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Guidelines for getting into the veterinary market.

Like a Saint Bernard coming to the rescue with a keg of brandy , veterinary testing can help revive flagging finances at hospital laboratories mired in DRGs and declining census.

A small hospital stands a good chance of increasing its reference revenue by 10 to 15 per cent through aggressive pursuit of this market. Veterinarians have a great need for reliable laboratory service. They are, on the whole, a pleasure to work with-engaging, inquisitive, receptive to new ideas, and willing to talk about potential problems.

With proper training and supervision, the lab technologists and technicians choosen to perform such testing--and given a unique opportunity to expand their skills--can accurately process routine veterinary specimens.

That's what we have found since our 95-bed hospital's veterinary reference laboratory opened in the summer of 1985. Operating within the hospital lab, it serves 150 veterinarians at 60 clinics. Most of the specimens come from suburban cats and dogs, but our large service radius also brings in a lot of testing on cows and horses. To make the work even more interesting, the veterinary consultant for an area zoo sends in specimens from lions, tigers, bears, and other wildlife.

Laboratory administrators must be made aware that the new service will not show an immediate profit. Startup costs include establishment of a courier fleet and training of the technical staff. There is also the matter of preparing marketing materials and hiring at leastone salesperson to call at area veterinary clinics. The salesperson can also visit physicians' offices, nursing homes, and companies with employee testing programs. Our marketing packet includes a test menu, price list, specimen requirements, and sample requisition sheets. We now have two full-time salespersons and two full-time customer service representatives. Besides making calls on present and prospective clients, they also attend veterinary association meetings.

While getting ready to market our services, we visited area veterinarians and surveyed them on their needs. A high percentage gave the same response: A new laboratory would be well received if it provided courier pickup and delivery, 24-hour turnaround time on most tests, and accurate results.

Here is how we met the challenge:

* Courier service. We were able to economize by adding our veterinary clients to the hospital laboratory's established courier routes. Maintaining a courier service for veterinary specimens alone can be an expensive proposition, so driver time, fuel costs, and repairs must be weighed against projected revenue.

It is quite likely that the service will operate at a loss initially, as couriers travel long distances to pick up a few scattered specimens. But in time, with sufficient marketing, the number of clients and their test ordering will grow, and the runs should become profitable.

* Staffing. Most hospitals do not have doctors of veterinary medicine on staff (DVMs can be found at hospitals large enough to operate an animal research laboratory). We send slides and biopsies to two consulting veterinary pathologists for workups. Consulting veterinarians are also available if needed.

Co-author Wass, who has a Ph.D. in animal laboratory medicine and served as research associate in the hospital laboratory, was named director of the veterinary reference lab. From the hospital laboratory staff of more than 40 full-time equivalents, one medical technologist and two medical laboratory technicians were chosen for the veterinary lab. The director of the new lab provided them with initial instruction in animal laboratory medicine, including in-depth coverage of hematology, where accuracy is vital. Then they attended training sessions at veterinary schools in the region and spent three days at the small-animal clinical laboratory of the state veterinary medical school.

Veterinary lab staff members keep up to date by continuing to attend training sessions. In addition, veterinary pathologists come in to conduct in-service programs.

Only those employees trained on animal specimens should perform the tests. We made that a clear matter of policy after a well-intentioned weekend night crew got hold of some of our specimens and decided to help out the veterinary lab. On Monday morning, we were shocked to see band counts of 20 to 30 on almost every dog slide and a 4 + microcytosis on each of the cats. These were misreadings of normal cells in the animal specimens.

* Scheduling. An overlapping schedule helps us provide the widest possible coverage with a limited staff. The couriers are on the road all day, and most of the specimens come in during the late afternoon. One technologist works from 7 a.m. to 3:30 p.m., another from 10 a.m. to 5:30 p.m., and the third from 4 p.m. to 10 or 11 p.m., depending on the workload. On Saturdays, the couriers finish at noon, and the bench staff stays until 2 or 3 p.m. to process that day's specimens.

* Specimen collection. Blood specimen volume is usually small, and redraws are difficult for veterinarians. The animals aren't always available to redraw; when they are, they put up resistance (cats are usually much harder to draw than dogs).

So we try hard not to waste any of the specimen. We provide pediatric red- and lavender-top tubes and small barrier tubes designed for small quantities.

* Quality assurance. One of the tragedies of veterinary laboratory medicine is the great degree of variability between labs. We know of no national program, comparable to the College of American Pathologists' surveys, for standardized veterinary lab testing.

Thus it is absolutely essential to establish in-house normals for all tests you plan to offer. This should be done as part of the feasibility study.

We established normal animal values for three chemistry analyzers and one hematology analyzer in the hospital laboratory by first running 20 to 50 specimens of frozen pooled commercial animal sera for chemistry controls, along with freshly drawn serum and whole blood for both chemistry and hematology. We calculated the means and standard deviations, compared the results with published data, and reconciled any gross discrepancies by retesting and consultation with instrument manufacturers and veterinarians.

