Microbiology work cards: preprinting gets the message across.
Until two years ago, we had that problem--even though we thought we were communicating as well as possible about work in progress. Then the addition of a screen for Campylobacter species on routine stool cultures compelled us to redesign our microbiology work cards. Suddenly, better and faster message techniques became apparent.
The key was to preprint much of the information that formerly was entered by hand. Technologists now only had to circle the correct finding or cross off the correct box. They all began talking the same, clear language.
We process 180 to 250 new specimens a day for our 225-bed hospital and its clinics. The workload is double to triple that, counting two- and three-day cultures. In the past, one multipurpose work card served to record data on stool, urine, and miscellaneous (throat, cervix, fluids) specimens. We had to handwrite the four culture media used: gram negative broth, eosin methylene blue, Shigella and Salmonella agar, and Hektoen, abbreviated on the card as GN, EMB, SS, and HE. Documentation of other tests performed and all reporting also were written in by technologists.
A single staff member ideally followed through from one day to the next on a long-term culture, but vacations, days off, and weekend rotations would at times force technologists to read cultures that had been set up by others.
With introduction of the Campylobacter screen, we expected technologists to team up more often on the same culture. The new medium and its incubation differed from our routine stool media, so all steps could be performed together. The Campylobacter plate was incubated at a higher temperature and held longer. There had to be a way to clearly document when each portion of the culture was complete.
The eight full-time, part-time, and rotating technologists, the three lab assistants, and I contributed to the format of the new card. In a month's time, after several group meetings and rough drafts, a final version was ready for the printer.
We kept our 5 X 8 card size, which facilitates clipping to lab slips and filing. The three basic areas of information that the work card covers were retained in the same positions on the card. Patient identification appears at the upper left; documentation of procedures performed, on the left, takes up a little more than half the space of the card; and reporting of final results appears on the right.
The main changes were in the extent of preprinted information and the use of the card for stool specimens only (Figure 1). An orange color (but other cards were white) set off the form for quick identification and retrieval from files.
Previously, the patient identification block included name, medical number, doctor, date, antibiotic, and specimen source. In addition to a space for the patient's room number, we inserted cross-off boxes to indicate other areas where specimens might originate: UCC (urgent care clinic), ER (emergency room), OP (outpatient), and clinic (outpatient clinic). These entries are necessary because the work card notifies the infection control nurse of infections present in the hospital. We had always provided the information, but it was handwritten before.
The card also has a space for the initials of the person processing the specimen. A time/date stamp registers receipt of the specimen in the lab.
Since only 2 to 5 per cent of our stool specimens have the type of pathogen requiring susceptibility testing, we did not permit "susceptibility requested" on the stool work card. It does appear on our new urine and miscellaneous work cards.
On the documentation side of the card, we added CAMPY BAP (Campylobacter blood agar plate) to the other culture media (GN, EMB, SS, and HE). Two other preprinted notations, Na and Cl, refer to the antibiotics nalidixic acid and cephalosporin. For these, a technologist circles S for susceptible or R for resistant.
We use the r/b enteric system to identify nonlactose fermenters. Biochemical reactions can rapidly be recorded by circling + or - for each biochemical test. A cross-off box indicates normal flora (NF). Documentation of work done and reported results are clear, concise, and easy to follow.
Bench technologists judged the stool specimen work card a success within a few months. It reduced the time required to process specimens and log results. Moreover, communication from technologists to technologist was unambiguous. The technologist preparing the final report could follow what came before without actually having worked on the culture.
The hospital's physicians and infection control nurses told us how much easier it was to read the reports. Laboratory assistants and clerical personnel no longer had to decipher handwriting, thereby increasing the accuracy of phoned reports.
As a result, we decided to take another look at the old work card, which was still in use for urine and miscellaneous cultures. We thought it important to develop a urine card next because we process about 1,500 urine specimens a month. The documentation was quite tedious and often hard to follow.
Another round of staff suggestions produced a 5 X 8 yellow card (Figure II) with a patient ID block and a documentation format similar to the stool card. We usually perform susceptibility testing on any significant pathogens in urine cultures. Therefore the final report section of this card includes an area for documentation of susceptibility patterns.
Antibiotics are listed by abbreviation, and the technologist circles the appropriate results: s for susceptible, i for intermediate, or r for resistant. Colony counts and identification of organisms are handwritten.
After a few months of use, the urine work card was further modified to include cross-off boxes on the report side for mixed flora, gram positive flora, and probable coliforms. This change further reduced handwritten notations. Laboratory and hospital personnel reacted as favorably as they had to the stool cards.
Our third custom-designed card, 5 X 8 and white, was completed this year. Since it covers several kinds of cultures--throat, cervix, and fluids--it contains less formatted information (Figure III). For the future, we are considering specific work cards for anaerobes and positive blood cultures.
Our original intent was to find space for a new screen on our work card and improve written communication. We achieved this and reaped an extra benefit: We saved time. When asked how much time, our technologists recently came up with the following numbers:
The new work cards save 30 seconds per stool culture read, 25 seconds per positive urine culture, 15 seconds per negative urine culture, and 15 seconds per miscellaneous culture read. That amounts to 58.3 minutes of total technologist time each day. On top of that, the new cards save 10 seconds of lab assistant time per culture setup, or about 20 minutes a day.
We can't measure the other time saved, the minutes the head-scratching and puzzling over unreadable entries. Suffice it to say, we are all in a better frame of mind.
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|Publication:||Medical Laboratory Observer|
|Date:||Feb 1, 1984|
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