OPTIMIZING LABORATORY WORKFLOW AND PERFORMANCE

Understanding the Workflow

PREEXAMINATION PHASE

 The patient
 Test selection
 Sample collection
 Sample transport

LABORATORY EXAMINATION PHASE

 Report creation

POSTEXAMINATION PHASE

 Report transport
 Result interpretation

Preanalytic - refers to all the activities that take place before testing.

Analytic-consists of the laboratory activities that actually produce a result.

Postanalytic- comprises patient reporting and result interpretation.

Laboratory
Handbook
Policies & Practices
 Information needed
 Collection preservation
 Labeling
 Assessing, processes, tracking
 Retention, storage and disposal
 Transport

Laboratory testing process

The diagnostic testing process can be separated

Three phases:

1. Preanalytic phase
2. Analytic phase
3. Post analytic phase
 Variables that may affect proper interpretation of test results are present in each phase.
 Test results changes due to clinical factors must be interpreted in consideration of these variables.
PREANALYTIC PHASE

 Laboratory request
 Patient identification
 Specimen collection
 Proper transport

ANALYTIC PHASE

 Sample is prepared for analysis

 Sample is analyzed
 Result is verified

POSTNALYTIC PHASE

 Result is reported
 Test result interpreted in context of clinical scenario
 Action taken
 Patient care is affected

TECHNIQUES TO COLLECT WORKFLOW DATA

1. SAMPLE AND TEST MAPPING

 depending on what is mapped, the time interval can be a day (e.g., hour increments for
frequently ordered tests like those in general chemistry) or a week (e.g., daily increments
for tests batched several times a week)
 The goal is to identify overall workload patterns to assess whether resources are
appropriately matched to needs and whether turnaround time or other performance
indicators can be improved.
2. TEST ANALYSIS
 “Tube labor” includes sorting and centrifuging; aliquoting; racking, unracking, loading,
and unloading samples on analyzers; retrieving tubes for add-on tests; performing manual
dilutions or reruns (depending on instrument); and storing tubes.
 Automation can often reduce this labor, but redesigning the workflow may be a less
expensive and more efficient alternative. To the extent that a laboratory reduces the
number of tubes and/or the number of tasks associated with each tube, it can reduce
tube labor and positively influence workflow and staffing needs
 Tube analysis includes the number of containers other than tubes (e.g., fingerstick
collections that may require special processing or aliquoting) and the number of reruns
(i.e., repeats) needed as the result of instrument flags and/or laboratory policies

GOALS OF WORKSTATION ANALYSIS

1. Instrument audit
 Equipment is the key of any workstation.
 Maximum number of samples that can be processed per hour
  Number of samples that can be loaded at a single time
 Number of reagent containers and assays that can be stored on board.
 Instrument throughput (cost/tests/hour)
 Statistical reports that can be extracted from the instrument and the LIS.
2. Test menu
Examination Test :
 Send out test- to send specimen sample to a reference laboratory where it is performed
more frequently.
3. Processing mode and loading balancing
 A batch analyzer cannot be interrupted during operation; thus a newly arrived sample
cannot be processed immediately if the instrument is already in use.
Batch Sample – fixed number of samples with scheduled day and time of test run.
Random Access Sample-can accommodate an emergency sample at any time.
Continuous sample processing is facilitated by load balancing, a technique that distributes work
evenly among analyzers and spreads testing over a longer period to better match instrument,
throughput.
4. Test ordering patterns and interviews
 This exercise provides an opportunity for staff to participate in analyzing workflow and
improving performance. It also identifies issues that would not be readily apparent from
data collection alone.
 orders for “add-on” tests that are called into the laboratory (or added electronically),
processing special requests, and troubleshooting incorrect orders, unacceptable samples,
or misaligned bar code labels applied by non laboratory staff during sample collection.
 Thus “computer-generated orders” may still be associated with considerable manual
laboratory labor that may be identified only through interviews.
 Interviews are particularly valuable in understanding what occurs outside the laboratory.
Test ordering patterns or habits can have a significant impact on a laboratory’s ability to
meet clinician needs. Visits to
 Interviews are particularly valuable in understanding what occurs outside the laboratory.
Test ordering patterns or habits can have a significant impact on a laboratory’s ability to
meet clinician needs.
5. Test mapping
 A rigorous review will detail every specimen-handling step, each decision point, and
redundant activities. Task mapping can be applied to any segment of a laboratory’s
workflow, whether technical or clerical.
 Task mapping should be an ongoing activity and should also be undertaken whenever one
contemplates adding a workstation, test, new technology, or any significant change to a
laboratory process. When implementing change, it is important to avoid unnecessary or
additional steps that are inadvertently added in the name of “efficiency”; task mapping
helps identify these steps.

