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A support program for physicians' officelabs.

Our reference laboratory created an extensive, free consulting service on office lab operations for physicians who send us test work.

We furnish periodic check samples for proficiency testing, teach record-keeping techniques, help develop procedure manuals, and present seminars for office laboratory personnel. The service also provides discounted reagents, supplies, and quality control materials; assistance in selecting test methods and instruments; loaner equipment (primarily centrifuges and microscopes); educational materials, including use of our continuing education video library; and timely infon-nation on changing regulations through seminars, memos, and newsletters.

More than 1,000 physicians refer 700,000 tests per year to our laboratory. Ninety of these physicians use the office lab consulting service at present.

The service is an outgrowth of a Laboratory Support Program (LSP) developed in 1965 to help our hospital clients comply with Medicare requirements. Unlike the office lab program, LSP charges a monthly fee.

Ninety facilities-hospitals ranging in size from 15 to 176 beds and larger clinics-receive such services as regular on-site visits by a consulting pathologist, statistical analysis of daily quality control results, consultations on new instruments and procedures, continuing education, microscope cleaning and repair, instrument and procedure troubleshooting, loaner equipment, and discounted reagents and supplies through our buying group.

Office lab consulting started in 1985 in response to physicians' requests for assistance. It is implemented in three phases with each client:

* Phase 1. From the outset, we seek to develop a non-threatening relationship with the physician and the office laboratory staff. The underlying message is that we do not intend to run the lab but to help as much or as little as the physician wants us to.

One of our reference laboratory's five marketing representatives introduces the program to a prospective client. The physician gets an overview of the free services available if he or she refers tests to our laboratory. Emphasis is placed on access to the periodic check samples, discounted reagents and supplies, and CE resources.

If a physician expresses interest, the marketing representative completes an information sheet on the office laboratory (see Figure 1), including the names of those responsible for the lab work, an outline of the tests performed, and the instruments used. This sheet is returned to the LSP department. (From that point, I am the one primarily responsible for implementing the program with the physician's office lab. I spend about 16 hours a month working on the program, the majority of the time troubleshooting on the telephone.)

We then send an information packet to the physician's office. A cover letter fully explains the services available and tells how to use samples of quality control recording forms (Figure 11) and other packet contents. The forms gently impart the need to use QC materials and procedures, to record QC results daily, and to document such items as expected values and daily temperatures of refrigerators and incubators. In addition, they indicate a simple way to add a patient test log to laboratory records.

The packet also contains a catalog of our two videotape collections . One set is made up of continuing education programs that we purchase through an annual subscription; there are more than 200 videotapes, and the list grows monthly. These tapes relate to the diagnosis, and treatment of patients in the physician's practice.

We assembled the second collection, more than 150 tapes and also growing, by recording our own lab's CE programs. These range from basic subjects, such as how to perform phlebotomy or a Gram stain, to advanced matters, such as bone marrow examination or the interpretation of hepatitis profiles.

Monthly check samples targeting one or another area of the laboratory have introduced many of our physicians to the concept of proficiency testing, and they perceive this as the most beneficial part of the support program. The samples are self-graded in order to be non-threatening. We encourage physicians to compare the results with the expected ones that are provided and to contact the LSP department if any questions or problems arise.

The check samples come from a variety of sources. In chemistry, our laboratory reconstitutes, pools, and reassays lyophilized outdated controls for the particular test being challenged. The materials are then aliquoted and packaged to be sent to clients.

In microbiology, cultures of organisms are used to prepare smears, which are air-dried and sent to clients to be fixed, stained, and read according to their procedures. Outdated controls, stained and unstained peripheral smears, and 35 mm slides are used for hematology. In urinalysis, check samples are created by adding materials to distilled water that will result in positive reactions to various parts of the dipstick. For urine sediment, 35 mm slides are used.

An insert accompanying each check sample names the test to be performed, gives simple instructions, and suggests safety precautions if necessary. A Quick Fact Sheet, sealed in a separate envelope, includes expected results with both a target value and an acceptable range when appropriate (Figure III). We encourage clients to compare their results and record them for future reference. If a client contacts us with a discrepancy, we will work with the office lab to identify the problem.

The fact sheet also serves as an educational tool. It briefly describes test methodologies, including advantages and disadvantages, and potential sources of error in particular test procedures applicable to the check sample. In addition, it explains diagnostic clues offered by the expected values and correlates the values with signs and symptoms a patient with such results might exhibit.

* Phase II. This part of the office laboratory support program provides consultation on instruments. A physician's lack of experience in the clinical lab, combined with the large vafiety of small analyzers now being marketed, often leads to a request for such consultation.

First, a questionnaire about the office lab is completed. Among other things, it asks about tests that need to be added, expected volume, the desired charge for each test, the amount of money the practice wants to spend on an instrument, the level of staff expertise in testing, and the need for profiles and/or random access.

