordant with <2% CV. These data illst u illustrate the Abbott Alinity m system's high concordance with reference assays and analyti high analytical for SARS-CoV-2 molecular detection.

Evaluation of red blood cell parameters provided by the UF-5000 urine auto-analyzer in patients with glomerulonephritis

OBJECTIVES

The microscopic examination of hematuria, a cardinal symptom of glomerulonephritis (GN), is time-consuming and labor-intensive. As an alternative, the fully automated urine particle analyzer UF-5000 can interpret the morphological information of the glomerular red blood cells (RBCs) using parameters such as UF-5000 small RBCs (UF-%sRBCs) and Lysed-RBCs.

METHODS

Hematuria samples from 203 patients were analyzed using the UF-5000 and blood and urine chemistries to determine the cut-off values of RBC parameters for GN and non-glomerulonephritis (NGN) classification and confirm their sensitivity to the IgA nephropathy and non-IgA nephropathy groups.

RESULTS

The UF-%sRBCs and Lysed-RBCs values differed significantly between the GN and NGN groups. The cut-off value of UF-%sRBCs was >56.8% (area under the curve, 0.649; sensitivity, 94.1%; specificity, 38.1%; positive predictive value, 68.3%; and negative predictive value, 82.1%), while that for Lysed-RBC was >4.6/μL (area under the curve, 0.708; sensitivity, 82.4%; specificity, 56.0%; positive predictive value, 72.6%; and negative predictive value, 69.1%). Moreover, there was no significant difference in the sensitivity between the IgA nephropathy and non-IgA nephropathy groups (87.1 and 89.8% for UF-%sRBCs and 83.9 and 78.4% for Lysed-RBCs, respectively). In the NGN group, the cut-off values showed low sensitivity (56.0% for UF-%sRBCs and 44.0% for Lysed-RBCs).

CONCLUSIONS

The RBC parameters of the UF-5000, specifically UF-%sRBCs and Lysed-RBCs, showed good cut-off values for the diagnosis of GN.

Serum or plasma? An old question looking for new answers

Serum or plasma? An old question looking for new answers. There is a continual debate on what type of sample a clinical laboratory should use. While serum is still considered the gold standard and remains the required sample for some assays, laboratories must consider turn-around time, which is an important metric for laboratory performance and, more importantly, plays a critical role in patient care. In addition, a body of evidence emphasise the choice of plasma in order to prevent modifications of some analytes due to the coagulation process and related interferences. Advantages and disadvantages of serum and plasma are discussed on the basis of current literature and evidence. In addition, data are provided on the current utilisation of the samples (serum or plasma) in Italy and in other countries. Finally, a rationale for a possible switch from serum to plasma is provided.

Triboelectric Effect Enabled Self-Powered, Point-of-Care Diagnostics: Opportunities for Developing ASSURED and REASSURED Devices

The use of rapid point-of-care (PoC) diagnostics in conjunction with physiological signal monitoring has seen tremendous progress in their availability and uptake, particularly in low- and middle-income countries (LMICs). However, to truly overcome infrastructural and resource constraints, there is an urgent need for self-powered devices which can enable on-demand and/or continuous monitoring of patients. The past decade has seen the rapid rise of triboelectric nanogenerators (TENGs) as the choice for high-efficiency energy harvesting for developing self-powered systems as well as for use as sensors. This review provides an overview of the current state of the art of such wearable sensors and end-to-end solutions for physiological and biomarker monitoring. We further discuss the current constraints and bottlenecks of these devices and systems and provide an outlook on the development of TENG-enabled PoC/monitoring devices that could eventually meet criteria formulated specifically for use in LMICs.

Errors within the total laboratory testing process, from test selection to medical decision-making - A review of causes, consequences, surveillance and solutions

Laboratory analyses are crucial for diagnosis, follow-up and treatment decisions. Since mistakes in every step of the total testing process may potentially affect patient safety, a broad knowledge and systematic assessment of laboratory errors is essential for future improvement. In this review, we aim to discuss the types and frequencies of potential errors in the total testing process, quality management options, as well as tentative solutions for improvement. Unlike most currently available reviews on this topic, we also include errors in test-selection, reporting and interpretation/action of test results. We believe that laboratory specialists will need to refocus on many process steps belonging to the extra-analytical phases, intensifying collaborations with clinicians and supporting test selection and interpretation. This would hopefully lead to substantial improvements in these activities, but may also bring more value to the role of laboratory specialists within the health care setting.

