Dear Patient Safety Focus Editors,
Thank you for the recent discussion in CLN’s Patient Safety Focus section on how quality improvement is hindered by the disconnect between lab staff and patients, as well as between lab staff and direct care providers. I believe this is one of the most important points presented here on how labs can improve patient care. In the hope that other laboratorians feel the same way, I am writing to share my hospital’s experience. Recently, we have been trying to improve the connection between lab staff and direct care providers by meeting with them more frequently so that we can understand problems from their point of view. I believe that this is making a difference and provide the following two examples to illustrate our experience.
The first example involves extracorporeal membrane oxygenation (ECMO), which is used in the neonatal intensive care unit to save the lives of newborns in cardiopulmonary distress by supporting their heart and lung function. Our technologists were concerned that the nurses were not answering the phone quickly enough to receive critical results. The technologists also worried that the nurses did not realize the importance of the results.
To better understand the issue, we invited a pediatric open-heart perfusionist to talk to lab staff about ECMO, and then we went on a “field trip” to see the babies. The lab staff observed that there is one respiratory therapist and one nurse for each baby undergoing ECMO and that the nurse and therapist cannot leave that baby without a replacement. When you see the amount of intravenous lines, other tubing, monitors and equipment involved in ECMO and the obvious critical nature of the situation, it is an humbling experience.
Actually seeing a baby undergoing ECMO, while a dedicated care team labored to provide care, affected the technologists deeply. It only took about 20 minutes to create a dramatic shift in their thinking by connecting them to these tiny patients and their care providers. This change has improved teamwork between lab staff and nursing and created a fertile environment for carrying out other quality improvements. Some examples of this enhanced teamwork include: chemistry technologists now provide continuing education to respiratory therapists on kidney function and hematology tests; respiratory therapists and nurses touring the lab so that they can see things from the viewpoint of lab staff; and joint projects to work on improving turnaround times.
A lab “field trip” to the neonatal intensive care unit
connected technologists to the patients and care providers.
Another example of how we have improved quality by connecting with care providers comes from working with our pediatric oncologists. To decrease turnaround times, the chief pediatric oncologists wanted oncology staff to perform POC CBCs in outpatient oncology. Lab staff met with the oncologist and explained that one problem that oncology staff would face is the frequently “flagged” results that oncology patients have. The oncologist responded, “Of course the patients have flagged results, since the results are usually outside the reference range.” Lab staff explained that to us flagged results are not results outside the reference range but rather results that are not reportable until reviewed by a technologist. We also had the opportunity to explain that the CBC POCT would not give the 5-part differential they desired and that the testing they wanted involved a number of instrument maintenance issues requiring technical expertise.
This dialog made the oncologist realize the testing was out of the scope of his staff’s capabilities. It also helped lab staff realize that the lab needed to meet the turnaround-time requirements of the oncology patients. After further analysis and discussion, the lab was able to provide hematology services directly in outpatient oncology, which is staffed by our technologists and uses a smaller version of our lab instrument.
Being in such close proximity to the actual care site literally opened a window for lab staff to see the obstacles faced by oncology staff and why results were needed so quickly. This arrangement also gave the oncology staff an appreciation of the technologists’ expertise in dealing with complex instrumentation, flagged results, and manual review of peripheral smears. Most importantly, it helped lab staff see and understand what cancer patients and their families suffer through, while underscoring the critical nature of lab results.
Finally, I want to share a proud moment for our lab. After working in pediatric oncology, lab staff began a blanket buddies group to make fleece blankets for patients. Lab staff either participated in making the blankets or donated money for supplies. We won our hospital’s Mission, Values, Philosophy Award for Compassion for this project. When lab staff at some of our sister hospitals heard what our technologists were doing, they began their own blanket buddies groups to comfort pediatric oncology patients at their sites.