Improving Critical Value Notification through Secure Text Messaging.

BACKGROUND: To improve communication between clinical providers and the laboratory, we recently implemented secure text messaging for our critical value notifications. This was done to communicate laboratory critical values (CV) to providers faster so changes to patient care could be done faster. Our previous method of communicating CV to providers was paging and relied on a call back to receive the critical value. METHODS: We implemented delivery of CV through a secure texting application in which the CV was directly communicated to the provider on their smart phone device. RESULTS: The mean pre-implementation turnaround time (TAT) was 11.3 minutes (median: 7 minutes, range: 0 - 210 minutes). The mean post- secure text messaging implementation TAT was 3.03 minutes (median: 0.89 minutes, range: < 1 - 95 minutes).When comparing pre- and post-implementation, there was a significant reduction in the TAT from using secure text messaging (p < 0.001). Of the 234 surveys sent out, 81 providers responded (35%). Of these responses, 85% reported that critical value notification by secure text messaging has increased their efficiency and 95% reported that critical value notification is more effective than a pager-phone-call based system. 83% of providers reported that they were able to provide better, faster care to their patients. CONCLUSIONS: Using secure text messaging (STM) to deliver critical values significantly reduces the CV TAT. Furthermore, providers noted they preferred to receive CV notifications through STM and reported that they were able to provide more effective care to their patients.

Reducing Phlebotomy Utilization With Education and Changes to Computerized Provider Order Entry.

INTRODUCTION: Daily phlebotomy is often a standard procedure in hospitalized patients. Recently, this practice has begun receiving attention as a potential target for efforts focused on eliminating overuse. Several organizations have published their efforts in this arena. Interventions have included education, feedback, and changes to computerized provider order entry (CPOE) but have yielded mixed results. METHODS: A quality improvement initiative to reduce the utilization of daily phlebotomy was conducted at a 505-bed Academic Medical Center. This project involved a combination of educational interventions and changes to CPOE. The primary end point evaluated was the daily performance of complete blood counts (CBCs) and basic metabolic profiles (BMPs) on medical and surgery units relative to the corresponding hospital census. RESULTS: Over the course of this project from August 1, 2013, to September 23, 2016, there was a 15.2% reduction in CBCs (p < .001 for linear trend) and 13.1% reduction in BMPs. DISCUSSION: Our results suggest that layering multimodal interventions that involve both "hard-wired" changes to CPOE and education and performance feedback can result in decreased utilization of phlebotomy.

Improving Laboratory Processes with Total Laboratory Automation.

BACKGROUND: To further improve workflow efficiency, our laboratory implemented a total laboratory automation (TLA) system that connected our preanalytic processing system with various testing (hematology, coagulation, and chemistry). METHODS: Detailed time and motion studies were performed to create process flow maps before and after TLA. The before maps identified opportunities for workflow improvements. We used postimplementation studies to quantify efficiency gains. RESULTS: The implementation of our TLA system resulted in 86% fewer discrete processing steps in specimen handling, even when starting from a partially automated laboratory. Instrument consolidation reduced the testing footprint by 45% and reduced the number of testing personnel by 2.5 full-time employees (FTEs). An 82% reduction in hands-on time associated with add-on processes was achieved. Combining STAT and outreach work on the testing system did not impact turnaround time. CONCLUSIONS: With careful planning, a TLA system can effectively optimize laboratory processes and efficiency.

Differential in Maximal Aerobic Capacity by Sex in Collegiate Endurance Athletes Consuming a Marginally Low Carbohydrate Diet.

PURPOSE: Although current sports nutrition recommendations advocate for a high carbohydrate (CHO) intake among endurance athletes, recent research has suggested that training with low CHO availability may augment adaptations to aerobic training. The purpose of this study was to observe the dietary habits of collegiate distance runners and to investigate the effects of habitual CHO intake on aerobic performance [VO2max(post)] during a competitive season. METHODS: During an 8-week trial period, 12 (N = 12) collegiate track athletes recorded their self-selected dietary intake via 24-hour recall. Analysis of CHO intake was conducted by a registered dietitian. Pre [VO2max (pre)] and post [VO2max (post)] season aerobic capacity assessments were performed using a one-way analysis of covariance (ANCOVA) with 2 covariates controlling for VO2max (pre) and CHO intake compared to the variance in VO2max (pre) and VO2max (post) by sex. RESULTS: The average CHO was 4.11 ± 1.03 g/kg body mass (BM), with only one female athlete meeting dietary recommendations, consuming ≥ 6 g/kg BM. Male distance runners on average had a lower CHO than females. After adjusting for VO2max (pre) and CHO, there were statistically significant differences between VO2max (post) group means by sex with a difference of 12.62 ml/kg/min (95% confidence interval [CI], 2.12-23.12, p = 0.02), with CHO accounting for 18% of the variance in VO2max (post). CONCLUSION: Collegiate distance runners exhibited marked improvements in maximal aerobic capacity during the in-season while consuming a marginally low-CHO diet, with a predominant effect in males. Therefore, CHO intakes below current recommendations for endurance athletes might not be detrimental to aerobic training adaptations.

