Without Laboratory Medicine, much of patient care would come to a halt. Indeed, “between 80 and 90 percent of medical decisions are based on the results of lab testing,” said Deborah Mincarelli, MBA, MT, administrative director of Lab Medicine. “In many cases, the medical lab scientists make the diagnosis and advise on the treatment.”
For example, after reading a blood slide, MLS will determine a patient has leukemia. Once this initial diagnosis is verified by a pathologist, “the MLS will perform a whole set of tests to determine the kind of genetic mutation in the cells so the doctor knows what kind of chemo to give,” Mincarelli said. Or, in another specimen from a different patient, “they’ll identify an infection and do an antimicrobial susceptibility test to determine which antibiotic will be most successful in treating it. And that’s what gets reported out.
“Scientists in the lab work with doctors every day. We are that front line.”
Where It All Starts
Every day, between 12,000 and 15,000 specimens— blood samples and other fluids — make their way to Lab Medicine. Many come from HUP’s inpatient units and outpatient practices in the Perelman Center, but they also arrive — via courier — from the other Penn Medicine hospitals, physician practices and outpatient collection sites. “We are the reference lab for the Health System,” said Beth Lussier, MS, MT, technical manager of the Automated Laboratory. “More than 6,000 different types of tests are performed at HUP.”
A New Era in Lab Medicine
Lab Medicine’s current automated track, which processes specimens in the main core lab, helps keep the flow of specimens moving, but a new track – the “Power Express” – will bring this process to a new level, improving efficiency, speed… and patient care. The new system is scheduled to come on board next spring.
The new system will provide multiple features to boost turnaround time. For example, it will automatically prepare all blood and fluid specimens for analysis and then sort them according to which labs they need to go to and put them in the appropriate racks. “This removes a lot of the manual ‘touches’ in Central Receiving,” said Rulander. Its four-lane, two-way track (versus two lane on the current one) will allow specimens to bypass stoppages while specimens with a problem (eg, if the label can’t be read or there isn’t enough sample to do the test) will automatically be sent to “parking lots.” And there will be twice as many centrifuges to separate blood into its components.
Typically, specimens are kept in Lab Medicine for three to seven days, in case additional tests must be performed. Currently, they are manually put in specific positions in racks throughout all the labs so they can be located quickly. “With 12,000 tubes coming every day, that’s thousands of tubes we store and have to know how to find,” Rulander said. The Power Express will automatically place the tubes in a storage unit and “the minute the specimen reaches the final day, it will remove the tube, put in a chute that leads to the trash and the open position will be re-assigned to a new tube.”
But perhaps the new system’s most important improvement impacts patients themselves. Critically ill patients require multiple draws of blood every day to track their disease and the effectiveness of treatment. And each discipline requires its own tube of blood, for example, one for immunology and one for chemistry. “A healthy patient can recover four to five tubes worth of blood a day [approximately 20 ml] but this doesn’t happen with a patient who’s compromised,” said Mincarelli. “Drawing this much blood day after day decreases hemoglobin and iron levels, resulting in hospital-acquired anemia and a need for transfusions.”
The new track will automatically separate one tube of blood from the patient into multiple “daughter” tubes, depending on how many different tests are requested, and distribute them to the appropriate labs. The primary tube remains in the system, in case additional testing is required. “This should cut in half what we normally draw for each patient,” Mincarelli said.
Most of the specimens remain in the main core lab, where hematology, basic coagulation, and chemistry testing as well as urinalysis are performed. Others are distributed to one of the 25 “boutique” labs, for instance, the special coagulation lab that identifies conditions resulting in bleeding, clotting and bruising, or the molecular lab which examines infectious diseases (such as hepatitis and HIV) at the nucleic acid level. Tests not available in Lab Medicine are sent to outside resources.
In Central Receiving, 38 specially trained staff triage all specimens. This includes manually scanning them into the Lab Medicine computer system and then pre-processing them (e.g., separating blood into its components) to make them ready for testing, either manually or on the automated track located in the core lab. The final step is to manually sort all the specimens into specific racks according to which lab they will be sent for testing. “The Central Receiving staff know what goes where, what the specimen requirements are, how to process and, if necessary, how to package it to get there,” said Nichole Rulander, MS, MLS, technical manager. Currently, only chemistry specimens — such as a complete metabolic panel — are both processed and tested on the automated track but that will change when a new automated track comes onboard next spring (see /add link to other article/).
Because so many lives rely on the accuracy of these results, Lab Medicine adheres to specific regulatory requirements from both the Clinical Laboratory Improvement Amendments, which is part of the Centers for Medicare and Medicaid Services, and the College of American Pathologists, which has more stringent measures “We perform quality control measures every eight hours with a known sample,” Rulander said. “We have to make sure we get a known value and troubleshoot if we don’t.”
Seeking Out The Whys
All “normal” test results go directly to the patient’s electronic medical record in Penn Chart, but those that show critical results, for example, a life-threatening diagnosis, are flagged and must be reviewed by a medical lab scientist. “Our work is more than just pushing buttons,” Mincarelli said. “Someone has to evaluate these results, look at the whole picture.”
This is where the detective work comes in, closely examining each flagged specimen on the computer to see if it makes sense. “It’s a complex process. All types of things affect results and it’s up to the MLS to figure it out. For example, the sample itself may be at fault or maybe how it was drawn,” said Nicole Bademan, BS, MT, technical supervisor in the Automation Laboratory. “It doesn’t mean something is wrong with the patient.”
The MLS first examines the consistency of the blood. “A runny specimen could mean a patient has below normal blood counts … or that it’s a diluted sample,” she said. “If all the numbers in the CBC [complete blood count] are low, did the specimen get clotted so it’s not sampling whole blood? Or maybe the probe [on the automated track] didn’t pull up any blood.” After eliminating possibilities, the MLS will reach out to the patient’s nurse or doctor to see if the results are consistent with the patient’s condition. “If not, we ask for another sample.”
Results of lab tests help clinicians diagnose their patients but sometimes, the MLS is the first to know. “There are cases when we’ll see cells that indicate cancer and will send the specimen to the hematology lab and alert the patient’s doctors. That information is just one piece of the whole picture the doctor uses in the diagnosis,” Bademan said.
“We have an amazing team,” Mincarelli said. “They really care about patients, even if there is no direct patient contact. Where else can you help so many people, play a part in so many lives?”