For quality control, we use human and frozen-pooled animal sera on each chemistry run. In addition, one of our consulting veterinarians draws biweekly fresh specimens from healthy animals for comparison with our other controls.

Normal ranges are printed on our master work sheet, which is also distributed to clients for their use in taking down test over the phone (Figure 1)

* Test menu. Since cats an dogs account for 99 per cent of the patients at the typical urban small animal clinic, it makes sense to concentrate the laboratory's efforts initially on these two species. The test menu should at a minimum offer routine testing in hematology (complete blood counts and differentials), chemistry (either 22-test or 24-test panels), endocrinology (T(sub.3) and T(sub.4)), microbiology (cultures and susceptibilities), and any special tests that can be performed with a kit (feline leukemia virus, canine heartworm, and brucellosis, for example).

At the outset, the laboratory should avoid tests that require antibody preparations as well as in-house development (most immunologic procedures). Very low-volume tests (virus, yeast, and mold procedures) should also be avoided. The lab's marketing survey can ask veterinarians about the type of tests they require and the anticipated volume.

Now let's look at the technical side of veterinary testing.

* Hematology. The key to veterinary hematology is taking the time to perform a systematic and detailed examination of each slide. Here's a guide to microscope techniques:

With low magnification (on a thin area where cells are evenly distributed), check for rouleaux formation, red blood cell agglutination, and platelet aggregation, and estimate the relative number of leukocytes. With high-dry magnification, check whether leukocytes are low, normal, or high, and do a differential count. These results should be compared with the automated count. With oil-immersion magnification, evaluate erythrocyte morphology and look for RBC inclusions, perform a second differential count if there were difficulties in count at high-dry magnification, and evaluate leukocyte morphology and platelet adequacy and morphology.

Canine erythrocytes (Figure II) are large (7 mm), uniform in size, and have a central pallor. Crenation does not readily occur. Feline erythrocytes (Figure III) average 5.8 mm in diameter and exhibit very slight central pallor and mild anisocytosis. Crenation is common. Howell-Jolly bodies (Figure IV) are present in up to 1 per cent of the cells.

The two major parasites detected in the peripheral blood smear are Hemobartonella felis (Figure V), causative agent of feline infectious anemia, and Dirofilaria immitis or canine heartworm (Figure VI).

The following points should be borne in mind when one performs hematology tests on veterinary specimens:

+ Some species normally have small RBCs compared to human RBCs. Thus what sometimes appears to be microcytosis may, in fact, be normal cells.

+ Always report neutrophil hypersegmentation (greater than six segments) and hyposegmentation (less than three segments).

+ True band cells are rare in dogs and cats. To be a band, the bar must be very thick and the arms parallel.

+ If the mean corpuscular volume is low, check for microcytosis. The results of these two tests should parallel each other.

+ If giant platelets are present, to a significant degree, the RBC count will be falsely elevated on a platelet counter. In this case, you must either reset the windows on the counter or do a manual count.

+ If Dirofilaria immitis is seen in the peripheral blood smear, run antigen-antibody tests for confirmation. The untrained observer can mistake several nonpathogenic species for this heartworm.

+ True Hemobartonella, the causative agent of feline infectious anemia, presents as very small inclusions in the red blood cell. It should not be confused with larger inclusions, such as Howell-Jolly bodies.

* Chemistry. Veterinary chemistry testing is a bit more straightforward than hematology and requires less head-scratching. Many of the same analytes' rises and falls with illness occur as in human chemistry--in BUN, creatinine, and liver enzyme testing, for example. The following points should be noted:

* Chemistry analyzers that accept very small specimen volumes help insure a low incidence of QNS (quantity not sufficient) results.

+ Some results may be anomalous, because of instrument methodology or the animal's diet.

+ All values that fall significantly outside normal ranges should be rechecked.

+ Amylase and lipase are extremely important enzymes to veterinarians. Since animal values for these enzymes run higher than instrument ranges for humans, dilution factors are crucial.

* Immunology. Reagents with antibodies specific to the species are required, so immunology really warrants extensive discussion. For our purposes here, we will just point out that most methods are manual, and the lab must develop procedures in-house for lupus erythematosus, antinuclear antibody, and Coombs' antiglobulin tests, among others.

Some tests are available in kit form--feline infectious peritonitis, parvovirus, feline leukemia, heartworm, brucellosis, and gamma globulins, for example. The laboratory has to do homework, since many of the reagents and procedures require stringent quality control, Veterinarians find T(sub.3) and T(sub.4) analyses indispensable, and these should be done by modified RIA procedures to insure accuracy at the lower values.

