Wrath of the Younglings

I am trying to keep my head above water in all of the work required, so I apologize for not being able to post as often as we would all like.  As those of us in teaching facilities know, July 1st brought in a new wave of babies … aka freshly born MD residents.  With the deluge of inappropriate and duplicate orders, I was tasked with a developing a 10 “pet peeves” list for these new younglings.  Check it out – feel free to steal and personalize as needed!

TOP 10 ISSUES

MISORDERING OR MISINTERPRETATION

IN THE MEDICAL LABORATORY

1. CLINICIANS ORDERING HYPERCOAGULATION TESTING WHILE THAT PATIENT IS ON ANTICOAGULANTS. Most of the hypercoagulation testing that is performed requires the measurement of either time to clot formation or the activity of coagulation factors, both of which are inhibited by the presence of anticoagulants. Results of hypercoagulation testing when a patient is on anticoagulants are uninterpretable because the anticoagulant grossly interferes with the test. It is recommended that patients who are in need of hypercoagulation testing be tested once they have not taken anticoagulants for a minimum of 7 days to ensure accurate test results (1).

2. CLINICIANS ORDERING DUPLICATE TESTING. Please review your colleagues’ orders on that patient and make sure that you are not ordering duplicate testing. There are several panels that include the same tests; for example BMP, CMP, and Renal panels have several common tests. If you have ordered a BMP and your colleague has ordered a Renal panel for the same or very similar time, the duplicate orders must be corrected first prior to testing being performed. If the duplicate orders are not resolved, the patient is billed twice for the same test which is considered fraud. Ensuring that you are not duplicating another physician’s order will speed up the entire process.

3. CLINICIANS NOT WAITING FOR TEST RESULTS BEFORE ORDERING THE SAME TEST AGAIN. This is not in reference to daily kidney functions for patients on certain medications; this is in reference to not waiting, or checking to see if it was ordered and results are just pending, tests for an infectious disease, or presence of a particular antibody, or specialty test that may have been sent to a reference laboratory prior to re-ordering the test. Checking to see if the test has already been ordered can save both your patient from an additional venipuncture and wasteful use of healthcare dollars.

4. OVER UTILIZATION OF BLOOD PRODUCTS. Blood products have a very limited supply and they must be utilized appropriately. Understand appropriate reasons for transfusion and which blood product is appropriate for which condition. A unit of pack red blood cells should not be utilized for volume replacement. Current American Association of Blood Banks standards for transfusion state that the threshold for transfusion in adult hospitalized hemodynamically stable patient is <7.0 g/dL (2). For patients undergoing cardiac surgery, orthopedic surgery, or those with a history of cardiovascular disease, the threshold is <8.0 g/dL (2).

5. GENETIC TESTS TYPICALLY REQUIRE ADDITIONAL INFORMATION AND PAPERWORK AND SHOULD BE DONE AS AN OUTPATIENT WHEN POSSIBLE. Genetic testing is very expensive ranging from $100 to $10,000 per test. Because of DRG’s, genetic testing should be done on an outpatient basis unless medically necessary; medically necessary is generally only NICU and occasionally PICU. Insurance companies also occasionally require pre-authorization on genetic testing. Also, due to the legal ramifications of genetic testing, it often requires signatures of both the ordering physician AND the patient on specific completed forms. If you are contacted by either the laboratory or by a genetic counselor about a missing form, please complete it in a timely manner and return it to the requesting person so that the ordered test can be sent and processed.

6. ALL SPECIALITY SEND OUT TESTING THAT COSTS GREATER THAN $200 WILL BE EVALUATED BY THE PATHOLOGY DIAGNOSTIC MANAGEMENT TEAM FOR MEDICAL NECESSITY. Especially with DRG’s, the laboratory has implemented a policy to ensure that all expensive send-out testing is medically necessary. If the team determines that the test is medically necessary, the test will be sent to the specialty laboratory for testing. If the team determines that the test should be cancelled/deferred/or changed, the ordering physician and attending physician, if applicable, will be notified.