With this information, the LSP department prepares a list of instruments, including advantages and shortcomings, that are suitable choices for the physician's laboratory. No specific instrument is recommended. The aim is to provide data that enable the physician to make an informed decision.

Our laboratory does recoup a portion of its investment in this process. Select instruments, which we feel are useful and reliable in the office setting, can be purchased at a discount through our buying group. The group also offers reagents for these instruments at a lower price.

This phase of the support program leads to greater physician reliance on the reference laboratory and a more tightly bonded working relationship.

* Phase 111. Here we take an even higher profile in the working relationship with the physician's office laboratory, through an occasional on-site visit. We offer to visit when telephone troubleshooting is not solving a particular problem or when more insight is required into the need for a new instrument.

Technical problems can often be solved visually, by observing lab personnel at work and picking up on small hand-skill errors-poor pipetting technique, for example, or failure to use a well-mixed specimen for a blood count.

This third phase also involves continuing education. By way of background: Twice a year we present an all-day seminar for hospital laboratory support program panicipants. In January 1987, the seminar drew more than 300; in November, more than 200. Till now, the seminars have been held in Oklahoma City, but in 1989 we plan to conduct a series of regional seminars throughout the state. The seminars are usually technical, providing refresher information for technologists from remote areas where CE is not readily available as well as new information on changing technology.

Recently, we have invited our physician clients' staff members to these seminars. It quickly became apparent, however, that a separate program is needed to meet the educational needs of office laboratory personnel. They require more basic information and opportunities to refine hand skills that hospital laboratory personnel take for granted.

In addition, the seminars have usually been held on a Friday because attendance from small hospitals is better on weekdays. Attendance from the physicians' offices is poor on Friday because the staff cannot be spared from the regular work schedule.

So we are mapping plans for workshops that more closely fit office lab needs. Shorter programs are under consideration, early in the morning before office hours begin or on Saturdays when physicians' offices are closed.

The possibility of developing a series of written, self-instructed, individually paced educational materials is being explored. These materials would be available for purchase by physicians' offices.

Physician clients have eagerly received our office laboratory support program. It has been designed with the philosophy that physicians neither want nor need us to oversee their office labs. Instead, we provide ready but unobtrusive assistance and support when desired. The consulting program also prepares office labs for possible future regulation.

Our reference laboratory benefits when physicians send us tests in order to take advantage of the program. Our personal service philosophy establishes a level of trust with clients that allows a working relationship to develop. That is a big advantage in the rapidly changing, increasingly competitive reference laboratory market.

Quick fact sheet for a check sample

Serum potassium

The check sample this month is serum potassium (K+), which is one of the serum electrolytes, Although potassium is in high concentration inside cells of the body (including red cells, where sodium is in low concentration) just the reverse is true in serum where the normal concentration is only a traction of that of sodium. However, only small fluctuations of serum potassium above or below normal can produce a variety of problems for the patient, particularly if it is high; it may so disturb the electrical activity of the heart that cardiac arrhythmia and death can result. Thus it is important for the physician to closely monitor serum K' values in patients who might be prone to high or low results. Two of the more common clinical situations of this type are patients with kidney failure (serum K + may tend to run high) and patients on diuretics (serum K + may tend to run low because of provoked potassium loss through the kidneys).

There are several basic methods used for measuring serum K + . The more classicial method uses flame photometry. This method is rapidly being replaced by methods based on ion-selective electrodes (ISE). However, because of the expense and complexity of this instrumentation, serum K ' is measured in many smaller laboratories by various colorimetric methods in which the K + of the patient's serum is reacted with reagent to form a colored compound that can then be measured by a photometer in a light beam.

Accuracy in measuring serum K ' is important because of the very small normal range in healthy patients (generally about 3.5 to 5.0 milliequivalents per liter) and because only relatively minor changes from normal may have major adverse effects on the patient (possible "panic" values: less than 3.0 and above 6.0 mEq/L,).

Contaminating potassium from outside sources may cause a false high potassium reading in specimens. Common sources of such errors include hemolysis in the specimen (red cells are very rich in potassium), unclean glassware or equivalent, or potassium-containing anticoagulant from simultaneously collected whole blood specimens. To avoid the latter situation, if you are drawing more than one type of specimen from a given patient, particularly if you are using a Vacutainer adapter method, always draw the serum sample (red stopper) tube first and the anticoagulated specimen (e.g., purple stopper) last.

Target value for this specimen: 4.2 mEq/L

Acceptable range: 3.9-4.5 mEq/L

Dan F. Keller, M. D.

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Author:Moser, Elaine
Publication:Medical Laboratory Observer
Date:Jan 1, 1989
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