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Filling the special needs of extended-care facilities.

Filling the special needs of extended-care facilities

Chronic disease and the infirmities of old age often make the goal of extended care not cure but rather relief of discomfort. The extended-care facility and its health care providers assume a role that is quite different from that of health care workers in other institutions. We must focus on managing metabolic and chronic conditions, preventing secondary complications, delaying deterioration and disability, and insuring patients' privacy, comfort, and dignity.

Our independent laboratory serves about 30 nursing homes in addition to various physician offices and industrial clients. We help these facilities attain their objectives not only by providing correct test results but also through personal interaction and communication with their staffs and patients. * Liaisons. Phlebotomists have long been called the ambassadors of the laboratory. Their role in serving the extended-care facility is particularly vital, since they come into direct contact with patients and staff.

Our phlebotomists receive an orientation about working with the elderly before being dispatched to do so. We feel that as much time should be spent teaching new employees to adapt to the atmosphere of the nursing home as teaching phlebotomy techniques.

One of the first lessons for health care givers working with the elderly is to comprehend that geriatric patients represent a wide range of physical, mental, and emotional health. (See "Testing needs of the elderly" elsewhere in this article.) The visual, auditory, and speech impairment common among old people understandably lead to increased stress and decreased cooperation. Taking an extra minute to explain a procedure or to gain a nurse's assistance very often makes the difference between a positive interaction and a negative one. * Scheduling. To provide laboratory testing effectively, many facilities establish "lab days" - that is, specific days of the week when phlebotomists routinely visit the facility to draw ordered specimens. Because fasting is often necessary before a specimen can be acquired, our phlebotomists arrive between 5:00 and 6:30 a.m. Patients can be found in their rooms at this time, usually asleep.

At this early hour, the nursing staff tends to be nearing the end of their shift - and of their energy. They are working hard to complete their duties and prepare for a staff changeover. Successful phlebotomists are good rapport builders who know how to minimize stress on the nurses. The patients benefit and the phlebotomists are far more productive than if they did not have excellent social skills. * Open 24 hours. We staff phlebotomists around the clock so that someone will always be available for timed draws and Stats. The early-morning staff is largest because that's when most specimens are drawn.

Our phlebotomists are dispatched upon arrival. Once they are on the road, we use beepers to maintain contact for last-minute instructions and Stats. Weather and traffic conditions, car problems, or a sudden influx of Stats - not uncommon just before a holiday weekend - may cause delays. Nevertheless, we can usually provide Stat results within two to six hours from the time of the order. We are able to provide this service while covering a metropolitan area of over 600 square miles for 24 hours a day, seven days a week. * The specimen not taken. Documentation of specimens that have been requested but not obtained is important for follow-up at the lab and charting at the extended-care facility. There are many legitimate reasons for such a situation. Geriatric patients are notoriously difficult to draw because of calcified veins, paralyzed limbs, or permanent fetal positions. Some refuse to cooperate; others are outright combative. A certain number of specimens is not obtained because the patients have been transferred to a hospital or sent home.

Whenever a specimen has not been obtained as requested, the phlebotomist fills out a notification form. On the form the phlebotomist indicates the patient's name and room number and the reason for failure to collect the specimen. Both the phlebotomist and someone from the nursing staff must sign the form, verifying that the facility has been notified about the situation. A copy of the form is left for charting at the facility.

When a patient refuses to be drawn or the specimen is difficult to obtain, at least two more distinct attempts are made. In this way, different or more experienced phlebotomists can follow up on problem patients.

If the specimen cannot be acquired after three tries, our lab generates a report stating "unable to obtain" and listing the reason. The form allows the patient's physician to evaluate the situation. Supervisory staff regularly review these forms.

According to our state inspection team, the nurse is required to keep a traceable record of the specimen collection in the patient's chart. Often the inspectors check for a draw release form. Although our notification forms are not mandatory, the nursing staff can use them to help document a patient's care. Once the specimen has been obtained, the nurse indicates this in the notes and charts the test results. * Keeping in touch. Our lab's microbiology department notifies the extended-care facility whenever methicillin-resistant staphylococci are identified. Also called in immediately is any isolation of enteric pathogens or any blood or spinal fluid culture or acid-fast-bacillus (AFB) smear that is positive for bacterial pathogens.