Pneumatic Tube system

 large hospital facilities, use pneumatic tube systems for specimen transport to the laboratory.
They can greatly decrease transport time and thus total turnaround time for test results.
  Usually the plant operations or engineering department of the hospital maintains the system on
a daily basis. In addition, enough specimen carriers must be available to supply all areas of the
hospital in need of specimen transport to the laboratory.

Optimizing performance refers to the process by which workflow (including laboratory design) and
technology are integrated to yield an operation that best meets the clinical needs and financial goals of
the organization: high quality at low cost.

Optimizing performance is an ongoing process that requires one to constantly assess and reassess
workflow and needs. This requires periodic data collection and analysis. Table 2-3 provides examples of
workflow metrics that are useful to monitor.

Optimizing performance is an ongoing process that requires one to constantly assess and reassess
workflow and needs. This requires periodic

data collection and analysis.

PRE-ANALYSIS

PRE-ANALYTIC PHASE

 Occurs first in the laboratory process

 Refers to all the complex steps that must take place before a sample can be analyzed

 Major source of residual error

 32-75% of all testing errors occur in the pre-anaytical phase

 Steps starting in chronological order

 Clinician’s request

 Examination requisition

 Preparation of the patient

 Collection of the primary sample

 Transportation to and within the laboratory

PRE-ANALYTICAL FACTORS

 Patient-related variables

 Diet, age, sex

 Specimen collection and Labelling techniques

 Specimen preservatives and anticoagulants

 Specimen transport
  Specimen processing and storage

Potential sources of error or failure in pre-analytical process include the following:

1) Improperly ordered tests

2) Sample misidentification

3) Improper timing

4) Improper fasting

5) Improper anticoagulation/blood ratio

6) Improper mixing

7) Incorrect order of draw

8) Hemolyzed or lipemic specimens

The most frequent pre-analytic errors include improperly filling the sample tube, placing specimens in the
wrong containers or preservatives and selecting the incorrect test.

10 common errors in specimen collection:

1. Misidentification of patient

2. Mislabeling of specimen

3. Short draws/wrong anticoagulant:blood ratio

4. Mixing problems/clots

5. Wrong tubes/wrong anticoagulant

6. Hemolysis/lipemia

7. Hemoconcentration

8. Exposure to light/extreme temperatures

9. Improperly timed specimens/delayed delivery

10. Processing errors

Processing errors such as incomplete centrifugation, incorrect log-in, improper storage

Lipemia presence of blood of an abnormality high concentration of emulsified fat.

HEMOLZED INCREASE RBC NO SERUM

PHYSIOLOGIC FACTORS:

DIET

 Greatly affect laboratory results

 Effect is transient

 Glucose, triglycerides, cholesterol and electrolytes should be analysed in the basal state.

