The Effect of Li-Heparin Plasma Preference In Emergency Unit And New Emergency Test Request Panel On Troponin I Turnaround Time

Öz

INTRODUCTION: Serum to plasma sample type change and renewal of the emergency test request panel were carried out in our laboratory workflow to decrease the turnaround time (TAT) of the troponin I test requested from the emergency department. The aim of the present study was to compare the TATs of the troponin I test between the short and long term periods before and after the workflow arrangements.
METHODS: In our study, TAT times of the emergency service troponin I test were compared in the study groups as; three months before the organization (n=1852), short-term post organization (n=1278) and long-term post organization (n=2786) at three months intervals. The data were obtained retrospectively from the Laboratory Information System.
RESULTS: Troponin I TAT times were compared between the study groups and statistically significant decreases were observed; before and after short-term workflow organization (48±20 vs 43±16 minutes, p=0.0007) before and after long-term workflow organization (48±20 vs 35±12 minutes, p=0.0002). The percentages of the troponin I values exceeding the target TAT emergency periods were also found to be significantly decreased between the study groups; before and after short-term workflow organization (p=0.001) before and after long-term workflow organization (p<0.001).
DISCUSSION AND CONCLUSION: The use of Li-heparin plasma instead of serum as a sample type and the application of new emergency test panel significantly shortened the TAT of troponin I results and the number troponin I specimen exceeding the troponin I target TAT were also found to be significantly decreased and the laboratory quality emergency unit was increased.

Anahtar Kelimeler

• process assessment,quality improvement,quality indicators,plasma,troponin I

Acil Serviste Li-Heparinli Tüp Kullanımı ve Yenilenen Acil Test Panelinin Troponin I Sonuç Verme Süresi Üzerine Etkisi

Öz

GİRİŞ ve AMAÇ: Acil servisten istenen troponin I testi sonuç verme süresini (TAT) kısaltmak amacıyla laboratuvarımız iş akışında serum yerine plazma örnek tipi değişikliği ve acil test istem panelinin yenilenmesi gibi süreç iyileştirme düzenlemeleri yapılmıştır. Çalışmamızda yapılan değişikliklerin; düzenleme öncesi ile düzenleme sonrası kısa ve uzun dönemler arasında troponin I TAT üzerine etkisinin karşılaştırılması amaçlanmıştır.
YÖNTEM ve GEREÇLER: Çalışmamızda düzenleme öncesi üç ay (n=1852) ve düzenleme sonrası üç aylık kısa dönem (n=1278) ve üç aylık uzun dönemde (n=2786) laboratuvarımıza gelen acil servis troponin I testi TAT süreleri karşılaştırılmıştır. Veriler Laboratuvar Bilgi Sistemi'nden geriye dönük olarak elde edilmiştir. 
BULGULAR: Troponin I TAT süreleri karşılaştırıldığında; düzenleme öncesi ile düzenleme sonrası kısa dönem (48±20 vs 43± 16 dakika, p=0.0007) ve düzenleme öncesi ile düzenleme sonrası uzun dönem (48±20 vs 35±12 dakika, p=0.0002) arasında istatistiksel olarak anlamlı azalma bulunmuştur. Düzenleme sonrası kısa dönem ile düzenleme sonrası uzun dönem TAT süreleri arasında da (43± 16 vs 35±12 dakika, p=0.0004) istatistiksel olarak anlamlı kısalma tespit edilmiştir. Hedef süreyi aşan örnek yüzdesinde; düzenleme öncesi ile düzenleme sonrası kısa dönem (p=0.001) ve düzenleme öncesi ile düzenleme sonrası uzun dönem (p<0.001) arasında istatistiksel olarak anlamlı azalma bulunmuştur.
TARTIŞMA ve SONUÇ: Acil servis troponin I testinin analizinde Li-heparinli plazma kullanımına geçilmesi, ve acil servis test panelinin yenilenmesi gibi süreç geliştirme düzenlemeleriyle ile troponin I TAT kısalmış, hedeflenen acil TAT ‘ı aşan örnek sayısı anlamlı olarak azalmış ve acil servis hizmet kalitesi artmıştır. 

Anahtar Kelimeler

• süreç değerlendirme,kalite iyileşmesi,kalite belirteçleri,plazma,troponin I

Kaynakça

1. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117:e25-146.
2. Morrow DA, Cannon CP, Jesse RL, Newby LK, Ravkilde J, Storrow AB, et al. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Circulation 2007; 115:e356–375.
3. Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, et al. Errors in a busy emergency department. Ann Emerg Med 2003; 42: 324-333.
4. Hardin E. Emergency medicine and the laboratory. J Natl Med Assoc 1996; 88: 279-282.
5. Goswami B, Singh B, Chawla R, Gupta VK, Mallika V. Turn Around Time (TAT) as a Benchmark of Laboratory Performance. Ind J Clin Biochem 2010; 25: 376–379.
6. Sciacovelli L, Aita A, Plebani M. Extra-analytical quality indicators and laboratory performances. Clin Biochem 2017; 50: 632–637.
7. Howanitz JH, Howanitz PJ. Laboratory results. Timeliness as a quality attribute and strategy. Am J Clin Pathol 2001;116:311–315.
8. T.C. Sağlık Bakanlığı, Sağlık Hizmetleri genel Müdürlüğü, Hastane Hizmet Kalite Standartları Kitapçığı (Versiyon-5), Bölüm Biyokimya Laboratuvar Hizmetleri, 2017, sf 287.