Optimizing platelet transfusions.

PURPOSE OF REVIEW: Platelet transfusion remains a challenging procedure. Concerns about bacterial contamination and other complications, and the interest in improving the evidence base for criteria for platelet transfusion thresholds and policies have provided impetus for studies that challenge the status quo. The current review highlights recent studies and reviews which address these questions in innovative and thoughtful ways. RECENT FINDINGS: Randomized controlled trials have determined that prophylactic platelet transfusions for the prevention of bleeding in chemotherapy and hematopoietic stem cell transplant patients are superior to a therapeutic approach. For the treatment of immune refractoriness, an observational study identified that of the two main ways to treat, the provision of human leukocyte antigen-matched or cross-matched platelets, neither appears to be as effective as previously believed. When emergent reversal of antiplatelet medications is desired, platelet transfusion is common, however the evidence as to the benefit of this practice is indeterminate. ABO plasma-incompatible platelet transfusion remains a challenge as this product may pose an increased risk for hemolysis. Low-anti-A, anti-B titered products are encouraged, but are not routinely available. SUMMARY: Platelet transfusion practices are being questioned more than ever before. As we develop better therapies and guidelines, the practice of platelet therapy can be expected to change in the near future.

Default settings of computerized physician order entry system order sets drive ordering habits.

BACKGROUND: Computerized physician order entry (CPOE) systems are quickly becoming ubiquitous, and groups of orders ("order sets") to allow for easy order input are a common feature. This provides a streamlined mechanism to view, modify, and place groups of related orders. This often serves as an electronic equivalent of a specialty requisition. A characteristic, of these order sets is that specific orders can be predetermined to be "preselected" or "defaulted-on" whenever the order set is used while others are "optional" or "defaulted-off" (though there is typically the option is to "deselect" defaulted-on tests in a given situation). While it seems intuitive that the defaults in an order set are often accepted, additional study is required to understand the impact of these "default" settings in an order set on ordering habits. This study set out to quantify the effect of changing the default settings of an order set. METHODS: For quality improvement purposes, order sets dealing with transfusions were recently reviewed and modified to improve monitoring of outcome. Initially, the order for posttransfusion hematocrits and platelet count had the default setting changed from "optional" to "preselected." The default settings for platelet count was later changed back to "optional," allowing for a natural experiment to study the effect of the default selections of an order set on clinician ordering habits. RESULTS: Posttransfusion hematocrit values were ordered for 8.3% of red cell transfusions when the default order set selection was "off" and for 57.4% of transfusions when the default selection was "preselected" (P < 0.0001). Posttransfusion platelet counts were ordered for 7.0% of platelet transfusions when the initial default order set selection was "optional," increased to 59.4% when the default was changed to "preselected" (P < 0.0001), and then decreased to 7.5% when the default selection was returned to "optional." The posttransfusion platelet count rates during the two "optional" periods: 7.0% versus 7.5% - were not statistically different (P = 0.620). DISCUSSION: Default settings in CPOE order sets can significantly influence physician selection of laboratory tests. Careful consideration by all stakeholders, including clinicians and pathologists, should be obtained when establishing default settings in order sets.

Description of a formal clinical pathology on-call simulation workshop in preparing pathology residents to address common after-hours phone calls.

OBJECTIVES: Residents take clinical pathology call beginning in the second year of residency. However, this additional responsibility often causes anxiety in residents who may have had only limited contact with laboratory sections they will be covering on call. We set out to improve the practical knowledge and comfort of the residents before taking clinical pathology call. METHODS: A scenario-based simulation-style workshop was developed to acquaint residents with the common issues that arise, and guide them through acquiring the necessary data and developing an action plan. A nine-question survey was given before and after the workshop to determine if the workshop improved their comfort level with taking call. RESULTS: Of the nine questions, the six questions dealing with clinical pathology laboratory section-specific knowledge showed that residents were less anxious and more confident about taking call after the workshop. CONCLUSIONS: A scenario-based workshop is an effective way to acquaint residents with the basics of taking call, and teaches practical approaches to common clinical pathology issues.

