Fecal Transplants and the Laboratory Professional

Fecal transplants are used to cure patients with stubborn C. difficile infections by repopulating their colons with normal flora. (If you want a refresher, check out Lab Medicine’s podcast on fecal transplants.) Ideally, family members of such patients donate the necessary stool, but that’s not always possible. Perhaps the family member has bowel issues themselves, or maybe they have an infectious disease that can be transmitted through stool. So what’s a patient to do? Thanks to companies like OpenBiome, they can use banked stool for their procedure.

The New York Times published an article about OpenBiome. The article touches on the FDA stance on this procedure and mentions that if this procedure is restricted, there is a risk of a black market. Fecal transplants are effective, after all, and the source material is free and easy to obtain. However, like anything done in the metaphorical back alley, there could be serious consequences (disease transmission comes to mind).

Fecal transplants aren’t going away, so if you work in micro they need to be on your radar. Perhaps making a fecal bank of sorts for your patients is an avenue worth exploring.

 

Swails

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Resident Didactic Training – How Do You Learn Best?

Lately, I’ve been thinking about what I need from my residency training to become a competent pathologist when I graduate and how I learn best. I’ve never been a good audio learner so I don’t learn as much from a purely lecture-based education. And truth be told, I often skipped classes during medical school but wasn’t reprimanded probably because I did fine in my classes. It’s taken me years to realize but I learn best by making connections. Maybe it’s the scientist in me but I remember more, and can figure out the concept again if I forget it, if I understand mechanisms than by rote memorization. So for me, what I need most is time that often is not afforded in a live lecture. I often prefer to watch video recordings on pathology topics because I can stop the recording and think (or jot down a note or two). The “flipped classroom” concept works better for someone like me.

And so, this brings me to resident education. Unlike other specialties, we spend a lot of time on didactics. But there are many different permutations to how programs accomplish this objective. At my program, we have a lot of live lectures or multi-scope sessions. I faithfully try to attend (especially since we have a 90% attendance policy), but most of my attendings know that this is not how I learn best. Anything I have to learn by hearing on the spot has never been my strength.

But, I’ve found two methods at my program that do fit my learning style. First, we have a whole slide scanner. It’s great because we are allowed to scan slides to build our own virtual slide sets for repetitive study later if we so choose. Also, our surgical pathology director has given much of her time to annotating slides for us to use for “unknowns.” She can even compile data such as tracking how long it takes us to find an important required feature on the slide as well as our movements on the slide. She can also compare our scores from year to year if we use the same slide set (which we found didn’t significantly increase our knowledge if tested on the same subject the following year so we’re no longer required to do so).

With digital slides, I like having the option to go back and look over the slides as many times as I need. I didn’t realize how fortunate we were to have a slide scanner at our disposal until I presented some of this data at USCAP during my first year – many residents and attendings that stopped by my poster told me that they didn’t have access to digital slides or a slide scanner at their institutions. But looking at whole slide imaging (WSI) is a skill we all need to master since up to 2/3 of our AP boards can be digital (not glass) slides so I’m glad that I’m exposed to it early and throughout my training.

The second method that I found that really helps me to learn surgical pathology is the unknowns conference conducted at one of our four hospitals. We’re given four slides (which is the perfect number to cover in up to an hour) a couple of days in advance and the residents work together to come up with a differential and diagnosis. Since our attending always gives us papers on the diagnoses, we often read articles while we are working up the differential – which for someone who is used to reading journal articles and reviews, is right down my alley! We take turns during the conference driving at the scope and describe what we see at low then high power and then we give our differential and begin to narrow it down.

After each slide, our attending will reveal the correct diagnosis, point out salient morphologic features (especially with mimickers that can confuse us), and ask us about appropriate ancillary tests and expected results before giving us articles to read on the diagnosis. I’ve found that the interactive approach really helps but more so than that is the visual learning (ie – reading books and articles, googling on the internet) that I did to prepare for this conference. More important than getting the right diagnosis by “wallpapering” (ie – matching up a picture with the slide to reach a diagnosis) is the thought process to narrow down the differential.