 Basal State – state of the body early in the morning, approx. 12 hours after the last meal

 DEPENDING OF DIET REQUEST, LOW, HIGH OR VEGETARIAN, DEPENDING OF HOURS LIKE 2, 12 OR

24 HOURS.

STRESS

Type of Stress Effect

Mental and Physical Stress Increase ACTH

Increase Cortisol

Increase Catecholamine

Mild Stress Increase Total cholesterol

Decrease HDL cholesterol

Hyperventilation Leukocytosis

Lactic acidosis

Increase free fatty acids

Hdl HIGH DENSITY LIPOPROTEIN ALSO KNOW OF GOOD CHOLESTEROL

LEUKOCYTOSIS INCREASE Of WBC IN BLOOD FOR INFECTIONS

LACTIC ACIDOSIS – OVERPRODUCES OF LACTIC ACID THAT CANNOT ADJUST CHANGES. (HINDI
NORMALIZE DUMADAMI) DAMAGE OF LIVER OT SOMETIMES IN THE KIDNEY

USES MAIN PRODUCED MUSCLE CELLS AND RED BLOOD CELLS. OR FERMENTATION OF MUSCLE PRODUCS
OF WASTE PRODUCT CALLLED LACTIC ACID

LACTIC ACID MUSCLE CELL CONTRIBUTES TO THE FATIGUE WHEN WE FEEL LONG RUN OR PUSH UPS
POSTURE

 Elements that are affected by postural changes are:

1. Albumin

2. Total Protein

3. Enzymes

4. Calcium

5. Bilirubin

6. Cholesterol

7. Triglycerides

8. Drugs bound to protein

TORNIQUET APPLICATION

Prolonged application increases:

1. serum enzymes

2. proteins

3. protein-bound substances

- cholesterol

- calcium

- triglycerides

ONLY ONE MINUTES PROLONGED – INCREASE PRESSURE

AGE

AGE EFFECT HORM/ENZ

Increase  Bilirubin concentration

Newborn

Decrease  Uric Acid level

Newborn - male

Decrease  Glucose level

  Serum alkaline phosphatase
Infants Increase  Creatinine levels

Bilirubin concentration up to 5 days

Uric acid level decrease in newborn male but increases until they reach age 20

Lower glucose level in infants due to low glycogen reserve

AGE EFFECT HORM/ENZ

Men (aged 20s) At its peak  Uric Acid Level

 Triiodothyronin

 Parathyroid hor
Elderly Decrease  Aldosterone

 Cortisol

Elderly - men Decrease • Testosterone

Elderly - women Increase  Pituitary gonad

 Follicle-stimulat

GENDER

Male Female

Higher: Lower:

Alkaline phosphatase Magnesium

Aminotransferases Calcium

Creatinine kinase Albumin

Aldolase Hemoglobin

Serum Iron

Ferritin
SPECIMEN COLLECTION

TEST ORDER

 Selecting the wrong laboratory test or panel of tests leads to inappropriate interpretation of
results.

 Official laboratory request.

 Patient demographics:

 Name

 Age

 Sex

 Date of birth

 Date of admission (for in-patients)

 Date of test order

 Location

 Physician

 All specimens must be clearly labelled.

 Add-on tests

 Additional test requested on a previously collected sample

 Potential problems

 Specimen is not the proper type for the add-on requested test

 Residual volume is not sufficient

 Storage conditions deteriorate analyte

 Policy on patient refusal

 Policy whenever patient is unavailable

 Policy to deal with combative patient

 Emergency measures for patients who become ill or fainted during phlebotomy

 Health Insurance Portability and Accountability Act (HIPAA)

 ensures the security and privacy of health data

 protects the confidentiality of all patient record information, including all laboratory data.
Time of Collection

• Samples have to be collected at a specific time.

• Failure to follow the planned time schedule can lead to erroneous results and
misinterpretation of a patient’s condition.

