A 5-step root cause analysis model for test overutilization: A study on its application to plasma transferrin testing.

OBJECTIVES: This study aimed to develop a root cause analysis (RCA) model for test overutilization, applying it to transferrin overordering at our institution. METHODS: A comprehensive review was undertaken to establish a systematic RCA model. Upon implementation, the questionnaire identifying the root causes of transferrin overordering with infographic intervention was distributed to clinicians and nurses. RESULTS: The RCA model comprises 5 steps: (1) problem identification, (2) causal factor determination, (3) data collection, (4) significant factor identification, and (5) corrective action development and outcome measurement. The major causes of transferrin overutilization were confusion between transferrin and transferrin saturation, as well as unfamiliarity with the laboratory handbook. An infographic reduced postintervention transferrin ordering among clinicians (84.9%, P < .001) and nurses (46.8%, P < .001). CONCLUSIONS: This study presents a 5-step RCA model that offers a customized method to identify the causes of test overutilization. Applying this model to transferrin at our institution revealed 22 leading root causes. Laboratories are encouraged to adopt this RCA model as it can contribute to optimized patient care and more efficient resource allocation.

Whole blood clotting time: Current practices among Thailand National External Quality Assessment Scheme for blood coagulation member laboratories.

INTRODUCTION: The Thai National Guidelines for Hemostatic Laboratory Testing were established in 2018. The guidelines recommend that the 20-min whole blood clotting time (20WBCT) method be used to diagnose/monitor snake bites. The aim of this study was to survey members of the Thailand National External Quality Assessment Scheme (NEQAS) for Blood Coagulation to investigate the use of 20WBCT testing compared between the 2021 post-guideline and 2007 pre-guideline periods. METHODS: In July 2021, questionnaires were sent from the Faculty of Medicine Siriraj Hospital, Mahidol University to 521 Thailand NEQAS for Blood Coagulation member laboratories to survey their WBCT practices. Current WBCT practices were compared with pre-guideline WBCT practices, and chi-square test (x2) was used to test for differences between groups. RESULTS: Ninety-seven (18.6%) of 521 surveys were returned. Seventy-one laboratories (73.2%) reported knowing about 20WBCT from the Thai national guidelines. The reported average frequency of overall WBCT testing in 2021 was 12.4 times/month. The proportion of laboratories that reported using the 20WBCT test increased from 2.0% in 2007 to 46.4% in 2021 (p < 0.001), and the indications for performing WBCT were virtually unchanged from 2007 to 2021. The proportion of laboratories that reported having problems with WBCT testing decreased from 32.7% in 2007 to 16.5% in 2021. CONCLUSION: Despite our findings that almost three-quarters of respondent laboratories reported knowing about 20WBCT testing from the WBCT guidelines, and that WBCT-specific problems decreased significantly from 2007 to 2021, more work and training is needed to improve WBCT guideline dissemination, understanding, and adherence in Thailand.

An evaluation of two small group learning strategies among third-year medical students at the Faculty of Medicine, Siriraj Hospital, Mahidol University.

Small group learning (SGL) is a discussion-based teaching strategy that can improve critical thinking, analytical skills, problem-solving, and interpersonal skills. This study aimed to evaluate student satisfaction in two SGL models among third-year medical students enrolled in a blood and lymphoid systems II course at the Faculty of Medicine Siriraj Hospital, Mahidol University in Bangkok, Thailand. A total of 318 students were divided into 12 groups, and each group had one facilitator. All included students and groups were exposed to both the central summary (CS) model and the individual facilitator summary (IFS) model (both SGLs). A questionnaire was developed to evaluate student rating of learning activities, perceived benefit, timing, workload, and satisfaction. Medical students rated the IFS model superior to the CS model for four of five parameters [confidence in performing and interpreting a laboratory test (83.6% vs. 78.8%), guidance for self-learning (52% vs. 39.5%), increased understanding of a disease (87.7% vs. 72.1%), and application of knowledge (77.4% vs. 70.2%), respectively]. Moreover, the IFS model was rated as having more suitable timing and workload and better satisfaction than the CS model. The results of this study suggest a strong preference for the IFS model over the CS model among medical students.

Point-of-care glucose testing: on-site competency assessment.

PURPOSE: The purpose of this pilot paper is to use on-site assessment to determine common non-compliance in point-of-care (POC) glucose testing, deficiencies that should be improved by the POC team or emphasized in further training. DESIGN/METHODOLOGY/APPROACH: Assessment forms for POC site and staff competency were developed and used for direct observation in four POC sites. Nurses were sampled in these sites. FINDINGS: The on-site assessment demonstrated that initial operator training was insufficient. Only three of 15 nurses achieved a satisfactory score on the first assessment. In all nine participants who had been assessed at least twice improved their performance. In total, 16 (30 percent) of 53 competency items were not achieved, so these should be addressed during refresher training. Improved compliance with the checklist was observed in two of four POC sites. RESEARCH LIMITATIONS/IMPLICATIONS: Medical students and residents also perform the test, so more representative samples are needed. PRACTICAL IMPLICATIONS: The assessment of staff performance in the workplace with constructive input and POC site inspections to identify common deficiencies are recommended. Refresher trainings should be focussed on the deficiencies identified. SOCIAL IMPLICATIONS: Assessing staff performance in the workplace with constructive input and POC site inspections to identify common deficiencies are recommended. Refresher trainings should focus on deficiencies. ORIGINALITY/VALUE: This study involved directly observing POC site staff during glucose testing. The assessment forms were based on ISO 22870:2006 technical requirements.