And lastly, this is not specific to my program, but I am a strong supporter of open sourcing and sharing of free online didactics. I’ve often found great videos from other programs online or on YouTube to supplement my learning. So how do you learn best? Does your program provide all the tools that you need?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Dispensaries

I know a lot of you have heard already, but for those of you who haven’t, last week CMS ruled to amend CLIA regulations that will now allow laboratories to release test results directly to patients.  Once you pick your jaw back up off the floor your mind will start processing a mile a minute what this means for individual laboratories.  If you are a supervisor/manager such as me your mind is going exponentially faster thinking of all the ways that this now makes your life more difficult.

Right off the bat as a supervisor/manager you should be thinking about producing an SOP (standard operating procedure) that details how you will handle requests and what you are and are not responsible for when it comes to providing information to patients.  You are going to need detailed information on how you will properly identify the patient, patient’s personal representative; or my personal favorite, a person designated by the patient.  I can hear the phone ringing now.

“Laboratory this is Matt, How can I help you?”

“Yes, Hello, My name is Lenny Lipase and my neighbor Pete Potassium wanted me to call in to your laboratory and get some of his lab results.”

There is most definitely going to be some individual interpretation of this new amendment and each laboratory is going to have to determine how it wants to address requests.  No matter which direction you go a solid policy/procedure for handling these new requests will be your best friend.  When you receive complaints, and you know they will come, you will have something to fall back on that states a definite policy/procedure and that meets the new standard that has been set forth by CMS.

So let us address the 800lb. gorilla in the room.  You have started taking requests for results and a patient comes to your lab, picks up the results, opens them, and then says, “Why is my glucose so high? Does eating a candy bar for breakfast affect this?”  Your worst nightmare, right?  A patient wanting counsel on results will be the biggest challenge for any laboratory and may have been a possible oversight by CMS on this ruling.  One way to nip this right off the bat is to send hard copies of results in the mail.  This assures that patients will not be wandering around your lab asking for counsel on their results.  If you decide to be brave and let patients physically pick their results, I would either have a disclaimer page with every result handed/mailed out or written very clearly in your policy/procedure stating that patients only discuss their results with their physician.  You must protect yourself from liability when it comes to discussing results with patients.  I felt as though the previous ruling was a laboratory professional’s layer of protection against this.  We could not directly give patients results so it forced them to speak with their physicians.

I have read that some laboratory professionals are happy with this saying that patients should take more of the responsibility of their own healthcare.  I agree with this but I also have spoken to physicians who are not happy with this ruling because they want to go over results with their patients to properly explain what they mean.  More than likely a physician will still have to release the results first before a patient can view them but if not you may have a panicked patient calling physician offices or even worse 911.  This may seem extreme but you don’t know how patients will react seeing results they do not know anything about.  We will now be another controller of patient information that has been deregulated a bit.  It is for medical use only of course but how comfortable will you feel being a result dispensary?

 

Herasuta

Matthew Herasuta, MBA, MLS(ASCP)CM is a medical laboratory scientist who works as a generalist and serves as the Blood Bank and General Supervisor for the regional Euclid Hospital in Cleveland, OH.

Customer Service—A Global Perspective

Last time we talked about how customer service changes the perspective of our patients/customers, and how they judge the quality of our laboratories by their snapshot visit to the drawing station. Over the years, I’ve seen some good, some bad, and some very ugly customer service practices…one I discovered even in my own laboratory one day, just by having my blood drawn in the outpatient phlebotomy draw station!

There are lots of “best practices” around the world, and it is interesting for me to hear from colleagues or observe practices that I think are worth knowing, and worth sharing. One comes to mind in a favorite place in Africa. The rural clinic was always very busy, people everywhere lined up on benches waiting to be seen or for pharmacy or for a lab/radiology procedure. It looked like every busy primary clinic everywhere, except for the lovely colorful headdresses on the women and the different kinds of “baby carriers.” When you looked closely, many people did not have shoes, and also had their lunch nearby in a tin carrier because they were prepared to spend the day. When you looked even more closely, sometimes you see smiles and congenial conversation…but more often you can see eyes showing pain or illness, tears, fear, compassion and concern on the faces of those there to receive care, and those there for support.

