Developing an evidence-based approach to quality control

Effective Quality Control remains one of the pillars of Clinical Biochemistry. An understanding of the possible analytical errors that may occur, how to detect them efficiently and how to prevent them from causing patient harm are critical components of a Quality System. For some time, there have been questions about the theoretical basis of the models used to describe and detect analytical error. The current theory recognises two types of error, systematic and random and a system based on sampling the analytical process using a synthetic material to detect these errors. However, there are at least two other errors that are present. One is related to the QC material and the other, irregular errors. In this Opinion Piece, some of the underlying assumptions of Quality Control systems are described and analysed.

Implementation evaluation of pre-hospital blood collection in regional Australia: a mixed methods study

BACKGROUND

In response to increasing emergency department presentations and wait times in Australia, multiple strategies and models of care have been implemented with varying results. One effective strategy has been the implementation of pre-hospital blood collection by paramedics when they insert an intravenous cannula. This research aims to determine the efficiency of and barriers to wider implementation of a pre-hospital blood collection trial in a regional context. In particular, to evaluate the impact of the pre-hospital blood collection on time to pathology results and error rates, and paramedic opinion.

METHODS

This retrospective controlled cohort study was conducted over 12 months from August 2018. Emergency and pathology data were used to determine the haemolysis and error rates, as well as the time to result availability of pre-hospital blood collection samples compared to in hospital samples arrived by ambulance. To determine the facilitators and barriers to wider implementation a survey of 48 paramedics was conducted following completion of the 12-month trial. The survey was informed by the Theoretical Domains Framework, a behavior change theory associated with improved uptake when applied.

FINDINGS

Overall 237 samples were collected. There was a 65% (51 min) reduction in time taken for samples to be received at pathology and a 38% (50 min) improvement in time taken for results to return from pathology for patients arrived by ambulance. There were no labelling errors in the pre-hospital blood collection group or change in haemolysis rates. The majority (79%) of paramedics who completed the survey were optimistic about the protocol improving patient outcomes and 89% regarded the change in practice as acceptable. Three main themes emerged: 1. Training, environmental challenges and adequate equipment; 2. increased efficiency and improved patient care and 3. Prerequisites to implementing a new practice. Integration of Quantitative and Qualitative data resulted in 10 key influencers of behavior that need to be addressed in any future implementation.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The introduction of pre-hospital phlebotomy reduced the time to blood results availability by 38% and resulted in fewer labelling errors. Wider implementation is supported by paramedics, but more training is required.

Inappropriate use of laboratory tests: How availability triggers demand - Examples across Europe

INTRODUCTION

The appropriate use of laboratory diagnostics is increasingly at stake. The aim of this study was to depict some paradigmatic examples of under- and overutilization, as well as possible solutions across Europe.

METHODS

We collected six examples from five European countries where a rise or decline of orders for specific laboratory parameters was observed after organizational changes but without evidence of changes in patient collective characteristics as source of this variation.

RESULTS

The collected examples were the following: 1-Germany) Switch from a Brain-Natriuretic-Peptide assay to NT-pro Brain-Natriuretic-Peptide assay, resulting in a 374% increase in these analytics; 2-Spain) Implementation of a gatekeeping strategy in tumor marker diagnostics, resulting in a 15-61% reduction of these diagnostics; 3-Croatia) Stepwise elimination of creatine-kinase-MB assay from the laboratory portfolio; 4-UK) Removal of γ-glutamyl transferase from a "liver function" profile, resulting in 82% reduction of orders; 5-Austria) Implementation of a new device for rapid Influenza-RNA detection, resulting in a 450% increase of Influenza testing; 6-Spain) Insourcing of 1,25-(OH)₂-Vitamin D measurements, leading to a 378% increase of these analyses.

CONCLUSION

The six paradigmatic examples described in this manuscript show that availability of laboratory resources may considerably catalyze the demand, thus underscoring that inappropriate use of laboratory resources may be commonplace in routine laboratories all across Europe and most probably beyond. They also demonstrate that the application of simple strategies may assist in overcoming this issue. We believe that laboratory specialists need to refocus on the extra-analytical parts of the testing process and engage more in interdisciplinary patient-care.