The internal quality control in the traceability era

To be accurate and equivalent, laboratory results should be traceable to higher-order references. Furthermore, their quality should fulfill acceptable measurement uncertainty (MU) as defined to fit the intended clinical use. With this aim, in vitro diagnostics (IVD) manufacturers should define a calibration hierarchy to assign traceable values to their system calibrators. Medical laboratories should know and verify how manufacturers have implemented the traceability of their calibrators and estimate the corresponding MU on clinical samples. Accordingly, the internal quality control (IQC) program should be redesigned to permit IVD traceability surveillance through the verification by medical laboratories that control materials, provided by the manufacturer as a part of measuring systems, are in the clinically suitable validation range (IQC component I). Separately, laboratories should also monitor the reliability of employed IVD measuring systems through the IQC component II, devoted to estimation of MU due to random effects and to obtaining MU of provided results, in order to apply prompt corrective actions if the performance is worsening when compared to appropriate analytical specifications, thus jeopardizing the clinical validity of test results.

Requiem for the STAT Test: Automation and Point of Care Testing

OBJECTIVE

Quick turnaround of laboratory test results is needed for medical and administrative reasons. Historically, laboratory tests have been requested as routine or STAT. With a few exceptions, a total turnaround time of 90 minutes has been the usually acceptable turnaround time for STAT tests.

METHODS

We implemented front-end automation and autoverification and eliminated batch testing for routine tests. We instituted on-site intraoperative testing for selected analytes and employed point of care (POC) testing judiciously. The pneumatic tube system for specimen transport was expanded.

RESULTS

The in-laboratory turnaround time was reduced to 45 minutes for more than 90% of tests that could reasonably be ordered STAT. With rare exceptions, the laboratory no longer differentiates between routine and STAT testing. Having a single queue for all tests has improved the efficiency of the laboratory.

CONCLUSION

It has been recognized in manufacturing that batch processing and having multiple queues for products are inefficient. The same principles were applied to laboratory testing, which resulted in improvement in operational efficiency and elimination of STAT tests. We propose that the target for in-laboratory turnaround time for STAT tests, if not all tests, be 45 minutes or less for more than 90% of specimens.

Switching from serum to plasma: Implementation of BD Vacutainer® Barricor™ Plasma Blood Collection Tubes improves sample quality and laboratory turnaround time

BACKGROUND

For blood, most 24/7 standard (immuno)chemistry parameters are either measured in serum or in lithium heparin plasma. Standard serum and plasma gel tubes have their shortcomings when timely analysis of high quality results is required. Serum requires clotting time and interference of gel globules in the plasma and adsorption of hydrophobic analytes into the gel layer potentially compromises high quality results from lithium heparin gel tubes. We sought to evaluate the impact of BD Vacutainer® Barricor™ Tube (Barricor™) on laboratory efficiency by measuring its effect on TAT and sample quality, as well as evaluate potential cost opportunities resulting from improved sample quality.

METHODS

TAT data and remediation activities were extracted and captured during two 6 months phases. Serum was used as the predominant matrix in the first phase and Barricor™ plasma was used in the second phase.

RESULTS

Barricor™ significantly reduced the median TAT, especially for routine-priority samples during peak-hours. The TAT key-performance-indicator (percentage of results available within 90 ​min) improved to >90% for STAT as well as routine priority samples. Converting from serum gel, Barricor™ reduced fibrin-related remediation activities from 2.3% to 0.4%. This resulted in remediation-related cost reduction of €6.010,47 over the study period.

CONCLUSIONS

By implementing Barricor™, we saw a significant reduction in TAT and a reduction in fibrin-related remediation time and costs, when compared to a predominant serum workflow. The improved TAT opens up the possibility of consolidating to one single priority level, eliminating the need for the use of the STAT priority level.

