Value Added Impact of Both Point-of-Care and Laboratory Lactic Acid Analysis When Emergently Evaluating Cancer Patients.

INTRODUCTION: Cancer patients are immunosuppressed and may present to an emergency department with atypical symptoms. In the emergency setting, it is important ascertain rapidly if lactic acid levels are high, either due to sepsis or tumor lysis syndrome, to effectively manage symptoms. Therefore, it is critical to determine the blood lactic acid level to timely identify who is at risk of sepsis and provide early intervention. We have compared blood lactic acid concentrations (BLAC) in cancer patients obtained by point-of-care testing (POCT) and those measured by laboratory analysis in blood samples drawn within a short time of each other. METHODS: This was a retrospective study in cancer patients whose BLAC had been determined by POCT and laboratory analysis. Only those patients who had blood withdrawn for both testing methods within a 2-h timeframe were included in the study. Regressions were performed together with an analysis categorizing the BLAC from both testing methods. RESULTS: A total of 274 patients met the criteria for the study. The BLAC from POCT correlated well with the values from laboratory testing (R = 0.925). Categorization of BLAC showed that 88.32% of the patients had BLAC that directly matched between the two tests; 28 (10.22%) patients had a normal BLAC according to laboratory analysis but a high BLAC on POCT; and four (1.46%) patients had a high BLAC according laboratory analysis but normal BLAC on POCT. CONCLUSIONS: There was a high correlation between POCT and laboratory analysis values of BLAC in cancer patients, with the results from both testing methods agreeing 96% of the time. This finding suggests that POCT would suffice in most cases. Importantly, in 2% of the cancer patients who presented emergently, BLAC determined by POCT and laboratory analysis did not agree. Therefore, in subsequent decision-making, we recommend that if sepsis is suspected and BLAC determined by POCT is normal, nucleic acids, proteins, circulating cells, and interleukin-3 levels should also be obtained by POCT to confirm sepsis and/or rule out tumor lysis syndrome in patients with cancer.

Improving Patient Experience of Wait Times and Courtesy Through Electronic Sign-in and Notification in the Phlebotomy Clinic.

CONTEXT.­: The phlebotomy clinic, which sees on average 900 patients a day, was faced with issues of congestion and noise due to inefficient workflow and processes. The staff called each patient name for his or her turn, and patients were unsure of wait time and position in line. These factors led to unfavorable patient satisfaction regarding wait times and courtesy of the staff. OBJECTIVE.­: To improve patients' experience of wait times and courtesy in the phlebotomy clinic through an electronic sign-in and notification system, redesign of the area, and training of employees. DESIGN.­: An electronic sign-in and notification system was implemented in the phlebotomy clinic. Several sign-in stations and whiteboard wall monitors were installed in the clinic, along with a redesign of the patient flow. A Press Ganey survey was given to patients after their visit which included 3 questions related to wait times, courtesy, and information about delays, respectively. The mean responses for each month between March 2016 and December 2018 were aggregated and compared for each measure. RESULTS.­: Overall, wait time saw a 7.7% increase in satisfaction score, and courtesy saw a 1.0% increase in satisfaction score during the course of the several interventions that were introduced. The operational efficiency of the clinic also saw a veritable increase because the percent of patients processed within 20 minutes increased by 27%, from 62% (8212 of 13 245 blood draws) to 89% (11 703 of 13 143 blood draws). CONCLUSIONS.­: The interventions implemented proved to increase the patient satisfaction in each of the measures. The electronic sign-in and whiteboards provided valuable information to both patients and staff.

Causes and impact of specimen rejection in a clinical chemistry laboratory.

