Solitary blood cultures: a College of American Pathologists Q-probes study of 132,778 blood culture sets in 333 small hospitals.

OBJECTIVE: To determine the frequency with which solitary blood culture samples were submitted to laboratories serving small hospitals and to ascertain whether certain hospital practices relating to the performance of blood cultures were associated with lower solitary blood culture rates (SBCRs). DESIGN: Participants in the College of American Pathologists Q-Probes laboratory quality improvement program collected data prospectively on the numbers of solitary blood culture sets from adult patients submitted to their laboratories and answered questions about their institutions' practice characteristics relating to the collection of blood culture specimens. SETTING AND PARTICIPANTS: Three hundred thirty-three public and private institutions with a median occupied bed size of 57. Participants were located in the United States (n = 329), Canada (n = 3), and Australia (n = 1). MAIN OUTCOME MEASURE: The solitary blood culture rate was defined as the number of instances in which only 1 blood culture venipuncture was performed on an individual patient during a 24-hour period divided by the total number of blood culture venipunctures that were performed during the study period. RESULTS: Participants submitted data on 132 778 adult patient blood culture sets. The SBCRs were 3.4% or less in the top-performing 10% of participating institutions (90th percentile and above), 12.7% in the midrange of participating institutions (50th percentile), and 42.5% or more in the bottom-performing 10% of participating institutions (10th percentile and below). In half the participating institutions, the SBCRs for inpatients were 8.3% or less and for outpatients, 22% or less. Solitary blood culture rates were lower for institutions in which phlebotomists rather than nonphlebotomists routinely collected blood culture specimens, in which internal policies required drawing at least 2 blood culture sets, in which hospital personnel contacted clinicians when their laboratories received requests for solitary blood culture sets, and in which quality control programs monitored SBCRs routinely. CONCLUSIONS: Hospitals can achieve SBCRs under 5%. Those hospitals with particularly high SBCRs may lower their rates by altering certain institutional practices.

Reference laboratory telephone service quality.

OBJECTIVES: To establish the rates with which reference laboratories resolve inquiries telephoned to them from primary laboratories and to identify reference laboratory practices associated with higher rates of inquiry resolution. DESIGN AND PARTICIPANTS: For 2 months, or until 50 contacts had occurred, 545 primary laboratories participating in the College of American Pathologists Q-Probes laboratory quality improvement program prospectively documented and characterized telephone inquiries they made to a reference laboratory of their choice. Participants also cataloged their own laboratory's demographic and practice characteristics and their reference laboratory's customer service characteristics. MAIN OUTCOME MEASURE: Rates with which reference laboratories resolved telephone inquiries. RESULTS: Participants characterized 11 031 (78.7%) of 14 017 telephone inquiries as resolved by the reference laboratories. Ranked according to inquiry resolution rates, primary laboratories in the 90th percentile characterized reference laboratories as resolving 100% of their inquiries; those in the 10th percentile characterized reference laboratories as resolving only 54.2% of their inquiries. The rate of resolved inquiries was significantly higher (P =.0047) for participants using reference laboratories with 24-hour customer service than it was for participants using reference laboratories with less than 24-hour service. Most primary laboratories (80.9%) chose to monitor 1 of 11 national reference laboratories; in this subset, median rates of inquiry resolution ranged from 90.2% to 55.0% (P <.0001), despite no significant variation in other measured customer service characteristics. CONCLUSIONS: Primary laboratories experience significant differences in the rates with which reference laboratories resolve telephone inquiries. The performance benchmark for reference laboratories is resolution of at least 90% of telephone inquiries from primary laboratory customers.

Neonatal bilirubin testing practices: reports from 312 laboratories enrolled in the Colege of American Pathologists Excel Proficiency Testing Program.

OBJECTIVE: To characterize laboratory practices for neonatal bilirubin testing and to identify opportunities for improvement. DESIGN: A voluntary self-assessment questionnaire was used to assess the laboratory practices of 312 laboratories subscribing to the College of American Pathologists (CAP) Excel Chemistry Proficiency Testing Program. RESULTS: A range of preanalytic and analytic practices were reported. The most notable problems identified were the use of overly long capillary puncture devices (17.8%), failure to protect the specimen from light prior to analysis (3.4%), failure to use a control containing >171 micromol/L bilirubin (26.1%), use of single-level control (4.2%), and lack of established linearity limits (7.0%). CONCLUSION: Opportunities exist to improve specimen collection, processing, and analysis for some physician-office and small-hospital laboratories.

