Abnormal hematology patients: flagged and not forgotten.

Abnormal hematology patients: Flagged and not forgotten

In our hematology department, we created a simple system to keep us from routinely reinventing the wheel. By recording on ordinary index cards the names of all patients with abnormal blood tests, we speed their treatment and prevent unnecessarily repeating tests. In the four years since the system began at our 101-bed acute-care hospital, we have accumulated about 600 cards.

Since initiating our "low-tech" system, we have identified undiagnosed patients more quickly and monitored diagnosed ones more accurately. A dimestore file box holding standard 3 X 5-inch file cards suits us, but a lab with a personal computer could institute a similar system in a more sophisticated way. (We never have to worry about electrical failures or system downtime!) Actually, a total laboratory computer system is in next year's budget. We're hoping to obtain a PC in our department ... one fine day. Until then:

Review of abnormal patient results takes place as follows. Our pathologist has established criteria for patient review (Table I).

Table 1 : Table I Criteria for patient review

WBC [less than]2.0 or

[greather than]18.0 x [10.sup.3]cells/[mm.sup.3]

HGB [less than]6.0 or [greater than]18.0 g/dl

MCV [less than]80 or [greater than]105(prewarm and rerun)

PLT [less than]20 or [greater than]1,000 x [10.sup.3] cells/[mm.sup.3]

RBC morphology [greater than]2 + Immature neutrophil series

younger than bands

Increased single-cell population [greater than]3% basophils

When a patient's medical condition qualifies, his or her card is placed in a designated in-basket along with the differential slide and the cell counter's histogram. All relevant information that's available about the patient is noted on the histogram, as are the technologist's reported differential and results of any other hematologic tests. When the pathologist brings back the histogram and differential slide, the technologist on duty makes up the card. The slide is filed separately.

Granted, data for any patient previously admitted to a different hospital would not be found there; but in our community, many patients are "repeats." We do not make the mistake of assuming that absence of a card from the file box implies no previous illness.

Before the pathologist goes on morning rounds, the hematology supervisor reviews the patient results left for the pathologist's scrutiny and checks the log book for any abnormal test results that may have been overlooked. The name of any patient who is suspected to have an ongoing hematologic process is then entered on a card and filed. Abnormal findings are left for further review only if the test results fail to conform with the primary diagnosis.

Any time a technologist encounters an abnormal result, he or she looks in the card file to see whether it contains a card for the patient. (Sample cards are shown in Figure I.) Such entries might include a hemoglobinopathy, a bone marrow diagnosis, or a chemotherapy-induced abnormal count. We now list the name of the admitting physician as well, so that we can give it to the ER physician right away.

As subsequent lab tests take place for each patient, any additional abnormal results are entered on the same card. The system has been particularly helpful for monitoring chronic conditions such as iron-deficiency anemias, megaloblastic anemias, and leukemia as well as patients undergoing chemotherapy. * Underlying benefits. The system has also stimulated technologists to think about each differential while performing it or as the result is displayed on the cell counter. We have found that abnormal results in general, especially in unknown patients, are being questioned sooner than they were before. Our technologists, who have learned to use the histograms generated by the cell counter before looking at a blood smear, are often seen reaching for the patient file as the work is being printed on requisition slips.

Having the box available to MTs performing differentials on all shifts has been a boon. We have greatly enhanced continuity of information between laboratory shifts and departments - not an easy task, with high technologist turnover, increased workload, and departmental rotations.

Technologists no longer have to rely on the colleague who has a memory like an elephant to dredge up former patients' names and diagnoses. New employees don't have to worry about their failure to recognize previous patients' names and can make the same contribution to patient care continuity as old hands. The office filing system is more orderly, simply because MTs no longer have to flip through months of files to learn the last time a patient came to the hospital and what results were reported.

Our pathologist occasionally relies on the file to see whether a patient has been previously reviewed, and if so, when. Patients unresponsive to therapy can therefore be evaluated more quickly. * Our turn. Blood banks have filed information about abnormal patients for years. Now it is hematology's turn to monitor patients and to become concerned about all CBC parameters, not just WBC and HCT.

In coordination with review criteria, our system encourages technologists to think about the possible etiology of a particular abnormal parameter. For example, low mean corpuscular volume may signify either iron deficiency or a hemoglobinopathy, whereas high MCV may suggest cold agglutinins, vitamin B[sub.12] or folate deficiency, or another problem.

Since the system was implemented, I have noticed increased interest and concern by the lab technologists. They are asking more questions about how the body responds to therapy and the etiology of disease states. The reference books in the library look more dog-eared, too - always a good sign.

Our little file box has made surprisingly far-reaching improvements in our hematology department. It has saved us time and money by increasing the productivity of our hematology technologists as well as giving them more confidence. It has stimulated the other technologists to pursue any deviations they find from previously reported results and normals. Our active review of abnormals by the technologist performing the testing, the hematology supervisor, and the pathologist helps insure the reliability of results. Most important, it has improved patient care and reminded technologists that enhancing health is our daily business.

The author is hematology/blood bank supervisor, Oneida City Hospital, Oneida, N.Y.