BACKGROUND: Pre-analytical errors necessitate specimen rejection and negatively affect patient safety. Our purpose was to investigate the factors leading to specimen rejection and its impact. METHODS: Specimen rejections in a clinical chemistry laboratory during a 1-year period were reviewed retrospectively and analyzed for frequency, cause, circumstances, and impact. RESULTS: Of the 837,862 specimens received, 2178 (0.26%) were rejected. The most common reasons for specimen rejection were contamination (n=764, 35.1%), inappropriate collection container/tube (n=330, 15.2%), quantity not sufficient (QNS) (n=329, 15.1%), labeling errors (n=321, 14.7%), hemolyzed specimen (n=205, 9.4%), and clotted specimen (n=203, 9.3%). The analytes most often affected were glucose (n=192, 8.8%); calcium (n=152, 7.0%), magnesium (n=148, 6.8%), potassium (n=137, 6.3%), creatinine (n=100, 4.6%), and blood urea nitrogen (n=97, 4.4%). Outpatient service and blood draw by phlebotomists were associated with low rejection rates (536/493,501 or 0.11% and 368/586,503 or 0.06%, respectively). Recollection due to specimen rejection increased the turnaround time by an average of 108min. The total cost for the recollection was around $43,210 USD with an average cost around $21.9 USD. CONCLUSIONS: The factors associated with rejection are remediable by improved training and quality assurance measures. Policies and procedures specific to specimen collection, transportation, and preparation should be strictly followed.

Innovative Strategies for Decreasing Blood Collection Wait Times for Patients in Early-Phase Cancer Clinical Trials.

PURPOSE: Long wait times are a primary source of dissatisfaction among patients enrolled in early-phase clinical trials. We hypothesized that an automated patient check-in system with readily available display for increasing awareness of waiting intervals would improve patient flow and use of our rooms, with decreased turnover time and increased throughput. METHODS: We recorded in-room wait times for patients seen in our clinic and observed the logistics involved in the blood collection process to delineate causes for delays. We then implemented a three-step strategy to alleviate the causes of these delays: (1) changing the collection of materials and the review of faxed orders, (2) improving our LabTracker automated database system that included wait time calculators and real-time information regarding patient status, and (3) streamlining lower complexity appointments. RESULTS: After our intervention, we observed a 19% decrease in mean wait times and a 30% decrease in wait times among patients waiting the longest (95th percentile). We also observed an increase in staff productivity during this process. Modifications in LabTracker provided the biggest reduction in mean wait times (17%). CONCLUSION: We observed a significant decrease in mean wait times after implementing our intervention. This decrease led to increased staff productivity and cost savings. Once wait times became a measurable metric, we were able to identify causes for delays and improve our operations, which can be performed in any patient care facility.

Colorectal adenoma stem-like cell populations: associations with adenoma characteristics and metachronous colorectal neoplasia.

Cancer stem cells have tumor-initiation and tumor-maintenance capabilities. Stem-like cells are present in colorectal adenomas, but their relationship to adenoma pathology and patient characteristics, including metachronous development of an additional adenoma ("recurrence"), has not been studied extensively. We evaluated the expression of aldehyde dehydrogenase isoform 1A1 (ALDH1A1), a putative stem cell marker, in baseline adenomas from the placebo arm of chemoprevention trial participants with colonoscopic follow-up. An exploratory set of 20 baseline adenomas was analyzed by ALDH1A1 immunohistochemistry with morphometry, and a replication set of 89 adenomas from 76 high-risk participants was evaluated by computerized image analysis. ALDH1A1-labeling indices (ALI) were similar across patient characteristics and in advanced and nonadvanced adenomas. There was a trend toward higher ALIs in adenomas occurring in the right than left colon (P = 0.09). ALIs of synchronous adenomas were correlated (intraclass correlation coefficient 0.67). Participants in both sample sets who developed a metachronous adenoma had significantly higher ALIs in their baseline adenoma than participants who remained adenoma free. In the replication set, the adjusted odds for metachronous adenoma increased 1.46 for each 10% increase in ALIs (P = 0.03). A best-fit algorithm-based cutoff point of 22.4% had specificity of 75.0% and positive predictive value of 70.0% for metachronous adenoma development. A larger population of ALDH1A1-expressing cells in an adenoma is associated with a higher risk for metachronous adenoma, independent of adenoma size or histopathology. If confirmed, ALDH1A1 has potential as a novel biomarker in risk assessment and as a potential stem cell target for chemoprevention.