Our microbiologists answer questions from the facilities. The usual queries concern susceptibilities and problems with interpreting the report. We make a preliminary report upon request. Final reports are printed from our computer 48 to 72 hours after the specimen has been received.

The microbiology department works in conjunction with the facility to promote infection control. We perform environmental and hand washing cultures for our clients and are glad to provide inservice programs by an infection control consultant from the lab. In rare cases, our microbiologists will seek advice from the state health department on behalf of the facility. Every effort is made to cover a facility's infection control needs.

Our other departments are equally aware of the importance of reporting test results. All lithium drug levels, abnormal "urgent" hematology and chemistry tests, and blood sugars greater than 200 mg/dl are called in immediately. In preparing our test reports, we remain aware of the alteration from the norm that can be expected with many tests on specimens obtained from elderly patients (Table I).

Table : Table I Common alterations

of test results

in the elderly

The chart below is intended for use only as a general guide. Multiple organ involvement, which can affect a variety of test results, is common in geriatric patients. The natural effects of aging can also alter values. Simply widening the normal range to establish geriatric values may thus mask the onset of a change in the patient's health status. Physicians often rely on baseline test values from each patient to evaluate results differing slightly from the norm.
Analyte Comments
Albumin Decrease associated with heart failure, liver
 disease, low total protein, poor nutrition,
 prolonged immobilization, and low
 levels of calcium
Alkaline Upper limits of normal increase with age. Alkaline
phosphatase phosphatase isoenzymes can be used to pinpoint
 cause. Bone isoenzyme: Elevated with osteoblastic
 activity. Slight
 increases are often seen in adults over 50.
 Observed in Paget's disease, renal rickets,
 carcinoma metastatic to
 bone, celiac sprue, osteomalacia
 Intestinal isoenzyme: Tends to become elevated
 after a fatty meal or in the presence of bowel
 perforation, ulcerative
 lesions of the GI tract, or hepatic cirrhosis, and
 in patients undergoing hemodialysis
Apolipoprotein Lower levels have been noted in men older than 80
B years in conjunction with increasing HDL
 cholesterol value, which may
 be associated with longevity
B12 Unbalanced diet, common among the elderly, can
 lead to below-normal levels. Vitamin and protein
 supplements may help
BUN Increases slightly in elderly. Also increases with
 heart or renal disease, both common in elderly


Cholesterol
 Total Increased levels have been noted until
 approximately age
 60, then tend to decrease by age 80
 HDL Increased levels have been noted; may be associated
 with longevity
 LDL Decreased levels have been noted after age 65, more
 markely in women than in men
Creatinine Increases with heart or renal disease
Glucose Tends to increase slightly in geriatric patients.
 Believed to
 increase 1 mg/100 ml for every year over age 50. Thus,
 upper limit of normal expanded for the elderly
Iron See B12
Transferrin See B12
Triglycerides Decreased levels noted in men over 80 years of age


When facilities ask to be notified of other test results, we accomodate them. Such calls enable the nurses to act as soon as possible.

A call sheet for abnormal results is generated by computer and printed out every morning to verify that the appropriate calls have been made. Also printed

early each day are final reports for all tests completed the previous day.

Most tests are completed within 24 hours. Our couriers deliver these reports to the facilities and pick up specimens. We have placed printers for result reporting in facilities that will benefit most - those that are a long distance from our lab, for example. Having the printers in house expedites response and relieves the burden on our couriers.

If a printer malfunctions, we have reports printed at the lab and temporarily hand-delivered by couriers. The delivery of reports and pickup of specimens are occasionally delayed for many of the same reasons that delay our phlebotomists on the road. To keep the system running smoothly, our couriers carry beepers as well. * Satisfaction guaranteed. Our client service department, staffed by experienced medical technologists, monitors the facilities to make sure they are satisfied with our service. They visit clients to perform in-service programs and to attend utilization review meetings for feedback.

At one review meeting, a nurse commented to our service representatives that the format of our telephone result form made it hard to use. We agreed and redesigned the form.