Morning rounds inpatient test availability: a College of American Pathologist Q-Probes study of 79860 morning complete blood cell count and electrolyte test results in 367 institutions.

OBJECTIVES: To determine the success with which laboratories were able to report morning test results on time, the laboratory practice characteristics associated with improved success, and the degree of satisfaction among clinicians with the timeliness of laboratory service. DESIGN: Hospital laboratories participating in the College of American Pathologist Q-Probes laboratory quality improvement program prospectively calculated the percentages of morning-run complete blood cell count (CBC) and electrolyte results that were reported on or before predetermined reporting deadlines, completed questionnaires concerning their departments' practice characteristics as they related to performing morning blood work, and distributed to physician utilizers of morning laboratory services questionnaires evaluating physician satisfaction with laboratory services. SETTING AND PARTICIPANTS: A total of 367 public and private institutions located in the United States (355), Canada (5), Australia (2), and 1 each in the United Kingdom, Spain, Brazil, Korea, and Guam. MAIN OUTCOME MEASURE: The percentages of morning-run CBC and electrolyte results reported on or before predetermined reporting deadlines. RESULTS: Participants submitted data on 40 256 CBC and 39 604 electrolyte specimens. In aggregate, a total of 88.9% of these tests (90.2% of CBCs and 87.6% of electrolytes) were reported on or before the reporting deadlines that the participating laboratories set for themselves. Half of the participants reported 94.6% of their CBC results and 95.5% of their electrolyte results on or before their self-imposed reporting deadlines. No specific demographic features or departmental practice characteristics were associated with higher or lower rates of institutional reporting compliance. Most physician utilizers of early-morning laboratory test results believed that the laboratory is sensitive to and meets the needs of clinicians for timely reporting of early-morning test results. CONCLUSIONS: Most laboratories are capable of reporting 95% of their routine morning laboratory tests on time, and most physicians are satisfied with their laboratories' morning testing service.

Early morning blood collections: A College of American Pathologists Q-Probes study of 657 institutions.

OBJECTIVE: To determine specimen collection and report times, and delivery, analytic, and total turnaround times (TAT) for routine early morning blood collections. DESIGN: The study was a 2-part College of American Pathologists Q-Probes study. In the first part, participants recorded specimen collection times, receipt in testing laboratory times, and test report times for all routine hemoglobin and potassium samples collected between the hours of 1 AM and 10:30 AM on one intensive care unit and one nonintensive care unit for a 1-week period. In the second part, participants provided information about their specimen collection, delivery, processing, analytic, and reporting practices in a questionnaire. SETTING: An intensive care unit and a nonintensive care unit in 657 institutions. MAIN OUTCOME MEASURES: Median collection time, delivery time, analytic time, total turnaround time, and report time. RESULTS: Median institutional collection times ranged from 3 AM to 9:20 AM, with the institution at the 50th percentile reporting a median collection time of 6 AM. Median institutional report times ranged from 3:45 AM to 12: 20 PM, with the institution at the 50th percentile reporting a median report time of 7:23 AM. Median delivery, analytic, and total turnaround times for the median institution were 25, 42, and 73 minutes, respectively. CONCLUSIONS: Factors shown to correlate with shorter total turnaround times were rural locations, a lower collections to full-time equivalent ratio, intensive care unit specimens, plasma for potassium measurements, the practice of delivering each specimen as it is collected, pneumatic tube delivery system, direct delivery route, and continuous versus batch testing.

Accidental needlesticks in the phlebotomy service of the Department of Laboratory Medicine and Pathology at Mayo Clinic Rochester.

