Innovation, Automation and Informatics Improves Quality in Lerdsin Hospital, Thailand

This paper describes a planned, continuous improvement journey, of a laboratory that has installed a system with a single sample touch from blood draw to result. To achieve this, physical connectivity of systems from phlebotomy through pre-analytical to the analytical phase were paired with informatics connectivity from the patient's national identity card to the hospital and laboratory informatics management systems (LIMS) and associated middleware. This allowed accurate time stamps to track turnaround time (TAT). TAT metrics were collected from the LIMS for inpatient, emergency room and outpatient samples and tests over a period of 7 months. This time span incorporated the 2-month period before automation was implemented. The results for all tests and specific tests are shown and the results of an analysis of the outpatient phlebotomy workflow are given. The implemented solution has improved outpatient TAT by over 54% and has shown that samples can be collected, and results obtained without touching the sample. Improving intra-laboratory TAT is an important quality goal for all laboratories. The implementation of automation is important in achieving this albeit more about obtaining predictable TAT. Automation does not necessarily improve TAT it removes variation which leads to predictable TAT (PTAT). Automation should only be considered with a strategic vision for the future as it is important to have clear goals and objectives based on the individual laboratories process and needs. Automating a poor process leads to an automated poor process. Here, an innovative use of automation, hardware and software has resulted in marked improvement in TAT across all samples processed in the central laboratory.

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BACKGROUND

Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.

METHODS

FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.

DISCUSSION

The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.

TRIAL REGISTRATION

ISRCTN63268739 . Registered on 14 September 2017.

Reducing the Environmental Impact of Clinical Laboratories

Healthcare is a significant contributor to environmental impact but this has received little attention. The typical laboratory uses far more energy and water per unit area than the typical office building. There is a need to sensitise laboratories to the importance of adopting good environmental practices. Since this comes at an initial cost, it is vital to obtain senior management support. Convincing management of the various tangible and intangible benefits that can accrue in the long run should help achieve this support. Many good environmental practices do not have a cost but will require a change in the culture and mind-set of the organisation. Continuing education and training are important keys to successful implementation of good practices. There is a need to undertake a rigorous cost-benefit analysis of every change that is introduced in going green. The adoption of good practices can eventually lead to ISO certification if this is desired. This paper provides suggestions that will allow a laboratory to start going green. It will allow the industry to enhance its corporate citizenship whilst improving its competitive advantage for long-term.

Comparison of the ADVIA Centaur and Abbott AxSYM immunoassay systems for a routine diagnostic virology laboratory

BACKGROUND

Routine diagnostic laboratories are confronted with an ever-increasing workload with limited resources. Automation has provided some solutions to these challenges particularly high through put analysers such as the Abbott AxSYM.

OBJECTIVE

The aim of the present study was to compare the performance of two automated immunoassay systems in a diagnostic virology laboratory. Samples previously tested using the Abbott AxSYM were tested with a recently introduced immunoassay analyser, the Bayer ADVIA Centaur, for six virology analytes: HBsAg, anti-HBc total, anti-HBc IgM, anti-HBs, anti-HCV and anti-HIV1/O/2.

STUDY DESIGN

This study was a retrospective analysis of stored serum samples previously tested on the Abbott AxSYM. Samples giving discrepant results were tested by other alternative immunoassays and re-tested on the Abbott AxSYM in the same freeze-thaw cycle.

RESULTS

Although the sensitivities of the two automated immunoassays were similar there was improved specificity demonstrated for anti-HIV and anti-HCV when using the ADVIA Centaur assays. The low background signals allowed resolution of samples previously shown to have indeterminate results for anti-HIV antibody in the AxSYM assay. In addition, samples shown to have Abbott AxSYM anti-HCV results that could not be confirmed by RIBA and HCV molecular methods were shown to be negative by the ADVIA Centaur assay.

Antibodies in crevicular fluid: an epidemiological tool for investigation of waterborne disease

A significant challenge in the epidemiological investigation of recreational waterborne disease is the establishment of a definite association between exposure to a contaminated water and infection. An increase in specific antibodies as a result of infection is a potent measure of disease exposure and its determination would enhance epidemiological studies of waterborne diseases. We report on the automated detection of HAV antibodies in crevicular fluid and its use in a field study. The method is easy to use, non-invasive, could be applied to volunteers of all ages and is comparable in sensitivity to serological procedures. Application to an epidemiological study of water recreationalists demonstrated that surfers were three times more likely to be immune to hepatitis A virus than either wind-surfers or a control group without recreational water contact.