Benefits of VISION Max automated cross-matching in comparison with manual cross-matching: A multidimensional analysis

BACKGROUND

VISION Max (Ortho-Clinical Diagnostics, Raritan, NJ, USA) is a newly introduced automated blood bank system. Cross-matching (XM) is an important test confirming safety by simulating reaction between packed Red Blood Cells (RBCs) and patient blood in vitro before transfusion. We assessed the benefits of VISION Max automated XM (A-XM) in comparison with those of manual XM (M-XM) by using multidimensional analysis (cost-effectiveness and quality improvement).

MATERIALS AND METHODS

In a total of 327 tests (130 patients), results from A-XM and M-XM were compared. We assessed the concordance rate, risk priority number (RPN), turnaround time, hands-on time, and the costs of both methods. We further simulated their annual effects based on 37,937 XM tests in 2018.

RESULTS

The concordance rate between A-XM and M-XM was 97.9% (320/327, kappa = 0.83), and the seven discordant results were incompatible for transfusion in A-XM, while compatible for transfusion in M-XM. None of the results was incompatible for transfusion in A-XM, while compatible for transfusion in M-XM, meaning A-XM detect agglutination more sensitively and consequently provides a more safe result than M-XM. A-XM was estimated to have a 6.3-fold lower risk (229 vs. 1,435 RPN), shorter turnaround time (19.1 vs. 23.3 min, P < 0.0001), shorter hands-on time (1.1 vs. 5.3 min, P < 0.0001), and lower costs per single test than M-XM (1.44 vs. 2.70 USD). A-XM permitted annual savings of 46 million RPN, 15.1 months of daytime workers' labor, and 47,042 USD compared with M-XM.

CONCLUSION

This is the first attempt to implement A-XM using VISION Max. VISION Max A-XM appears to be a safe, practical, and reliable alternative for pre-transfusion workflow with the potential to improve quality and cost-effectiveness in the blood bank.

Impact of total automation consolidating first-line laboratory tests on diagnostic blood loss

Background

Blood loss for laboratory testing may contribute to hospital-acquired anemia. When implementing the core laboratory (core-lab) section, we consolidated first-line tests decreasing the number of tubes previously dispatched to different sites. Here, hypothesized benefits of the amount of blood volume drawn were explored.

Methods

We retrieved, using a laboratory information system (LIS), the number of tubes received by laboratories interested in the change from all clinical wards in a year-based period, i.e. 2013 for pre-core-lab and 2015 for core-lab system, respectively. Data were expressed as the overall number of tubes sent to laboratories, the corresponding blood volume, and the number of laboratory tests performed, normalized for the number of inpatients.

Results

After consolidation, the average number of blood tubes per inpatient significantly decreased (12.6 vs. 10.7, p < 0.001). However, intensive care units (ICUs) did not reduce the number of tubes per patient, according to the needs of daily monitoring of their clinical status. The average blood volume sent to laboratories did not vary significantly because serum tubes for core-lab required higher volumes for testing up to 55 analytes in the same transaction. Finally, the number of requested tests per patient during the new osystem slightly decreased (−2.6%).

Conclusions

Total laboratory automation does not automatically mean reducing iatrogenic blood loss. The new system affected the procedure of blood drawing in clinical wards by significantly reducing the number of handled tubes, producing a benefit in terms of costs, labor and time consumption. Except in ICUs, this also slightly promoted some blood saving. ICUs which engage in phlebotomizing patients daily, did not take advantage from the test consolidation.

Automation and artificial intelligence in the clinical laboratory

The daily operation of clinical laboratories will be drastically impacted by two disruptive technologies: automation and artificial intelligence (the development and use of computer systems able to perform tasks that normally require human intelligence). These technologies will also expand the scope of laboratory medicine. Automation will result in increased efficiency but will require changes to laboratory infrastructure and a shift in workforce training requirements. The application of artificial intelligence to large clinical datasets generated through increased automation will lead to the development of new diagnostic and prognostic models. Together, automation and artificial intelligence will support the move to personalized medicine. Changes in pathology and clinical doctoral scientist training will be necessary to fully participate in these changes. KEYWORDS: Automation; artificial intelligence; deep learning; laboratory medicine.