• STAT

• “Statim” or “Short Turn Around Time”

• STAT specimens are collected and analysed immediately

• Given the highest priority

• Usually from the Emergency Department and Critical Care Units

STAT TESTS:

Clinical Chemistry Acetaminophen (Tylenol/Paracetamol) Glucose CSF

Albumin Iron

Ammonia (on ice) Lactate (on ice)

Arterial blood gases Lipase

Aspirin (ASA) Lithium

B-type natriuretic peptide (BNP) Magnesium

β-hydroxybutyrate Metabolic panel (b

Bilirubin Methanol

Blood Urea Nitrogen (BUN) Osmolality (serum

Blood Uric Acid (BUA) Phenobarbital

Calcium (total and ionized) Phenytoin

Carbamazepine Phosporus

Cortisol Protein (CSF and se

Creatinine Theophylline

Digoxin Tobramycin

Electrolytes Troponin

Ethanol Valproic Acid

Ethylene glycol Vancomycin

Gentamicin

Glucose (fasting or random)

Microbiology Hematology Blood Bank

Acid Fast Stain – Direct on Acute Stroke Coagulation Panel Antibody screen
Sputum (except samples
Complete Blood Count Blood typing
from ET tubes)
Fibrinogen Crossmatch
Cryptococcal Antigen (CSF
only) PT Direct Antiglobulin
Malaria smear aPTT
Strep Group A Antigen
(Throat Swab)

SPECIMEN ACCEPTABILITY & IDENTIFICATION ISSUES

• All specimens must be collected, labeled, transported, and processed according to

established procedures

• Failure to follow specific procedures can result in specimen rejection

• Specimen rejection is costly and time-consuming.

• Reasons for rejection

• Inappropriate specimen type

• Wrong preservative

• Hemolysis

• Lipemia

• Clots
 • Misidentification of patients

• Life-threatening medical error

• Joint Commission 2015 Laboratory National Patient Safety Goals

• First goal: Identify patients correctly

BLOOD COLLECTION

Cephalic Vein: the next preferred site.

Basilic Vein: Least preferred venipuncture site because the artery vein and some major nerves system are
near.

PHLEBOTOMY

• Syringe and needles

• One of the oldest methods use for extracting blood from the patient.

• Either made of plastic or glass

WINGED INFUSION/BUTTERFLY

• Used when the patient has a small/thin vein

• Much less painful for patients

EVACUATED TUBE

• Used for extracting multiple blood samples

• Used when blood must be transferred faster before clog formation begins

TORNIQUET

• Used to constrict the flow of the blood in the arm of a patient

• Helps the vein to be more prominent.

BLOOD COLLECTION TUBES

Ethylene Diamine Tetraacetic Acid (EDTA)

• Lavender tubes

• Prevents coagulation

• For cell counts, coagulation test and cell morphology

• CBC, CROSSMATHING.. FOR HEMATOLOGY USED

• ADDITIVES TUBES
Sodium Fluoride /Potassium Oxalate

• Gray-Stoppered tubes

• Stops coagulation cascade

• Glycolytic inhibitor

• Preserves glucose blood samples

• USED FIR TEST LACTIC ACID TESTING AND OTHER PLASMA OR WHOLE BLOOD DETERMINATION

• ADDITIVES TUBES

Sodium Citrate

• Light blue -stoppered tubes

• Prevents coagulation

• Binds calcium

• For coagulation studies

• USED FOR COAGULATION TESTING – MAEASURE OUT BLOOD ABILITY TO CLOTH AND HOW LONG
IT TAKES TO CLOT.. BLEEDING DISORDER. (PT, APTT TEST)

Heparin

• Green tubes

• pH determination

• electrolyte studies

• arterial blood gases.