* Urinalysis. Information routinely reported includes specific gravity, color, and clarity in the general workup; occult blood, glucose, ketone, protein, and bile, all reported as I + to 4 + from reagent strips; results of microscopic analysis for RBCs, WBCs, epithelial cells per high-power field, mucus, bacteria, and casts.

Examination of urinary sediments is of particular importance. Except for the occurrence of bilirubin crystals in animals, sediments are similar to those seen in humans. Occasionally, oil droplets are visible in these specimens. They result from the lubricants used to catheterize the animals prior to urine collection.

* Microbiology. Figure VII shows the more important veterinary isolates found in the gastrointestinal tract, genital tract respiratory tract, urinary tract, and central nervous system of cats and dogs. Also shown are the more common bacterial isolates associated with canine and feline mastitis, skin abscesses, and ulcerations.

* Histopathology. Specimens for this type of work should not be accepted unless the laboratory can refer them to a DVM with special training in pathology.

Veterinary laboratory medicine can be intellectually stimulating for the staff, profitable for the institution, and a valuable service to the community.

Suggested reading: Ettinger, S.J. "Textbook Of Veterinary Internal Medicine," 2nd ed. Philadelphia, W. B. Saunders Co., 1983.

Coles, E.H. "Coles Veterinary Clinical Pathology," 4th ed. Philadelphia, W.B. Saunders Co., 1986.

Duncan, J.R., and Prasse, K.W. "Veterinary Laboratory Medicine: Clinical Pathology," 2nd ed. Ames, Iowa, Iowa State University, 1986.

Carter, G.R. "Diagnostic Procedures in Veterinary Bacteriology and Mycology," 4th. ed. Springfield, Ill., Charles C. Thomas, 1984.

Jain, N.C. "Schalm's Veterinary Hematology," 4th ed. Philadelphia, Lea & Febiger, 1986.

Major veterinary microbiology isolates

Canine Feline

 Central nervous ~ Bacteria rarely ~ Bacteria rarely----
 system ~ involved in dogs ~ involved in cats---

 Gastrointestinal ~ Borrelia canis ~ Candida albicans---
 tract ~ Campylobacter ~ (in kittens)cans---
 ~ Salmonella ~ Salmonellas)cans---
 ~ Entgeric bacteria, ~ Salmonellas)cans---
 ~ other (possibly) ~ Salmonellas)cans---
 ~ Spirillum sp. ~ Salmonellas)cans---
 ~ Staphylococcus aureus ~ Salmonellas)cans---
 ~ (in puppies) ~ Salmonellas)cans---

 Genital tract ~ Brucella canis ~--------------------
 ~ Brucella sp., other (rare)--------------------
 ~ Candida albicans ~--------------------
 ~ Enterobacter ~--------------------
 ~ Klebsiella ~--------------------
 ~ Mycoplasma ~--------------------
 ~ Proteus sp. ~--------------------
 ~ Pseudomonas aeruginosa ~--------------------

 Respiratory ~ Actinomyces viscosus ~ Bordetella---------
 tract ~ Blastomyces dermatitidis ~ bronchiseptica---
 ~ Bordetella bronchiseptica~ Chlamydiaseptica---
 ~ Cryptococcus neoformans ~ Cryptococcustica---
 ~ ~ neoformanstica---
 ~ Klebsiella ~ Nocardia asteroides
 ~ Mycoplasma ~ Pasteurellateroides
 ~ ~ multocidateroides
 ~ Nocardia asteroides ~ multocidateroides
 ~ Pasteurella multocida ~ multocidateroides
 ~ Streptococcus canis ~ multocidateroides

 Urinary tract ~ Corynebacterium renale ~ Specimens rarely---
 ~ (rare) ~ submittedarely---
 ~ Enterobacter ~ submittedarely---
 ~ Enterococci ~ submittedarely---
 ~ Escherichia coli ~ submittedarely---
 ~ Proteus (usually mirabilis) submittedarely---
 ~ Pseudomonas aeruginosa ~) submittedarely---
 ~ Staphylococcus aureus ~) submittedarely---
 ~ Streptococci (fecal) ~) submittedarely---
 ~ Streptococci (pyogenic) ~) submittedarely---

 Associated ~ Staphyococcus aureus ~ Staphylococcus-----
 with mastitis ~ Streptococci ~ aureuscoccus-----
 ~ ~ Streptococcius-----

 Associated ~ Actinomyces viscosus ~ Nocardia asteroides
 with skin ~ Blastomyces dermatitidis ~ Pasteurellateroides
 abscesses and ~ Nocardia asteroides ~ multocidateroides
 ulcerations ~ Sporothrix schenckii ~ multocidateroides

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No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1988 Gale, Cengage Learning. All rights reserved.

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Title Annotation:animal testing in hospital labs
Author:Wass, John A.; Mohr, Ray
Publication:Medical Laboratory Observer
Date:Feb 1, 1988
Previous Article:Labs hit with cuts under final budget accord.
Next Article:Protocols for bedside testing.

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