OBJECTIVE: To determine the change in accidental needlestick rates in the Phlebotomy Service at Mayo Clinic Rochester and to identify safety practices implemented from 1983 through 1996. MATERIAL AND METHODS: We retrospectively reviewed yearly Phlebotomy Service accidental needlestick rates from 1983 through 1996. Interviews were conducted with representatives of the Infection Control Committee and the management team for the Phlebotomy Service, and minutes of meetings of these two groups were reviewed to identify implemented safety improvements that may have had an effect on accidental needlestick exposures. RESULTS: Accidental needlestick exposures in the Phlebotomy Service declined from a high of 1.5/10,000 venipunctures to 0.2/10,000 venipunctures. Several safety improvements were made during that time, including the implementation of a one-handed recapping block, change to single-use evacuated tube holders, increased number and improved locations of disposal containers for needles, implementation of resheathing needles and retractable capillary puncture devices, discontinuation of the practice of changing needles before inoculation of blood culture bottles, increased emphasis on safety for new and experienced phlebotomists, and improved exposure reporting tools. CONCLUSION: We believe that the decrease in our accidental needlestick exposure rate is correlated with the changes in education, practices, and products that we have implemented.

Timeliness of urinalysis: a College of American Pathologists Q-probes study of 346 small hospitals.

OBJECTIVE: To explore preanalytic handling of urinalysis specimens. DESIGN: The study was a College of American Pathologists Q-Probes study consisting of two parts. The first part was a questionnaire about participants' urinalysis practices. The second part required collection of information from four specific urinalysis specimens per shift on 30 consecutive days or from 200 urine specimens, whichever occurred first. SETTING: Three hundred forty-six small hospitals enrolled in the Small Hospital Q-Probes program. MAIN OUTCOME MEASURES: Compliance with guidelines requiring nonrefrigeration and specimen measurement within 2 hours of collection, and identification of practices associated with better performance. RESULTS: Almost 50,000 urinalysis specimens were analyzed. About 68% of the specimens were measured without prior refrigeration, 2.3% were refrigerated before, 17.9% were refrigerated after, and 4.5% were refrigerated before and after arrival in the laboratory. Aggregate analysis indicated that 11.2% of never-refrigerated specimens exceeded the recommended 2-hour time standard before analysis. For inpatients and outpatients, respectively, 64% and 77% of laboratories were able to meet the 2-hour goal 90% of the time. Improved performance was associated statistically with ordering urinalysis stat, an enforced policy of specimen rejection for delayed transport of inpatient specimens, and the listing of a collection time for outpatient specimens. CONCLUSIONS: A large number of urinalysis specimens exceeded current quality guidelines for handling. Laboratories must monitor and improve preanalytic handling of urinalysis specimens.

Clinical comparison of BACTEC 9240 plus aerobic/F resin bottles and the isolator aerobic culture system for detection of bloodstream infections.

The Plus Aerobic/F resin bottle of the BACTEC 9240 automated blood culture system (Becton Dickinson Diagnostic Instrument Systems, Sparks, Md.) was compared with aerobic culture of the Isolator system (Wampole Laboratories, Cranbury, N.J.) for the detection of bloodstream microorganisms from 6,145 blood cultures collected from adult patients with suspected septicemia. The BACTEC resin bottles were incubated for 7 days, and the sediment from the Isolator tube was inoculated to sheep blood and chocolate agars which were incubated for 72 h and to inhibitory mold, brain heart infusion, and Sabouraud agars which were incubated for 21 days. A total of 622 microorganisms were recovered from 583 blood cultures. The BACTEC resin bottle recovered statistically significantly more pathogens overall than the Isolator system (P = 0.0006). When individual pathogens isolated from either system for a 7-day study period were assessed, it was determined that the BACTEC resin bottle detected statistically significantly more isolates of Staphylococcus aureus (P = 0.0113) and coagulase-negative Staphylococcus spp. (P = 0.0029) than the Isolator system. The BACTEC resin bottle also detected statistically significantly more bloodstream infections (septic episodes) caused by coagulase-negative Staphylococcus spp. (P = 0.0146). The Isolator system recovered statistically significantly more contaminants overall (P < 0.0001), and among this group of microorganisms, recovered statistically significantly more Bacillus spp. (P < 0.0001), coagulase-negative Staphylococcus spp. (P < 0.0001), and viridans group Streptococcus spp. (P = 0.0156). The Isolator system detected statistically significantly more isolates of Histoplasma capsulatum (P = 0.004), but all of these isolates were detected at > or = 7 days of incubation of fungal plates, i.e., after the system to system comparison study period (7 days). In blood culture sets which produced growth of the same pathogen in both systems, there was a statistically significant difference in median time to detection for all pathogens combined favoring the BACTEC resin bottle over the Isolator tube (P < 0.05). When assessing individual microorganisms, the median times for detection of S. aureus, Enterococcus spp., and Pseudomonas spp. were all statistically significantly less for the BACTEC system (P < 0.05). The BACTEC instrument had 79 (1.3%) false positive signals. The BACTEC system required less processing time than the Isolator system and eliminates the hands-on time for detection of positive cultures required with the Isolator system.

