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A case review system for chemistry QA.

Following up on unusual test results and clinicians' questions used to be a rather informal affair in the clinical chemistry laboratory of our 331-bed childrenhs hospital. As a rule, I'd write down the point on a sheet of paper, follow up when I had the time (usually scribbling my findings on the same paper), and then give a verbal answer to the person who originated the question.

No organized records were kept of questions and complaints. Valuable findings kept trickling away. To collect this information systematically, I developed a versatile case review form (Figure I). It allows us to gather details quickly and use them in a variety of ways: for formal follow-up, documentation of quality assurance activities, and education. In addition, the form has improved communication between the lab and the medical staff, and given technologists insight into how test results affect patient care.

Whenever a technologist reports an unusual result or a clinician questions a finding or method, we initiate a case review and fill out a report form to keep track of the case. There are no hard and fast rules for "abnormal" test results, since we want the system to be as flexible as possible. Of course, critical values are always followed up, while most of the slightly unusual results don't prompt queries for more information. Between those extremes, however, there's a wide area for discretion. High ammonia and enzymes in a child, for example, or test results indicative of intoxication would almost certainly provoke a request for review.

Questions from clinicians take many forms, ranging from inquiries about methods and sample collection procedures to requests for further information about the significance of a result, such as the example shown in Figure I. In that case, a 10-month-old child was admitted for the second time in three months suffering from PCP intoxication. Could the patient still be experiencing the effects of the earlier exposure to PCP, the physician wondered, or was the lates exposure definitely a recent one--A possibility the parents denied?

We researched the matter, filled out the form, and reported the findings verbally to the physician. On this second admission, both urine and serum specimens were positive for PCP. Our conclusion, after searching the literature on PCP retention, was that the child's latest exposure was most likely a fresh one.

The case review form offers an organized approach to following up such questions. For background, the reverse side summarizes data from the patient's chart (Figure II). The front of the form poses the problem, details lab action, a and offers conclusions and comments. IT also identifies the patient, the person making the inquiry, and the lab staff member handling it--myself or a clinical pathology resident.

At the bottom of the page is a key word index for several file headings, such as lab test and disease. This information block also includes patient name and ID number and the dated signature of the case reviewer, making it easier to look up problem cases chronologically. The information boxes are photocopied weekly, five to a sheet, from a stack of overlapping forms; to give us a quick reference to the number and kinds of cases in a week, month, or year.

The completed forms are filed by patient name, and cross-filed by case description and major key words. The key-word filing system should prove really useful when we eventually enter the reviews into a microcomputer data base. At that point, our student technologists will be able to call up all cases on a particular subject, such as hypernatremia, by key word.

Several laboratory regulatory agencies require documentation of quality assurance activities, and the case report form makes it much easier to provide this information. It serves as a formal record of steps taken to invesgtigate and correct potential problems.

Last year, for instance, a clinician questioned the lab about results of the breath hydrogen test, used to detect lactose malabsorption. Several patients had been showing flat response curves following a lactose load, contrary to clinical indications.

WE immediately initiated a case report form and thoroughly checked all our standards and controls. When we felt sure our procedures were correct, we ran an experiment that verified our suspicion: Variations in specimen collection techniques affected the test's results. The completed report urged strict adherence to proper collection protocols.

Education is the third major benefit of the case report forms. In addition to their usefulness to medical technology students, the reports keep chemistry staff members up to date on unusual cases and their significance. At our regular weekly staff meetings, we review interesting recent cases. These in-Service programs give technologists insight into the meaning of unusual results in terms of patient care.

When warranted, we invite a clinician to discuss a case in greater detail. If one od the case report forms in the previous week concerned a patient with very high ammonia levels, we might ask the attending physician to give a talk on the significance of the result and how the case was subsequently managed. Besides being informative, such presentations act as morale boosters, showing technologists how their efforts are integrated into quality patient care. They also create channels of communication between the laboratory and clinical staffs.

Sometimes we even get to talk to patients or their parents as part of our detective work. In a case of mercury intoxication, for example, we learned from a mother that both she and the child had played with a bottle of "pretty quicksilver" that had been lying around in their garage.

Our chemistry section has used the report system for just over three years now, and we remain very enthusiastic about its benefits. The hematology department has also adapted the form for its own use. This simple quality assurance mechanism not only helps us perform our jobs better; it makes our work more rewarding in the bargain.
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Author:Cheng, Mary H.
Publication:Medical Laboratory Observer
Date:Jul 1, 1984
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