In this particular busy clinic, the laboratory drawing room was down a narrow hall off to one side, and had steel bars on the door with a buzzer for entry. A necessity, but not very inviting. My African colleagues were concerned that patients would be intimidated by the negative appearance, as many of them travelled miles to get there with children or family and often didn’t even speak the dialect of the district. So they decided to do what they called “walk around draws.” Two phlebotomists took turns, one in the “caged drawing room” and one with a lab tray “roaming the waiting room.” The “roamer” would ask if the patient wished to have their blood drawn in the room down the hall, or if they would prefer a “bed side draw” right there where they were waiting. It provided opportunity to smile at the children, reassure a grandmother, speak to a caregiver if the patient was very ill, and greet people around the patient while also (bonus!) talking out loud about lab procedures—VERY important in that culture. The patient felt surrounded by the clinic community, which was parallel to being in the healer’s hut in their village while everyone gathered around to hear and see the care being given. It worked for them, and even improved their drawing room wait times.

As we explore how we can make patients more at ease, more knowledgeable, and provide improved access to our lab services, we tend to think in terms of how it will improve the lab processes. I learned a valuable lesson from my Africa colleagues: we should also think of how to improve the “patient experience” in safe and culturally appropriate ways. There are many stories and observations on how we do things wrong, but this is an enlightened one about how our global colleagues are doing it right!

As I mentioned in my last blog, the next time YOU have to have your blood drawn, take a close look around and notice what your patients and customers see. I guarantee you will always be surprised by something, and will leave the drawing room with at least one idea of how your lab can do it better.   And, if you have a great example of improving the patient experience in the laboratory, let me know at bsumwalt@pacbell.net I’m always in the market for new ideas to share.

 

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Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

ASCP Call for Abstracts

Do you want to present your research at a national meeting? The American Society for Clinical Pathology is currently accepting abstract submissions for their Annual Meeting. This year it’s in October in Tampa, Florida. Soak up the sun while presenting your work and networking with your peers.

Pediatric Reference Intervals

All laboratory professionals are aware of the importance of reference intervals (RI). Without appropriate reference intervals, a test result is just a number. A numeric result for any given analyte cannot be used to diagnose or monitor treatment of disease unless there is an accompanying reference interval indicating what amount of that analyte should normally be present. In pediatrics, that’s even more important because as an infant develops through childhood and into adulthood, his or her biochemistry changes, adapts and develops with him or her. Using an adult RI to interpret a test result from an infant or child is likely to result in misinterpretation of the test, including misdiagnosis of disease states. A good example would be using adult alkaline phosphatase RI to interpret the results of a teenage boy’s test during accelerated bone growth in puberty.  His result will look pathological if interpreted using adult RI. Pediatric reference intervals (PRI) are age-related and often also gender-related intervals that must be used to interpret testing in the pediatric population.

Establishing reference intervals is problematic at the best of times because of the need to use 120 healthy individuals to establish them. In the pediatric population, especially in infancy, obtaining 120 healthy infants at each necessary time interval can be a daunting task. There are references available that present methods which allow the establishment of RI with smaller sample numbers (1,2). Also the CLSI document (2) allows the “validation” and “transfer” of current or literature RI, rather than complete “establishment” of RI in some cases.  Validating a current reference interval can be done with as few as 20 samples in a correlation study. “Transferring” a reference interval also involves using a correlation study and bias evaluation to adapt or adjust a current RI for use with a new assay. Transferring can also be performed with 20 – 60 patient samples.

These techniques especially come in handy with the hardest PRI to establish, the hormones during puberty. During this time, the RI are not really related to the child’s age, but related to the child’s phase of development, or Tanner Stage. To establish a PRI for these hormones, the healthy child donating the blood sample must also have his/her Tanner Stage determined, usually by an Endocrinologist.

Another consideration when dealing with PRI is that although all pediatric institutions use PRI, not all PRI are the same, even when the same instrument is used. An informal poll of 9 pediatric institutions using the same instrument resulted in 9 different PRI for common analytes such as electrolytes. There is a need to harmonize PRI, as we harmonize test results, in order to allow non-pediatric institutions a set of PRI that they can use also.

  1. Horn PS, Pesce AJ. Reference Intervals: a User’s Guide. AACC Press, Washington DC, 2005
  2. Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory: Approved Guideline – Third ed. CLSI C28-A3

 

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-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.