Simplifying the Ordering Process on Tests for Non Serum Body Fluids

Transcription

1 Simplifying the Ordering Process on Tests for Non Serum Body Fluids Bhavesh B. Shah, MD; Mamta Singh, MD, MS; Ethel Smith, MD Case Western Reserve University MetroHealth Medical Center, Cleveland, Ohio, USA Key Contact Person Background: Ordering labs on non-serum body fluids (ascitic, pleural, cerebrospinal, synovial) is important as the diagnostic information obtained has significant consequences on patient care. This task is complex and involves multiple steps. There are multiple contraindications for procedures, several special tests that need to be ordered; some require special preparation. Repeating a procedure due to inaccurate orders can lead to both patient and provider frustration. Additionally, the process involves laboratory personnel, thus inaccurate orders may create waste and stress an already overburdened system. Purpose: The purpose of this study was to assess whether an educational intervention about and the distribution of a Non-Serum Body Fluids Card simplified the ordering process in an Internal Medicine Residency Program at a large urban academic institution. Methods: The Internal Medicine Residency program at this 800 bed county hospital has 100 residents. A convenience sample of 45 of these residents was surveyed during a conference. They were questioned regarding each procedure (paracentesis, thoracentesis, lumbar puncture, arthrocentesis), and each fluid type (ascitic, pleural, cerebrospinal, synovial). Questions asked were about contraindications to procedures, ordering the correct routine laboratory values, their confidence in laboratory selection and specimen

2 preparation, and any problems/difficulties encountered throughout the process. A card to simplify the ordering process on tests for all of these fluids was designed, laminated, and distributed (the Non Serum Body Fluids card) to all of the residents. An extensive literature review was completed on each of the four fluid types and their respective procedures in order to compile the information included on this card. Several subspecialists who are considered experts in their field were questioned regarding its content, and their opinions were incorporated into the design. Laboratory personnel were also extensively involved in the content and design. This was followed by a detailed teaching session to familiarize and educate the residents on the use of this card. Two months following, the residents were surveyed again, this time in regards to whether they had referred to the card, if it improved their confidence level when preparing specimens, and if it simplified the ordering process on labs for these non serum fluids. Results: Regarding the initial survey (n=45), results are as follows. For paracentesis/ascitic fluid, 1% of residents identified all of the correct routine laboratory tests, 76% of residents felt confident in what they had ordered was correct, and 21% identified the correct contra-indications to performing a paracentesis. For thoracentesis/pleural fluid, 1% of residents identified all of the correct routine laboratory tests, 71% of residents felt confident in what they had ordered was correct, and 28% identified all of the correct contra-indications to performing a thoracentesis. For lumbar puncture/cerebrospinal fluid, 1% of residents identified all of the correct routine laboratory tests, 76% of residents felt confident in what they had ordered was correct, and 1% identified all of the correct contra-indications to performing a lumbar puncture. For arthrocentesis/synovial fluid, 1% of residents identified all of the correct routine

3 laboratory tests, 60% felt confident in what they had ordered was correct, 1% identified all of the correct contra-indications to performing a lumbar puncture. Regarding the postintervention survey, results are as follows. 83% of residents had referred to the Non Serum Body Fluids card. 96% of residents were confident in what they had ordered when referring to the card. 92% of residents believed that using the Non Serum Body Fluids card had simplified the ordering process on tests for non serum body fluids. Pre-Intervention Survey Results Table 1 Confident in Orders Correct Routine Laboratories Paracentesis/Ascites 76% 1% 21% Thoracentesis/Pleural 71% 1% 28% LP/Cerebrospinal 76% 1% 1% Arthrocentesis/Synovial 60% 1% 1% Post-Intervention Survey Results Table 2 Referred to Non Serum Body Fluids Card 83% Confident in Orders 96% The Card did Simplify the Process of 92% Ordering Correct Contraindications Conclusions And Implications: Initial survey results revealed that there was an exaggerated confidence regarding ordering of tests on these fluids. There was also a poor knowledge of identifying contraindications for procedures. The above results show the Non Serum Body Fluids card simplifies the ordering process on these tests, and improves the confidence in ordering these tests. Demonstrated also, is how professional knowledge and a multi-disciplinary approach assists clinical practice. To instill this card nationwide at all internal medicine residency programs may mean more accurate ordering of tests, less error, more confidence, and improved patient care. Further study needs to be done to

4 assess whether testing accuracy improved after implementation of the card, if resident knowledge was improved, whether patient care actually improved, or that this intervention significantly changed practice; keeping in mind that the purpose of this card was to simplify the ordering process and make certain information available, not to specifically educate residents regarding the fluid types.