First North American case of Hemoglobin Shepherds Bush (ß 74[E18] Gly → Asp) in a central Pennsylvania family.

BACKGROUND: Hemoglobin Shepherds Bush (Human Genome Variation Society name: HBB:c.224G > A) is an unstable hemoglobin variant resulting from a ß 74 GGC to GAC mutation (Gly to Asp) that manifests clinically as hemolytic anemia or gall bladder disease due to chronic subclinical hemolysis. CASE PRESENTATION: We report a Pennsylvania family of English descent with this condition, first noticed in a 6-year-old female. The proband presented with splenomegaly, fatigue, dark urine and an elevated indirect bilirubin. Hemoglobin identification studies and subsequent genetic testing performed according to a systematic algorithm elucidated the diagnosis of Hb Shepherds Bush. CONCLUSIONS: This is the first case of this rare hemoglobin variant identified in North America to our knowledge. It was identified using a systematic algorithm of diagnostic tests that should be followed whenever considering a rare hemoglobinopathy as part of the differential diagnosis.

Potassium changes associated with blood transfusion in pediatric patients.

Storing packed red blood cells (pRBCs) increases the potassium concentration. This effect is characterized in citrate phosphate dextrose/citrate phosphate dextrose adenine units but not published for Adsol (AS-5) units. The change in whole-blood potassium concentration in pediatric patients during routine transfusion is also poorly characterized. In this study, pediatric patients undergoing transfusion had pre- and posttransfusion whole-blood potassium measurements. The pRBC unit transfused and the unit's segment were sampled, with potassium concentration measured. In addition, potassium concentration in AS-5 units was measured over 42 days of storage. Unit extracellular potassium increased in AS-5 units after day 7 at 0.83 mmol/L/d. The mean change in patient potassium concentration was 0.08 mmol/L (range, -0.5 to 0.5 mmol/L). No correlation with unit age or unit potassium concentration was identified with change in patient whole-blood potassium concentration. The lack of clinical effect on patient potassium does not support the use of "fresh" pRBC units with routine pediatric transfusion.

Therapeutic selective neck dissection outcomes.

OBJECTIVE: To evaluate the effectiveness of selective neck dissection in patients with nodal metastases from head and neck squamous cell carcinoma. STUDY DESIGN: Historical cohort study. SETTING: Academic medical center. SUBJECTS AND METHODS: A chart review was performed on 156 subjects with clinically positive regional nodal metastases managed initially with surgery, including neck dissection. Sixty-nine subjects underwent selective neck dissection (less than 5 levels), and the majority received postoperative radiotherapy (80%). Primary outcomes included Kaplan-Meier three-year ipsilateral regional control and five-year overall survival. Cox proportional univariate and multivariate analyses were performed to determine those factors associated with outcome. RESULTS: There were two ipsilateral regional recurrences among those undergoing selective neck dissection, yielding a regional control rate of 95.9 percent. Among those undergoing comprehensive neck dissection, nine ipsilateral regional recurrences occurred, yielding a control rate of 86.0 percent (P = 0.053). No selective neck dissection recurrences occurred in a preserved level. Selective neck dissection, as compared to comprehensive neck dissection, was not adversely associated with regional recurrence, survival, or distant metastasis, even after adjusting for possible confounders (hazard ratio 0.21, P = 0.055). CONCLUSION: These results demonstrate high rates of regional disease control (96%) following selective neck dissection and radiotherapy in patients with positive neck node metastases. In this population, performing selective neck dissection with adjuvant radiotherapy for the majority of patients is supported as an effective treatment approach.

Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a risk-benefit analysis.

BACKGROUND: The only cure for primary hyperparathyroidism (1 degrees HPT) is parathyroidectomy. However, many elderly patients are not referred for surgery due to medical comorbidities and/or advanced age. The purpose of this study was to evaluate benefits against risks of parathyroidectomy in this patient population. MATERIALS AND METHODS: From March 2001 to June 2006, 50 patients aged 80 years or older with 1 degrees HPT underwent parathyroidectomy by a single surgeon. Clinical presentation and surgical outcomes of all patients were evaluated. The standard form of the SF-36 Health Survey, designed to measure patient quality of life (QOL), was completed by a subset of patients. RESULTS: There were 45 females and 5 males with a mean age of 83 +/- 2 y. Patient comorbidities included hypertension (72%), coronary artery disease (22%), diabetes mellitus (16%), chronic obstructive pulmonary disease (10%), and congestive heart failure (10%). Bone pain was the most common primary presenting symptom (44%), followed by fatigue (12%), confusion (6%), and joint pain (6%). Eleven patients (22%) had ectopic glands. The cure rate postsurgery was 98% (49/50). There were 2 postoperative complications (4%): one patient with transient hypocalcemia and another with cellulitus at an i.v. site. Of patients who completed QOL surveys, greater than 60% reported improved physical functioning, social functioning, and/or mental health, and reduction of bodily pain. CONCLUSION: Parathyroidectomy is safe and curative for octogenarians and nonagenarians with 1 degrees HPT, and maintains or improves quality of life. The surgical benefits outweigh operative risks, making parathyroid surgery an excellent option for patients over 80 years of age.

