Evaluation of the clinical utility of reflex GMS and AFB stains on BAL specimens from lung transplant patients

Reducing reflex first-line prescriptions in a surgical pathology laboratory: toward sustainable practice with positive economic and clinical effects

In surgical pathology departments, reflex first-line techniques (RFLTs) are aimed at reducing workloads and addressing recent shortages of medical personnel. However, the impacts thereof on economic and diagnostic factors have been poorly addressed. Also, in the era of global warming, environmental considerations are crucial. This study assessed the economic and diagnostic efficacies of routine pathological RFLT and the quality of care and sustainability. Ten RFLTs of the Bordeaux University Hospital pathology department (six special stains, one cytology technique, and three immunohistochemical tests) were studied. First, a retrospective economic analysis evaluated the average cost of these RFLTs per slide and per year. Second, diagnostic relevance was prospectively surveyed. Third, the effects of changes made were analyzed over 2 years. The ten RFLTs were associated with average annual costs of €46,708. Diagnostic relevance analysis indicated that most stains were unnecessary; only 17% were requested as second-line techniques. Elimination of 7/10 tests afforded annual cost savings of €22,522 and reduced the workload by 5568 tests/year, without compromising the workflow or diagnostic quality. Seven of ten RFLTs could be eliminated without compromising diagnostic quality or the workflow. This afforded not only financial benefits but also positive social and environmental impacts. We offer valuable insights into appropriate practices in surgical pathology laboratories. Collaboration between the medical and technical teams was crucial; other healthcare sectors would also benefit from our approach.

Empirical ordering of stains in cytology-are we saving or losing?

INTRODUCTION

Bronchoalveolar lavage (BAL) and body cavity fluids (pleural and peritoneal) have a useful role in the detection of infectious diseases, especially when combined with ancillary stains (Grocott methenamine silver, acid-fast bacilli, Fite, and cytomegalovirus). However, empirical ordering of stains and duplicate testing by concurrent microbiology cultures leads to unnecessary wastage of resources. The aim of our study was to optimize the use of resources.

MATERIALS AND METHODS

We performed a retrospective review of all BALs and body cavity fluids from 2016 to 2018 to determine the baseline stain order rate, which was then used in conjunction with clinical information to create a reasonable target for 2019. The methods implemented included communication with the clinical team to modify current ordering practice, monitoring stain orders prospectively through 2019, and updating the cytology requisition form to limit upfront ordering of ancillary stains.

RESULTS

From 2016 to 2018, of the 1270 specimens reviewed, 323 (55%) were BALs and 108 (16%) were body cavity fluids that had had ≥2 stains preordered. This was reduced by the end of 2019 to 10% of BALs and 3.4% of body cavity fluids, leading to $25,935.24 in costs savings (including 275 hours of technician time and 39.3 hours of pathologist time).

CONCLUSIONS

We found that ancillary microorganism stains have limited utility in cytology specimens and should only be ordered when indicated after a review of the initial smears. In today's era of cost savings, upfront ordering of ancillary stains can lead to significant wastage of resources that can be prevented by improving workflow.