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How the Clinical Laboratory
Enhances Patient Care
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Fred V. Plapp, MD PhD
Medical Director
Saint Luke’s Regional Laboratories
Diagnosis of Meningitis
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Expediting Patient Care
Infection of tissues
surrounding the brain
& spinal cord
 Bacterial or viral

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◦ Mostly viral
Viral usually mild
 Bacterial is lifethreatening

Diagnosis of Meningitis
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Traditional Practice
Patient presents to Emergency Room
 Lumbar puncture to collect CSF

◦ Bacterial cultures require 3 days
◦ Viral cultures require 10 days
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Patient admitted to hospital
 Treated with IV antibiotics until likely that
bacterial culture will be negative
 Discharged with outpatient antibiotics

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Viral Meningitis
Traditional Diagnosis
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4 – 10
Days
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Viral Meningitis
Real Time PCR Diagnosis
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1 million viral copies in 30 minutes
instead of 10 days
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New Meningitis Algorithm
RT PCR while patient is in ER
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Enterovirus
Detected
Enterovirus
Not Detected
Discharge
Admit to Hospital
Meningitis Outcomes
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Downstream Cost Savings

Traditional Approach
◦
◦
◦
◦
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
Average LOS is 2.8 days
Average hospital charge is $14,050
IV antibiotics during admission
Outpatient antibiotics for 10 – 14 days
SLH Molecular Approach
◦ Avoid admission if Enterovirus detected
◦ Avoid unnecessary antibiotics
Rapid ID of CoNS
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Improved Antibiotic Stewardship

Peptide Nucleic Acid FISH
◦ Non-amplified fluorescent molecular probe
 Recognizes species specific RNA
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◦ Distinguishes Coagulase Negative Staph from
Staph aureus
◦ Advantages
 Timely & accurate same day results
 Minimal equipment requirement
 Other probes for Gram-negatives & yeast
◦ Disadvantages
 Expensive cost per test
 Must batch test due to $$$$$
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Rapid ID of CoNS
Lab & Pharmacy Cost Savings
Culture
Alone
Culture +
PNA
Time to ID Antibiotic
Dose per
Patient
132 hours
5.8
38 hours
2.8
Cost per
Patient*
$72.02
$14.28
Cost per patient included antibiotics & laboratory tests
Rapid ID of CoNS
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Downstream Cost Savings
SLHS performed 23,652 blood cultures in
2009
 452 contaminants (1.9%)

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◦ 350 were CoNS
Each contaminant adds ~$5000 to cost of
hospital stay
 Rapid ID of CoNS saves ~$1.75M per
year by preventing  LOS

Recombinant rFVIIa Usage
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Laboratory as a Watchdog
Recombinant Factor VIIa (Novoseven)
 Binds directly to tissue factor & activates
FX
 FDA approved for hemophilia with
acquired inhibitor
 Off label use for acute bleeding 

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◦ Very expensive ( $1 per ug)
◦ Short half-life of 2-3 hours
◦ Possible thromboembolic events
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Reining in the Outlier
Surgeon
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1Q09
1Q10
1
$5450
$0
2
$0
$0
3
$0
$0
4
$0
$12,220
5
$98,690
$16,000
Open Heart Surgery
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Transfusion Review
OHS transfused ~one third of components
 Clinical Pathologist analyzed blood usage
each year

◦ Surgeon specific usage
◦ Reviewed with CTS team
◦ Evaluated risk factors, meds,practice variations
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Published transfusion guidelines & risks
 Presented to surgeons, Department Chair,
Chief Medical Officer

Average Number of Units
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Transfused per OHS Case
4.5
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Average # Units per Patient
4
3.5
RBC
FFP
Platelets
3
2.5
2
1.5
1
0.5
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
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Benefits of Decreased Transfusion
$260,000 cost savings in blood
products per year
 Transfusion reaction risks decreased
 Blood Bank workload decreased
 Nursing time for transfusion
decreased

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Order Sets
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Ensuring Appropriate Testing
Nurses & physicians write order sets
 Clinical Pathologists review lab tests

◦ Additions, deletions, substitutions
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Suggestions returned to authors
 Order sets published
 Test utilization monitored before & after

70 Order Sets
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Impact on Test Utilization
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Year
Cases/Yr
Tests/Cs
Test/Yr
1992
8823
50.3
443,797
1996
9630
44.3
426,609
Diff
807
-6
-17,188
% Diff
+9%
-12%
-4%
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Inpatient Tests per Discharge
60
50
40
30
20
10
0
75th per centi l e
25th per centi l e
1Q94 1Q95 1Q96 1Q97 1Q98 1Q99 2Q00 1Q01 1Q02 1Q03 1Q04
Specimen in Lab Policy
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Decreasing Wastage
Worked with Blood Management Team to
reduce iatrogenic blood loss
 SIL Policy implemented

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◦ Stored blood specimens for 1 week
◦ Publicized in Lab Letter & Nursing publications
◦ Avoided redrawing patients for add-on testing
Specimen in Lab Policy
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SLH Outcomes
11,244 requests for tests on SIL
 $51,726 savings in labor & supplies
 Avoided 11,244 venipunctures
 Conserved 71,428 mL of blood
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◦ Equivalent to 140 units of RBCs
POC Blood Glucose Testing
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Improving Patient Safety

Manual Patient ID entry
◦ 12,000 tests per month
◦ 9.7% average error rate
◦ ~450 unidentified results per month
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
PI project to reduce errors
◦ Accu-Chek Inform & RALS Plus
◦ Barcoded armbands & handheld devices
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Error Rate %
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Glucose Meter ID Errors
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Test Utilization Ideas
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