Worries of school-age children.

PURPOSE: To determine how worrisome some situations are for school-age children and if parents can identify how worrisome the situation would be for their child. DESIGN: Descriptive. SETTING: Families' homes. PARTICIPANTS: 48 school age-children (7-11 years old), 40 mothers, 8 fathers. MAIN OUTCOME MEASURES: The 27-item "What Worries You (Your Child) the Most" questionnaire. RESULTS: For the most part, parents were able to ascertain what would worry their child the most. However, they did underestimate the importance of pets to children as well as adequate family income. There were significant differences in child and parent perceptions of three items ranked among the most worrisome: "being asked to take drugs," being in a war," and "hearing parents quarrel." Age and gender of children were not significant factors in the distribution of scores. CONCLUSIONS: Findings indicate that considerable discrepancies can exist between what the parent and the child perceive as worrisome.

Clinical comparison of difco ESP, Wampole isolator, and Becton Dickinson Septi-Chek aerobic blood culturing systems.

The ESP 80A aerobic blood culture of the ESP automated blood culture system (Difco Laboratories. Detroit, Mich.) was compared with two manual aerobic blood culture systems, the Isolator (Wampole Laboratories, Cranbury, N.J.) and the Septi-Chek (Becton Dickinson, Cockeysville, Md.) systems, for the detection of bloodstream microorganisms from 5,845 blood samples for culture collected from adult patients with suspected septicemia. The bottles were incubated for 7 days, and the sediment from the Isolator tube was inoculated onto solid medium and this medium was incubated for 72 h. A total of 609 microorganisms were recovered from 546 blood cultures. There was no statistically significant difference in the total recovery of microorganisms for the ESP 80A system when compared with that for the Septi-Chek system (P = 0.083); however, the Isolator system recovered significantly more microorganisms overall than either the ESP 80A (P < 0.001) or the Septi-Chek (P < 0.001) system. When assessing individual probable pathogens, the Isolator system detected statistically significantly more Staphylococcus aureus and Candida spp. than either the ESP 80A or the Septi-Chek system (P < 0.05). Similarly, the Isolator system detected statistically significantly more bloodstream infections (septic episodes) caused by S. aureus and Candida spp. than either the ESP 80A or the Septi-Chek system (P < 0.05). In blood culture sets which produced growth of the same probable pathogens in the ESP 80A and the Isolator systems, there was no statistically significant difference in the median times to detection for all pathogens combined (P = 0.067). However, a similar comparison showed the Isolator and the ESP 80A systems to have statistically significantly shorter median detection times for all pathogens combined (P < 0.001) when they were independently compared with the Septi-Chek system. The ESP 80A system had 29 (0.5%) false-positive signals. The ESP system required less processing time than the Isolator system and eliminates the hands-on time for the detection of positive cultures required by the manual systems.

Evaluation of two rapid antigen assays, BioStar Strep A OIA and Pacific Biotech CARDS O.S., and culture for detection of group A streptococci in throat swabs.