Ex vivo radioactive counts and decay rates of tissues resected during radioguided parathyroidectomy.

BACKGROUND: Radioguided parathyroidectomy using TC-99m-sestamibi injection and the handheld gamma probe allows more precise and rapid intraoperative localization of abnormal parathyroid glands. This technique is based on the principle that hypercellular parathyroid tissues have markedly higher in vivo radiotracer counts than surrounding tissue including thyroid and lymph nodes. While in vivo radioactivity after TC-99m-sestamibi administration in various tissues has been documented, there is a lack of data regarding ex vivo radioactive properties after surgical resection. METHODS: During a 6-week period in June/July 2005, 21 patients underwent radioguided parathyroidectomy by a single surgeon. Fifty-four tissue samples (39 parathyroid, 15 nonparathyroid) from these patients were collected and analyzed for ex vivo radioactive counts over a 30-min period. These data were then compared with the pathologic results. RESULTS: There is a significant difference in ex vivo counts between parathyroid adenomas, hyperplastic glands, and nonparathyroid tissue immediately after resection. However, radioactive decay/slope rates do not differ between the tissues. Importantly, an ex vivo count of >20% of background is 100% specific for parathyroid tissue. These differences persisted for up to 30 min. CONCLUSIONS: This is the first comprehensive study of ex vivo radioactive properties after TC-99m-sestamibi injection during radioguided parathyroidectomy. Parathyroids have a greater rate of uptake compared to nonparathyroid tissue, allowing ex vivo counts to predict tissue type. These tissues have similar decay rates, allowing these predictions to be made anytime up to 30 min after gland resection.

A prospective evaluation of novel methods to intraoperatively distinguish parathyroid tissue utilizing a parathyroid hormone assay.

BACKGROUND: Frozen section analysis has traditionally been used to confirm the identity of parathyroid tissue intraoperatively; however, it is time-consuming and costly and requires the excision of a significant portion of tissue. An intraoperative biopsy and analysis with a parathyroid hormone (PTH) assay is a possible alternative; however, this technique has not been perfected. METHODS: Two hundred twenty-three tissue specimens were collected prospectively from patients undergoing neck exploration. Each specimen was sampled intraoperatively using three different biopsy techniques: a fine-needle aspiration (FNA) with 10 passes of a needle (FNA10), a FNA with 20 passes of a needle (FNA20), and a tissue biopsy of approximately 1.0 mm3 (BIOPSY). The PTH concentration of each sample was determined via the Elecsys 1010 PTH immunoassay. The final tissue diagnosis was determined by histology or operative data. RESULTS: Parathyroid samples from all techniques had higher median PTH concentrations than nonparathyroid samples. However, the accuracies for the detection of parathyroid tissue varied markedly (PTH cutoff of 1000 pg/ml): the accuracies of the FNA10 and FNA20 were 71 and 80%, respectively, while the BIOPSY was 99% accurate. CONCLUSIONS: This is the first prospective study evaluating multiple methods to diagnose parathyroid tissue intraoperatively using a rapid PTH assay. We conclusively show that the BIOPSY technique is 99% accurate for the diagnosis of parathyroid tissue, and therefore, should be the method of choice when the intraoperative confirmation of parathyroid tissue is needed.

Halophilic reactions of a stable silylene with chloro and bromocarbons.

A number of disilanes have been synthesized from a stable silylene, 1 (N,N'-di-tert-butyl-1,3-diaza-2-silacyclopent-4-en-2-ylidene), and a variety of halocarbons. It is proposed that disilane formation is a result of an initial halophilic interaction between the silylene and halocarbon. Formation of disilanes from 1 and CCl4, 2a, CHCl3, 2b, CH2Cl2, 2c, benzyl chloride, 2d, and bromobenzene, 5, are described here. An X-ray crystal structure of 2b was determined.