5 Non Serum Body Fluids Ascitic Fluid Paracentesis Contraindications: DIC/Fibrinolysis Tubes: Purple, Red, Urine, Yellow, BACTEC Tube Color Dept/Req Ascitic Fluid Cell Count with Differential (STAT) Purple/1cc HEME Ascitic Fluid Albumin Red/1cc CHEM Ascitic Fluid Gram Stain Urine/2cc MICRO Serum Albumin Yellow/1cc CHEM Bacterial Cultures (Aero/Ana) BACTEC/10cc MICRO Change needle after withdrawing fluid Inoculate BACTEC bedside with 10cc of fluid each PMNs >250/mm 3 is consistent with SBP, SAAG >1.1g/dl is consistent with Portal Hypertension Corrected PMNs if RBCs >250/mm 3 = {Abs. PMNs [(RBC/mm 3 )/250]}?TB 3AFB Smear & Culture/Urine/5cc/MICRO If fluid is milky 3Triglyceride level, if fluid is brown 3Bilirubin level 3Cytology if?carcinomatosis,?chylous ascites/lymphoma,?liver mets,?hepatocellular carncinoma Pleural Fluid Thoracentesis Relative Contraindications: Plts < 25, Cr > 6mg/dl, PT or PTT > 2x normal Tubes: Red, ABG, Yellow, Purple, Urine x 2 Tube Color Dept/Req Pleural Fluid Amylase Red 4cc CHEM Pleural Fluid Protein Red CHEM Pleural Fluid LDH Red CHEM Pleural Fluid Glucose Red CHEM Pleural Fluid ph (on ice) ABG/3cc CHEM Serum Total Protein Yellow 2cc CHEM Serum LDH Yellow CHEM Cell Count with Differential Purple/1cc HEME Fluid Gram Stain & Culture Urine#1/3cc MICRO Pleural Fluid Cytology Urine#2/3cc CYTO Exudative if: (1of 3) Fluid Protein/Serum Protein >0.5 Fluid LDH/Serum LDH >0.6 Light Criteria Fluid LDH >66% Normal Value?TB Pleural Fluid ADA/Red/CHEM & Pleural Fluid AFB Smear & Culture/Urine#3/5cc/MICRO Post procedure imaging if patient symptomatic

6 Non Serum Body Fluids Cerebrospinal Fluid Lumbar Puncture Contraindications: Platelets <50, ICP Tubes: CSF Tubes x 4, BACTEC x 2 Tube Dept/Req CSF Protein Tube #2 3cc CHEM CSF Glucose Tube #2 CHEM CSF Cell Count Tube #4/2cc HEME CSF Gram Stain & Culture Tube #3/1cc MICRO Blood Culture (Aero/Ana) BACTEC x 2/10cc MICRO Tube #1 (3cc) for storage/special laboratories Gram Negative Meningitis - CSF Protein elevation CSF Glucose depression CSF Leucocytosis Gram Stain +ve in 50% with +ve Culture If Chronic/HIV related: VDRL & Crypto Ag/Tube #1/2cc/HSEROLOGYH, AFB & India Ink/Tube #3/2cc/MICRO Head CT if: Íin MS, focal exam, papilledema, trauma, seizures, mass, immunosuppression, hx of neoplasms HCT read by Radiology/NeuroRadiology/NeuroSurgeryH H Immunology requisitionh Synovial Fluid Arthrocentesis Contraindications: None Tubes: Purple, Red, Urine Tube Color Dept/Req Synovial Cell Count with Differential Purple/1cc HEME Synovial Fluid Protein Red 3cc CHEM Synovial Fluid Glucose Red CHEM (if indicated) Crystal Examination Red #2/1cc HEME Synovial Gram Stain & Culture Urine Container/3cc MICRO Non-inflammatory fluid: <2000 wbc/mm 3, <75% PMNs Hints: Label each tube of serum/fluid (patient stamp, draw time, date, signature, pager#, pin#) All Samples to Core Lab (Tube Station #430) Do not send samples of therapeutic quantity to lab Core Lab/Hematology/Chemistry x85101, Microbiology x85174, Cytology x85521, Serology x82277 Consider: (collection of spare fluid) and/or (ordering of special tests on fluids as indicated) Dept/Req: Color coded for Color of Lab Requisition Concept & Design by Bhavesh B. Shah, MD (February 2003)