Two rapid methods, BioStar Strep A OIA (OIA; BioStar, Inc., Boulder, Colo.), an optical immunoassay, and CARDS O.S. (O.S.; Pacific Biotech, Inc., San Diego, Calif.), a color immunochromographic assay, and two culture methods, one with 5% sheep blood agar (SBA) and one with Todd-Hewitt broth (TH; Remel, Lenexa, Kans.), were evaluated for use in the detection of Streptococcus pyogenes from pharnygeal swabs. Seven hundred forty-six double swabs (Culturette II) were processed, with OIA and SBA culture performed on one swab and O.S. and SBA culture performed on the other swab. The pledget from the Culturette II was incubated overnight in TH and was subcultured onto SBA for an additional 48 h in ambient air. All beta-hemolytic streptococci from culture were tested by a direct fluorescent-antibody test (Difco Laboratories, Detroit, Mich.). Specimens with discordant fluorescent-antibody test and rapid test results were also tested by using the Streptex latex agglutination reagent (Murex Diagnostics Limited, Dartford, England). The results obtained by all testing methods were compared with a combined test result ("gold standard"), which was defined as any positive culture detected by the SBA or TH culture methods and confirmed by Streptex latex agglutination or, in the case of negative results by both culture methods, a concomitant positive result by OIA and O.S. antigen testing. Sensitivity and specificity results for each of the methods were as follows, respectively: OIA, 81.0 and 97.5%; O.S., 74.4 and 99.0%; SBA culture, 92.3 and 98.3%; and TH culture, 86.4 and 100%. Both OIA and O.S. are suitable screening methods for detecting S. pyogenes directly from throat swabs but are of insufficient sensitivity to eliminate the need for backup cultures for specimens with negative OIA and O.S. results.

Phlebotomy--a minimalist approach.

For each patient, laboratories usually collect more blood than is needed for specific determinations. We reviewed the amount of blood collected for laboratory measurements for an entire hospital stay of 113 patients admitted during a 1-week period to a medical ward or to a medical intensive-care unit in our tertiary-care facility. The amount of blood obtained was also compared with the minimal amount needed for analysis for 18 of the most frequently ordered laboratory tests in our facility. For routine collections, a mean of 45 times the required volume of specimen (range, 2 to 102 times) was obtained. For optimal utilization of laboratory services, both the positive and the negative consequences of testing must be thoughtfully considered. Two potential adverse effects of withdrawal of blood for laboratory determinations are iatrogenic anemia and infection. Moreover, the cost of care is increased with additional analyses. Practical strategies for decreasing the amount of blood collected include an increased awareness of ordering practices, a thorough knowledge of the volume of blood needed for each laboratory test, experienced phlebotomy personnel, storage of blood specimens for potential subsequent use, and communication of accurate minimal volumes needed for specific measurements.

Assessment of quality of life in school-aged children: a method--phase I.

This is part one of a programme of research directed toward the assessment of the Quality of Life (QOL) in chronically ill school-aged children. Phase I empirically derived QOL indicators of specific value to school-aged children. The ultimate purpose is to help health care professionals reduce or eliminate adverse consequences of chronic illnesses and their treatment in school-aged children through systematic identification and evaluation of these consequences as perceived by children. A convenience sample of 96 well children, aged 7 through 12 years, were interviewed to identify QOL indicators. Data collected included: demographic profiles of the child and parents; three wishes projective question (obtains data about the child's fantasies and wishes); semi-structured interviews (obtains information regarding the physical, psychosocial, and social development while focusing on the child's activities, family life, and home environment); and What Worries You (Your Child) the Most Questionnaire (lists 30 anxiety-provoking childhood experiences). Descriptive and nonparametric statistics will be used to describe the sample and compare the child and parent's responses, respectively. Data from the interviews will be analyzed to identify common themes. A category system was inductively derived to from the themes. The specific QOL indicators will be derived from the categories to provide a foundation for an instrument to psychometrically tested. This instrument will then be modified for use with children with chronic illness.

A multidimensional study of infants' behaviors associated with assumed painful stimuli: Phase II.

Researchers have found that physiologic changes occur that indicate infants do perceive pain. In the study, infants were audiovideotaped while receiving the first diphtheria-pertussis-tetanus (DPT) injection to document their responses to an assumed painful stimulus. The vocalization of crying and some facial movements were identified as behaviors associated with receiving the DTP injection. These findings support the need for nurses to use a multidimensional assessment when caring for infants believed to be having pain.

Malakoplakia of the parotid gland.

Xanthogranulomatous inflammation is an ubiquitous process that is most commonly observed in the kidney but may be observed in other organs. We report a case of xanthogranulomatous inflammation occurring in an enlarged parotid gland of a 65-year-old man as a result of salivary duct obstruction from sialolithiasis. We discuss the common histologic features and probably common aetiology of several inflammatory xanthograulomatous processes including malakoplakia.