7. CLINICANS NOT WAITING SUFFICIENT TIME BETWEEN TREATMENT AND TEST FOR CURE ON MOLECULAR ANTIGEN TESTS. The molecular tests available, such as PCR, can quickly determine if a particular infectious antigen is present based on the detection of the DNA or RNA of the infectious organism. This makes these tests very sensitive, which is what you want when diagnosing an infection. The problem is that since they are detecting DNA or RNA, the test cannot differentiate between viable genetic material and non-viable genetic material. If you order an antigen test, such as a Clostridium difficile or Neisseria gonorrhea PCR test too soon in testing for cure, you have a high risk of a false positive. If you are testing for cure and you see the positive result, is it because you tested too soon or is it because the organism is resistant to treatment? Waiting at least 3 weeks between testing will decrease the incident of false positive. A culture for the organism is best when testing for cure because only viable organisms will grow in culture (3).

8. CRITICAL VALUES. The medical laboratory scientists that work in the lab are required by law to contact the ordering provider should they obtain a value on a patient that is considered a “critical value”. “Critical values” are such that they would likely necessitate medical intervention in a timely manner to prevent a poor outcome. Please do not belittle, cuss, or yell at the medical laboratory scientist who calls you to report critical values. Please read them back as they are required to ask for a read back of the patient and the result. They are calling you for a reason. Failure to appropriately respond to critical values is increasing becoming a source of litigation for physicians (4). And, yes, the laboratory employs medical laboratory scientists that are highly educated and have degrees ranging from associate’s degree to PhD’s.

9. NOT UNDERSTANDING WHAT CONSTITUTES A CLINICAL CHANGE IN TEST VALUES. Every laboratory test must meet a certain amount of precision, but there is a certain amount of imprecision in every laboratory test. This means that the same tube of blood can be analyzed twice for the same test and the medical laboratory scientist can have two different numerical results but they are the same clinically. For example: your patient had a hemoglobin of 10.0 g/dL yesterday and today they have a hemoglobin of 9.9 g/dL. Your patient is clinically unchanged. If the tube of blood from today was rerun it entirely possible that the medical scientist would get a 10.0 g/dL result. Another example: your patient had a creatinine of 1.02 mg/dL yesterday and today has a creatinine of 1.04 mg/dL. These results are clinically the same.

10. SPECIMEN LABELING MATTERS. The laboratory receives more than 5,000 specimens every single day. Without appropriate and correct specimen labeling, the medical laboratory scientists would not be able to accurately report out your patient’s results. The laboratory has received unlabeled blood, urines, stools, joint fluids, pleural/pericardial/peritoneal fluids, swabs of all kinds, CSF fluids, and even tissues. Federal policy states that a minimum of two patient identifiers are on every sample sent to the laboratory. Patient identifiers include patient first and last name, patient date of birth, and patient medical record number. Room or bed number is not considered a patient identifier because patients change rooms and bed all the time. Blood bank specimens have more labeling requirements. Please ensure that any specimens you collect are appropriately and correctly labeled.

If you have any questions related to the laboratory you are welcome to contact the laboratory or clinical pathology and we are willing to help. The main laboratory phone number is _____.

References:

1. Chibisov I et al. Effects of Anticoagulant Therapy on Hypercoagulable Testing and Other Issues Affecting Results. Institute for Transfusion Medicine Coagulation Update. 2012. http://www.itxmdiagnostics.org/UserFiles/file/CU2012Issue2.pdf

2. Carson JL et al. Clinical Practice Guidelines From the AABBRed Blood Cell Transfusion Thresholds and Storage. JAMA. 2016;316(19):2025-2035. doi:10.1001/jama.2016.9185

3. Papp JR et al. Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae — 2014. MMWR Recommendations and Reports. March 14, 2014 / 63(RR02);1-19.

4. Higgins C. Critical Values in Laboratory Medicine. Acute Care Testing. January 2011. https://acutecaretesting.org/en/articles/critical-values-in-laboratory-medicine

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