Advantages and limitations of total laboratory automation: a personal overview

Automation is considered one of the most important breakthroughs in the recent history of laboratory diagnostics. In a model of total laboratory automation (TLA), many analyzers performing different types of tests on different sample matrices are physically integrated as modular systems or physically connected by assembly lines. The opportunity to integrate multiple diagnostic specialties to one single track seems effective to improve efficiency, organization, standardization, quality and safety of laboratory testing, whilst also providing a significant return of investment on the long-term and enabling staff requalification. On the other hand, developing a model of TLA also presents some potential problems, mainly represented by higher initial costs, enhanced expenditure for supplies, space requirements and infrastructure constraints, staff overcrowding, increased generation of noise and heat, higher risk of downtime, psychological dependence, critical issues for biospecimen management, disruption of staff trained in specific technologies, along with the risk of transition toward a manufacturer’s-driven laboratory. As many ongoing technological innovations coupled with the current scenario, profoundly driven by cost-containment policies, will promote further diffusion of laboratory automation in the foreseeable future, here we provide a personal overview on some potential advantages and limitations of TLA.

Clinical Microbiology Is Growing Up: The Total Laboratory Automation Revolution

BACKGROUND

Historically, culture-based microbiology laboratory testing has relied on manual methods, and automated methods (such as those that have revolutionized clinical chemistry and hematology over the past several decades) were largely absent from the clinical microbiology laboratory. However, an increased demand for microbiology testing and standardization of sample-collection devices for microbiology culture, as well as a dwindling supply of microbiology technologists, has driven the adoption of automated methods for culture-based laboratory testing in clinical microbiology.

CONTENT

We describe systems currently enabling total laboratory automation (TLA) for culture-based microbiology testing. We describe the general components of a microbiology automation system and the various functions of these instruments. We then introduce the 2 most widely used systems currently on the market: Becton Dickinson's Kiestra TLA and Copan's WASPLab. We discuss the impact of TLA on metrics such as turnaround time and recovery of microorganisms, providing a review of the current literature and perspectives from laboratory directors, managers, and technical staff. Finally, we provide an outlook for future advances in TLA for microbiology with a focus on artificial intelligence for automated culture interpretation.

SUMMARY

TLA is playing an increasingly important role in clinical microbiology. Although challenges remain, TLA has great potential to affect laboratory efficiency, turnaround time, and the overall quality of culture-based microbiology testing.

Implementation of total laboratory automation at a tertiary care hospital in Saudi Arabia: effect on turnaround time and cost efficiency

BACKGROUND

Total laboratory automation (TLA) is a relatively new way of improving the management of high volume clinical laboratories. TLA may reduce staff, reduce operating costs, decrease testing time and provide enhanced process control.

OBJECTIVES

Establish a cost efficient TLA that is less labor intensive, improves productivity and reduces turnaround time (TAT).

DESIGN

Implementation of TLA for random glucose and troponin-T as sentinel tests to compare change in TAT.

SETTING

Tertiary hospital with high volume of laboratory tests.

METHODS

Routine patient samples for random glucose and troponin-T were used to capture TAT. Information on staff grades and schedules before and after implementing the TLA, and cost of contracts to deliver the service were collected.

MAIN OUTCOME MEASURES

TAT, cost efficiency, and reduction in labor.

RESULTS

The consolidation of contracts resulted in a reduction of 28.8 million SAR in direct costs. Staffing cost was reduced by 1.14 million SAR with less senior staff required; there were reductions in staff at both senior and junior level. The overall TAT for all tests was reduced by 32% in 2016 (after TLA implementation) compared to 2012 (before TLA implementation). The median TAT for random glucose tests was reduced by 21% (to 55.7 minutes in 2016 from 70.1 minutes in 2012). Evidence of test optimization by exploring the impact of stat tests, auto-dilutions and reruns on the overall TAT of the TLA is shown by comparing troponin T TATs after reclassifying stat tests (in 2016) to routine (in 2017). At the 75th percentile, there was a 27% reduction in TAT when comparing August 2016 to March 2017 with a 19% reduction in median TAT.

CONCLUSION

By moving from stat to routine assays, the TAT was reduced, which is counter-intuitive. The use of stat assays slowed down the performance of the TLA. A careful review of the mix of assays should be conducted to maximize performance and to ensure that the system delivers what is required.

LIMITATIONS

Room for improvement by systematically analyzing and reviewing the impact of making minor changes that could have significant impact on TAT.

CONFLICT OF INTEREST

None.