The client service department also handles complaints. When a client files a complaint - concerning turnaround time, for example - our service department launches an investigation and the facility is informed of the outcome within 24 hours. If we discover an error, we tell our managers about it. Feedback is thus given not only to the facility but also to our laboratory. We then initiate whatever personnel interaction is appropriate, such as education, constructive criticism, disciplinary action, or a change in policy. * Meeting the challenge. Serving the geriatric population offers many challenges. It is not always easy to juggle logistics, interpret reports, and effectively communicate with clients.

We consider these efforts to be well worth while. Laboratories that extend themselves to meet the needs of extended-care facilities and their patients take advantage of a vast and growing business opportunity while performing an important public service.

General references:

Alvarez, C.; Orejas, A.; Gonzalez, S.; et al. Reference intervals for serum lipids, lipoproteins, and apolipoproteins in the elderly. Clin. Chem. 30(3): 404-406, 1984.

Ash, K.O. Research needed to set geriatic reference values. Clin. Chem. News (15)11: 7-8, November 1989.

Avorn, J.; Dreyer, P.; and Connelly, K. Use of psychoactive medication and the quality of care in rest homes, N. Engl. J. Med. 320(4): 227-232, 1989.

Berman, R.; Haxby, J.; and Pomerantz, R. Physiology of aging, Par II: Clinical implications. Patient Care 22(1): 39-54, January 15, 1988.

Blazer, D. Depression in the elderly. N. Engl. J. Med. 320(3): 164-166, 1989.

Campbell, J.A. Seeking diseases confused with dementia: "Treatable" dementia. Lab. Med. 16(7):414-416, 1985.

Finegold, S.M., and Baron, E.J. "Bailey and Scott's Diagnostic Microbiology." 7th ed. St. Louis, C.V. Mosby, 1986.

Fraser, C.G.; Cummings, S.T.; Wilkinson, S.P.; et al. Biological variability of 26 clinical chemistry analytes in elderly. Am. J. Clin. Pathol. 92(4): 465-470, 1989.

Fraser, C.G.; Wilkinson S.P.; Neville, R.G.; et al. Biologic variation of common hematologic laboratory quantities in the elderly. Am. J. Clin. Pathol. 92(4):465-470, 1989.

Jacob, R.A.; Russell, R.M.; Hartz, S.C.; et al. Blood chemistry and hematological values in the elderly compared to young adults. Clin. Chem. 29(6): 1191, 1983.

Kaplan, L.; and Pesce, A. "Clinical Chemistry: Theory, Analysis and Correlation," St. Louis, C.V. Mosby, 1984.

Lennette, E.H., ed. "Manual of Clinical Microbiology," 4th ed. Washington, D.C., American Society for Microbiology, 1985.

Lipowski, Z.J. Delirium in the elderly patient. N. Engl. J. Med. 320(9): 578-581, March 1989.

Lum, G. Serum alkaline phosphatase: Sources of increased activity. Lab. Managne. 23(5): 55-66, May 1985.

Pfaff, J. Factors related to job satisfaction/ dissatisfaction of registered nurses in long term care facilities. Nurs. Manage. 18(8): 51-55, August 1987.

Ravel, R. "Clinical Laboratory Medicine: Clinical Application of Laboratory Data." Chicago, Year Book Medical Publishers, 1984.

Resnick, N.M.; Yalla, S.V.; and Laurino, E. The pathophysiology of urinary incontinence among institutionalized elderly persons. N. Engl. J. Med. 320(1): 1-7, 1989.

Rodger, R.S.: Stuart, C.; Laker, M.F.; et l. Factors influencing normal reference intervals for creatinine, urea and electrolytes in plasma, as measured with a Beckman Astor 8 analyzer. Clin. Chem. 31(2):292-295, 1985.

Wells, T. "Aging and Health Promotion." Rockville, Md., Aspen Publishers, 1982.

Wolfson, M. Laboratory values in renal failure. Lab. Med. 16(2): 107-110, 1985.

Broka is manager of laboratory services and Standifer is client service supervisor at Perry ComfortCare Laboratory in Allen Park, Mich.
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Title Annotation:includes related article on testing needs of the elderly
Author:Broka, Jeffrey; Standifer, Robin
Publication:Medical Laboratory Observer
Date:May 1, 1990
Words:2211
Previous Article:Use strategic planning to reshape your lab's future.
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