Use of an automated coagulation analyzer to perform heparin neutralization with polybrene in blood samples for routine coagulation testing: practical, rapid, and inexpensive.

CONTEXT: Heparin contamination in blood samples may cause false prolongation of activated partial thromboplastin time (aPTT) and prothrombin time results. Polybrene can neutralize heparin, but it affects coagulation by itself. OBJECTIVES: To determine the optimal concentration of polybrene to neutralize heparin, to determine the suitable sequence of reagents for the neutralization method performed on the analyzer at the same time as prothrombin time and aPTT testing, and to detect the heparin contamination in blood samples for coagulation tests in our hospital using this method. DESIGN: Various concentrations of heparin were added to 10 normal and 76 abnormal plasma samples to study the efficacy of polybrene. Two programs of reagent sequencing for aPTT with polybrene performed on the analyzer were tested. Samples suspected of heparin contamination according to our criteria were selected for neutralization during a 3-month period. RESULTS: The optimal final concentration of polybrene was 25 µg/mL. Polybrene should be added after the aPTT reagent to minimize its interference effect. Even though results of prothrombin time and aPTT after neutralization did not equal those before the spike of heparin, the differences might not be clinically significant. Eighty-one of 4921 samples (1.6%) were selected for aPTT with the neutralization method, and the detection rate of heparin contamination was 84% (68 of 81), giving an overall incidence of 1.4% (68 of 4921). CONCLUSIONS: This method is inexpensive and can be performed rapidly with prothrombin time and aPTT on the automated analyzer, which makes it easy to practice with no need for extra plasma volumes.

Accuracy and precision evaluation of Thai plastic microhematocrit tubes: the first product from Thailand.

BACKGROUND: In Thailand, the spun microhematocrit method is usually performed using glass microhematocrit tubes even though broken glass tube during use may result in a risk of injury and blood-borne infection. The main reason is that the safer product alternatives such as plastic microhematocrit tubes are more expensive. Now, plastic tubes for hematocrit determination can be produced in Thailand at a much cheaper price. However precision and accuracy studies are necessary before being able to use them. OBJECTIVE: To compare the accuracy and precision of Thai plastic microhematocrit tubes against the routinely used glass microhematocrit tubes and imported plastic microhematocrit tubes using spun microhematocrit method. MATERIALS AND METHOD: One hundred residual EDTA blood samples from the Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand along with the three level hematology control materials were measured with spun microhematocrit values using three different types of plastic microhematocrit tubes. This was compared to the routinely used glass microhematocrit tubes as a gold standard. RESULTS: The repeated measures one-way ANOVA found no significant difference between the hematocrit values from each type of tubes with an F(1,99) = 0.667 and p-value = 0.574. Intraclass correlation coefficient (ICC) between four types of microhematocrit tubes ranged from 0.996-0.998 (p-value < 0.001). Correlation coefficients (r) between four types of microhematocrit tubes ranged from 0.996-0.998 (p-value < 0.05). Coefficient of variation (CV) for precision of both within run and between run of Thai plastic microhematocrit tubes ranged from 1.44 to 2.17% compared to 1.39 to 4.01% of the imported plastic microhematocrit tubes. CONCLUSION: The hematocrit values determined by all plastic microhematocrit tubes can be considered relatively equivalent to those of glass microhematocrit tubes in terms of accuracy and precision. The Thai plastic microhematocrit tubes are economical and with the cost-benefit over other plastic tubes of about 12 to 16 times. Therefore, the Thai plastic microhematocrit tubes should be the choice for glass tube replacement.

Mutation of ABO gene in Thai blood donors with A3 phenotype.

The ABO system is the most important of all blood group systems in transfusion practice. The subgroup gives a weak reaction when treated with anti-A or anti-B. The most common subgroup found in Thai blood donors is subgroup A3, which is characterized by mixed-field agglutination when reacted with anti-A and anti-A,B, was caused by mutation in the ABO gene, especially in the exon 7. In the present study mutation in A3 were charactered in exon 7 of the ABO gene in 10 A3 phenotype Thai blood donors from the National Blood Centre, Thai Red Cross Society by PCR amplification and DNA sequencing. Mutations in exon 7 were identified in the A allele of six cases. In four cases, mutations were detected at positions 646T > A, 681G > A, 771C > T and 829G > A. One case showed a double mutations at positions 467C > Tand 745C > T and one case showed a mutation at position 467C > T. Four cases showed wild type exon 7 as A101 allele. These mutations were previously reported in BGMUT database and no novel mutation was identified These data suggest genetic heterogeneity in A3phenotype in Thai blood donors.