• Has three forms:

 lithium, sodium, and ammonium

• Not acceptable if the blood sample may be stored for more than 48 hours

• ADDITIVES

• ALSO CALLED WARFARIN

• USE OF BLOOD GAS ANALYSIS, ABG

Trace Elements Tubes

• Royal blue-stoppered tube

• Used for element studies

• Lead
 • Zinc

• Arsenic

• Copper

• TUBES WITH STERILIZE

• NO PRESERVATIVE WITH CLOT ACTIVATOR

• WHOLE BLOOD OR SERUM FOR TRACE ELEMENTS

RED BLOOD ACTIVATOR BUT NO ANTICOAGULANTS, PRESERVATION \. USED FOR CHEMISTRY, SEROLOGY
& IMMUNOLOGY… BECAUSE OF SERUM

GOLD CLOT ACTIVATOR AND SERUM GEL, USED FOR CHEMISTRY, SEROLOGY & IMMUNOLOGY

LIGHT GREEN CONTAINS LITHIUM AND GEL SEPARATOR USED FO HEPARINIZED PLASMA FOR CHEMISTRY
TEST

BLOOD COLLECTION TECHNIQUES

VENIPUNCTURE

 collection of blood from a vein which is usually done for laboratory testing.

 The blood is normally drawn from a vein on the top of the hand or from the inside of the
elbow.

 Patient must be in a seated or reclined position

 Median cubital vein (primary site)

 15-30 degrees

 0.5cm below the vein

 Bevel up

 Tourniquet must never be left longer than 1 minute. Should be placed 3 to 4 inches above
the proposed site.

ARTERIAL PUNCTURE

• Not for beginning phlebotomist

• Used to obtain a sample for blood gas analysis

• Best done during steady state

• Allen Test

• The amount of anticoagulant should be 0.05 mL liquid heparin (1000 IU/mL) for each
milliliter of blood.
  Arterial sites:

 Catheterized umbilical arteries (newborn infant during first 24 to 48 hrs of life)

 Radial artery (preferred site)

FINGER OR HEEL SKIN PUNCTURE

 Simple method

 For pediatric patients

 In neonate, skin puncture of the heel is preferred site

 In older children, finger is preferred site

URINE AND OTHER BODY FLUIDS

• 3 laboratory tests

• Chemical

• Bacteriologic

• Microscopic

TYPE OF SPECIMEN PURPOSE

Random Routine screening

First morning Routine screening

Pregnancy tests

Orthostatic protein

Fasting Diabetic screening/ monitoring

 24-hour (or timed) Quantitative chemical tests

Catheterized Bacterial culture

Midstream clean-catch Routine screening

Bacterial culture

Suprapubic Bladder urine for bacterial culture

Cytology

Types of urine specimen collection

• Random: are collected by patients while at the laboratory and are used primarily for routine
urinalysis’

• First morning: is the specimen of choice for urinalysis because it is more concentrated

• Midstream clean catch: Proper collection of a clean catch specimen requires that the patient
first clean the external genitalia with an antiseptic wipe; the patient next begins urination, stops
midstream, and discards this first portion of urine, then collects the remaining urine in a sterile
container.

• Timed: -are obtained at designated intervals, starting from “time zero.”

• Catheterized: This sample is collected under sterile conditions by passing a sterile hollow tube
through the urethra into the bladder

• Suprapubic aspirate: is collected by external introduction of a needle through the abdomen into
the bladder.

• Cerebrospinal Fluid

• surrounds the brain and spinal cord to supply nutrients to the nervous tissue, remove
metabolic wastes, and produce a barrier to cushion the brain and spinal cord against
trauma.

• It is routinely collected by lumbar puncture between the third, fourth, or fifth lumbar
vertebrae.
 • FOR PEOPLE HAS MENINGITIS, OR OTHER CNS DISEASES

• Samples are collected by needle aspiration and collected into tubes based on the required
tests:

• sterile heparinized tube for Gram stain and culture and sensitivity

• heparin or EDTA tube for cell counts and crystal identification

• sodium fluoride tube for glucose analysis

• non-anticoagulated tubes for other tests

SPECIMEN TRANSPORT

 For blood specimen

Excessive agitation should be avoided to prevent hemolysis of blood

 Exposure to light

Light can be detrimental to some samples like bilirubin.

 Chilling of samples

Samples should be kept at 4C immediately after collection

E.g. Ammonia, plasma renin activity, ACP, ABG, lactic acid, catecholamines