Download Use of the IANC (Instrument Absolute Neutrophil Count) to Improve

Use of the IANC
(Instrument Absolute Neutrophil Count)
to Improve Turn Around Time
Background on UCSD Health System
• 2 hospital campuses with Rapid Response Laboratories in
each. Perform all inpatient testing.
• 1 Core lab where outpatients, special chem, special heme,
special coag, microbiology, HLA, genetics, flow cytometry,
cytogenetics, and toxicology testing is performed.
• Moore’s Cancer Center located on one hospital campus.
• Moore’s Cancer Center (MCC) had a small laboratory with 3.5 CLS FTEs
where STAT hematology and chemistry tests were performed.
• Lab was located across hall from Infusion Center.
• Lab was closed in August, 2012 for budgetary reasons.
• STAT testing (100 patients/day) was moved to hospital lab located 10
minutes away (by foot).
In September 2012, the Infusion Center approached the Lab asking for
help in improving their patient satisfaction survey.
Patients were not satisfied with the long waiting time before they received
their infusion.
One of the causes of long waiting time for infusion is the TAT for ANC
(Absolute Neutrophil Count). In most cases, the release of ANC is
tied to the completion of manual differential.
Pharmacy will not release medications until an ANC value is available
in the HIS.
Formulation of PDSA Project
Intend to reduce the time to post the ANC from 60 minutes 70% of
the time to within 60 minutes 90% of the time, from time the
samples are collected for Oncology patients at the Infusion Center by
December 2013 thus reducing the patient wait time for
chemotherapy and infusion of oncology patients.
Data Gathering
Based on September 2012 data from the LIS:
-ANC testing measured as part of CBC with diff is completed within
60 minutes 70% of the time from collection to posting of result.
-The mean TAT is 75 minutes.
Causes of Delay
• Transport time from MCC to Thornton Hospital lab was about 10 minutes via
walking courier.
• Each MCC patient had duplicate slides made by Sysmex sp1000i slide
maker/stainer.
•
Thornton only had one license to operate the automated slide reader
(Cellavision) so only one tech at a time could perform diffs.
Steps Taken to Improve TAT for ANC
1. Three couriers were hired to move samples from MCC to
Thornton
- The couriers were timed to determine how long it takes to
walk from MCC to Thornton to deliver samples and back (12.5
minutes).
- Based on the study, a walking schedule was developed by MCC
for the couriers.
Steps Taken to Improve TAT for ANC
2. Clinicians were asked to give up the requirement for duplicate
slides for their use. Clinicians agreed with the following
conditions:
- Provide Cellavision access at MCC for Clinicians to remotely
view slides.
- Retain the option to request the slide
- Develop an orderable test for them to request slide review
regardless of CBC results
Steps Taken to Improve TAT for ANC
3. Thornton purchased a second CellaVision license to
operate/edit automated differential results.
4. Hematology autoverification was instituted in December, 2012.
Monitoring of Improvements
Sep12
Mean:
75
<60 mins 70.3
Oct12
Nov12 Dec12
Jan13
57
70.4
62
69.5
55
71
60
71.5
Monitoring of Improvement
Mean ANC TAT
75
72
70
60
57
62
60
55
71
71
50
40
30
71.5
71.5
Mean
Percent
Time in Minutes
80
ANC TAT % <60 minutes
70.5
70
20
69.5
10
69
0
68.5
70.3 70.4
69.5
< 60 minutes
Monitoring of Improvements
Based on the initial results thru January 2013, it was apparent that
there was more room to improve on the TAT of ANC.
Request for Additional Improvements
Our Medical Director asked Sysmex if the instrument generated
ANC (IANC) could be released together with the Hemogram?
The answer was “Yes” but would take some modifications in WAM
by Sysmex.
Steps taken to Release IANC with Hemogram
1. A change request was submitted to Sysmex to allow the IANC to
be posted together with the hemogram for MCC location only.
The request took a little over a month to complete since it
required a change in WAM software.
Steps taken to Release IANC with Hemogram
2. A separate request was submitted to HIS and LIS to add IANC to
the CBC results.
3. Once all the changes were made, testing of the release of IANC
with hemogram was conducted. Sysmex supplied a Test Plan.
Implementation of IANC
On July 30, 2013, the release of IANC with the
hemogram was implemented.
Results of Implementation
Based on the September Data :
82% of IANC are posted within 60 minutes of
collection with a mean TAT of 46 minutes.
September 2012 data shows 70% and 75
minutes respectively.
Results of Implementation
Based on the September Data :
98% of IANC are posted within 60 minutes of
receipt with a mean TAT of 17 minutes!
The September 2012 data shows 82% and 54
minutes respectively.
Challenges of Implementation
1. Numerous WAM rules needed to be revised
to hold the IANC under various conditions
involving lots of rules testing.
Challenges of Implementation
2. Medical Director of HIS decided to include IANC for
patients in ALL locations. Original test plan had to
be revised and retested.
Challenges of Implementation
3. Hematology Medical Director noted that
the difference between the ANC and the
IANC was sometimes more than 10%,
mostly with lowest WBCs. On 9/17/13,
started reporting IANC only on
patients at MCC location.
Challenges of Implementation
4. Are still determining whether to post the
flagged IANCs before reviewing the smear.
Customer Satisfaction
The nurse manager at MCC stated that they are using the
IANC to determine whether infusion will occur. She felt
that the TAT had improved but didn’t have any statistical
basis to support it. If the IANC is close to the infusion
cutoff of 1.5, they will wait for the ANC.
Sometimes the CBC is completed but they still need to
wait for the chemistries to complete.