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It's time to computerize urinalysis.

The data management trend that extends to all manner of assays seems to have skipped one of the most common testing areas. Urinalysis is still by and large made up of manually recorded procedures, performed at several different work stations. It sorely needs computer help to reduce transcription errors, gather together a patient's scattered results, and present a comprehensive picture for diagnostic interpretation.

Our research department recently investigated the problem. Before I describe what we found, let's consider the scope of urinalysis today.

It is essential for early detection, diagnosis, and monitoring of many conditions, three of the most obvious being kidney damage, genitourinary tract infections, and diabetes. More than 200 million urinalyses are performed in the United States yearly, an average of 550,000 tests a day.

Urinalysis is one of the few laboratory tests that the Joint Commission on Accreditation of Hospitals requires for all hospital admissions. Most hospital labs offer it around the clock, every day. It's also performed in many independent and physicians' office labs.

Routine urinalysis may involve four principal subroutines. Physical examination includes macroscopic assessment of specimen appearance, color, and clarity. Chemical analysis, performed in most laboratories by the reagent dipstick method, provides results for pH, solute concentration (osmolality, refractive index, and specific gravity), protein, glucose, ketone bodies, hemoglobin, bile, urobilinogen, and nitrites.

Further confirmatory tests may be performed for positive glucose, protein, blood, glucose, and other reducing substance tests. The urine is then centrifuged, the supernatant discarded, and the sediment examined microscopically for red blood cells, white blood cells, casts, crystals, mucus, epithelial cells, microorganisms, and spermatozoa. Besides these four procedures, a fifth may be indicated to arrive at a diagnosis--the urine culture.

We visited 15 settings in the East and Midwest where urinalyses are performed by the dipstick method--physicians' offices, clinics, and hospitals that range in size from a solo practice to a 1,100-bed institution. The smallest performed no more than five to 10 urinalyses a day; the biggest, more than 100 a day.

The larger hospitals operate satellite laboratories for ambulatory, ICU, emergency, and prenatal patients. They have Stat Laboratories for evening, overnight, and weekend testing. Some also serve outlying renal and prenatal clinics, which adds to the urinalysis workload.

It was no surprise to find that these disparate facilities handle urine specimens differently. Some prepare specimen labels manually, while others use a hospital or laboratory computer to generate labels from worksheets.

Almost all the labs create corresponding workload lists of patient names, ID numbers, and specimen accession numbers, either manually or through a computer. In manual systems, each accession number is transcribed from label to workload list. Low-volume physicians' labs don't need workload lists.

Actual analysis varies only slightly among the labs we visited. Once a specimen is labeled and the patient's name and ID number are recorded, the technologist examines it for color and clarity and documents all observations.

Nine of the 15 labs use semiautomated strip readers. None of the readers are interfaced to other computers, however; test data are either transcribed from the instrument display to the patient result log and patient report, or they are printed on a separate report by a rol or form printer, then transcribed to the patient log. Confirmatory test results are also transcribed manually.

After sedimentation, every laboratory in our survey performs microscopic analysis at a separate work station, which may be as far as 30 feet from the chemical analysis station. Some labs transcribe microscopic analysis results onto the result log and patient report containing the chemistry data. Others note results on a separate record that's copied onto the patient log and patient report.

When urinalysis is completed, all of the laboratories have two full sets of results--the patient log for the laboratory record and the report that is charted for the patient's file. It takes at least seven manual transcription steps to report a routine urinalysis examination (Figure I).

Ironically, use of a hospital or laboratory computer entails additional transcription. At one of the hospitals, an optical card reader is used to enter results into the computer. A form printer interfaced to the dipstick reader transfers the urine chemistry results to the card, but microscopic findings must be added manually. At all other labs with computers, urinalysis results are entered through a keyboard.

There are relatively simple ways to alleviate time-consuming, manual documentation of urinalysis data. We found solutions on three levels, depending on initial financial investment, under a broad heading of automated collation of results. Here they are:

* Level I. A semiautomated urinalysis instrument reads the dipstick, increasing reliability and reproducibility of the chemical testing. The instrument transcribes those results only. Patient and specimen information and the specimen's physical and microscopic characteristics must be added to the report manually.

* Level II. Here, a urinalysis instrument equipped with a standard RS-232C or parallel interface is connected to a microcomputer for automated entry of chemistry results. With development of appropriate software, the following can be keyed into the computer: patient name and ID number; specimen accession number; time of collection and time of report; specimen type, color, and clarity; confirmatory test results; and microscopic examination results.

At this level, urinalysis data are readily collated and recorded on one patient report. The system is limited because all of the data but the chemistries must be entered by keyboard, but the software can be designed to allow some entries through a single keystroke chosen from a menu display.

This system would generate the daily patient log, eliminating manual logging of results and cutting the potential for operator error. The report provides reference values and flags any critical values and confirmatory test results, improving laboratory-clinician communication.

* Level III. At this level, a complete urinalysis data collation system ties together the urinalysis instrument, microcomputer, printer, and one or more video display terminals (VDTs).

The VDTs are placed at microscopic exam work stations, where technologists review urine chemistry results and enter microscopic findings. The latter data are transferred directly to the microcomputer and combined with patient and specimen information and chemistry results. The microcomputer generates a printed report to finish the sequence (Figure II). All records are stored on diskettes at the end of each day, to be recalled as needed.

The Level III system can be linked to a mainframe computer. Then operators can use the hospital's data base to enter patient information and transmit reports to terminals at nursing stations, emergency rooms, and satellite laboratories.

Urine cultures are usually indicated by abnormal findings in routine urinalysis, and growth takes one or two days. By that time, routine results have been sent out or filed. They're not conveniently available to to the microbiologist, who needs them for the best possible interpretation.

In Level III, microbiology has its own VDT. The operator calls up routine urinalysis results and correlates them with culture findings. Significant and insignificant organism growth can then be better distinguished without losing time combing reports or logs for the urinalysis data. Fast, accurate reporting is more important than ever under prospective payment. At Level III, the laboratory can also perform follow-up tests the same day, as the pathologist directs, based on abnormal findings.

Isn't it high time we computerized urinalysis?
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Author:Swezey, Carol B.
Publication:Medical Laboratory Observer
Date:Nov 1, 1984
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