9. Muthu V, Kozman H, Liu K, Smulyan K, Villareal D. Cardiac troponins: bench to bedside interpretation in cardiac disease. Am J Med Sci 2014;347:331–337.
10. Steindel SJ,. Howanitz PJ. Physician Satisfaction and Emergency Department Laboratory Test Turnaround Time. Arch Pathol Lab Med 2001;125:863–871.
11. 11.Steindel SJ, Novis DA. Using outlier events to monitor test turnaround time. Arch Pathol Lab Med 1999;123:607–614.
12. Novis DA, Jones BA, Dale JC, Walsh MK, College of American Pathologists. Biochemical markers of myocardial injury test turnaround time: a College of American Pathologists Q-Probes study of 7020 troponin and 4368 creatine kinase-MB determinations in 159 institutions. Arch. Pathol. Lab. Med 2004;128: 158–164.
13. McKillop DJ, Auld P. National turnaround time survey: professional consensus standards for optimal performance and thresholds considered to compromise efficient and effective clinical management. Ann Clin Biochem 2017;54:158-164.
14. Holland LL, Smith LL, Blick KE. Reducing laboratory turnaround time outliers can reduce emergency department patient length of stay: an 11-hospital study. Am J Clin Pathol 2005;124:672–4.
15. Cadamuro J, Simundic AM, Ajzner E, Sandberg S. A pragmatic approach to sample acceptance and rejection. Clin Biochem 2017; 50: 579–581.
16. Sciacovelli L, Aita A, Plebani M. Extra-analytical quality indicators and laboratory performances. Clin Biochem 2017; 50: 632–637.
17. Sciacovelli L, Panteghini M, Lippi G, Sumarac Z, Cadamuro J, Galoro CAO, et al. Defining a roadmap for harmonizing quality indicators in Laboratory Medicine: a consensus statement on behalf of the IFCC Working Group "Laboratory Error and Patient Safety" and EFLM Task and Finish Group "Performance specifications for the extra-analytical phases". Clin Chem Lab Med 2017;55: 1478-1488.
18. Wu AH, Apple FS, Gibler WB, Jesse RL, Warshaw MM, Valdes R Jr. National Academy of Clinical Biochemistry Standards of Laboratory Practice: recommendations for the use of cardiac markers in coronary artery diseases. Clin Chem 1999;45: 1104-1121.
19. van de Kerkhof D, Peters B, Scharnhorst V. Troponin I concentrations in heparinized plasma and serum differ when measured with the Advia Centaur TnI-Ultra assay. Scand J Clin Lab Invest 2008;68:513–515.
20. Stiegler H, Fischer Y, Vazquez-Jimenez JF, Graf J, Filzmaier K, Fausten B et al. Lower cardiac troponin T and I results in heparin-plasma than in serum. Clin Chem 2000;46:1338–1344.
21. Capolaghi B, Charbonnier B, Dumontet M, Hennache B, Henninot J, Laperche T et al. Prescription, assay and interpretation of cardiac troponins tests: guidelines from SFBC-CNBC troponin working group. Ann Biol Clin (Paris) 2005;63:245–261.
22. Volmar KE, Wilkinson DS, Wagar EA, Lehman CM. Utilization of stat test priority in the clinical laboratory: a College of American Pathologists q-probes study of 52 institutions. Arch Pathol Lab Med 2013;137: 220–7.
23. Holland LL, Smith LL, Blick KE. Total Laboratory Automation Can Help Eliminate the Laboratory as a Factor in Emergency Department Length of Stay. Amer J Clin Pathol 2006, 125, 765–770.
24. Lam CW, Jacob E. Implementing a laboratory automation system: experience of a large clinical laboratory, J Lab Autom 17; 2012 16–23.
25. Lou A, Elnenaei MO, Sadek I, Thompson S, Crocker BD, Nassar B.Evaluation of the impact of a total automation system in a large core laboratory on turnaround time, Clin Biochem 2016; 49: 1254–1258.
26. Inal TC, Goruroglu Ozturk O, Kibar F, Cetiner S, Matyar S, Daglioglu G, et al. Lean six sigma methodologies improve clinical laboratory efficiency and reduce turnaround times. J Clin Lab Anal 2018;32:e22180.
27. http://www.beckmancoulter.com.tr/UploadFiles/ProductFiles/ad7bcd18-da41-455f-947c-acb3dafc176e.pdf.(erişim tarihi: 12.11.2018)
28. Archetti C, Montanelli A, Finazzi D, Caimi L, Garrafa E. Clinical Laboratory Automation: A Case Study. J Public Health Res 2017;6:881.
29. Calleja J. Parallel processing and maintaining adequate alignment between instruments and methods, Clin Biochem Rev 2008; 29 71–77.
30. Angeletti S, De Cesaris M, Hart JG, Urbano M, Vitali MA, Fragliasso F, et al. Laboratory Automation and Intra-Laboratory Turnaround Time: Experience at the University Hospital Campus Bio-Medico of Rome. J Lab Autom 2015;20: 652-658.
31. Carraro P, Plebani M. Process control reduces the laboratory turnaround time. Clin Chem Lab Med 2002; 40: 421–422.
32. Lou AH, Elnenaei MO, Sadek I, Thompson S, Crocker BD, Nassar BA. Multiple pre- and post-analytical lean approaches to the improvement of the laboratory turnaround time in a large core laboratory. Clini Biochem 2017;50: 864–869