Updated Information about Indiana MERS-CoV Patient

The Community Hospital in Munster, Indiana held a press conference today (5/5/2014) regarding the MERS patient. This hospital is in northwest Indiana near Chicago, Illinois. Speakers included Mike Pence, Governor of the State of Indiana; William VanNess II, MD, Indiana State Health Commissioner; Daniel Feikin, MD, Medical Epidemiologist with Centers for Disease Control and Prevention; Don Fesko, CEO of Community Hospital; and Alan Kumar, Chief Medical Information Officer at Community Hospital. During the discussion, several facts about the case emerged:

  • The patient lives and works in Saudia Arabia and is in the United States for a planned family visit.
  • Patient doesn’t remember working directly with a MERS patient but does work at a facility that houses MERS patients.
  • The patient presented to Community Hospital on the evening of 4/28 with flu-like symptoms. He has been in private triage, examination, and patient rooms for the duration of his visit.
  • Infectious Disease doctors consulted on the case; quickly suspected MERS based on travel history and notified the CDC.
  • Healthcare workers that came in contact with the patient are currently on home isolation. They will most likely be kept on isolation for 14 days, which is currently the longest known incubation period for the MERS virus.
  • Currently, all evidence about MERS-CoV suggests that direct, sustained contact and exposure to droplets (from a cough or sneeze, for example) is necessary for transmission. NO evidence currently suggests that MERS can be transmitted through casual community contact.
  • The current mortality rate for MERS is 30%; most patients who succumb to the virus are elderly, have concomitant health conditions, or both.
  • The virus could mutate, and if it does there is a possibility that it could become more transmissible. However, there is NO EVIDENCE that has occurred.
  • The CDC is working to identify people who traveled on the same plane and bus as the patient. So far, three-quarters of travelers have been contacted and identified.
  • The patient is in good condition and is expected to go home soon.
  • Discharge instructions, including how long the patient will be in isolation, are still being determined.

If a suspected case comes to your facility and your laboratory needs to handle specimens, contact your local health department for instructions. Also, bookmark Lab Medicine’s resource page for up-to-date information.

Confirmed Case of MERS-CoV in the United States

Today, the CDC and the Indiana State Department of Health announced the first confirmed case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the United States at a community hospital in Munster, Indiana. The patient is currently in good condition.

If you’d like more information about MERS-CoV and how laboratory professionals should treat specimens from suspected cases, see Lab Medicine’s MERS information page.

 

Antiobiotic Resistance Worldwide

The World Health Organization assessed worldwide antibacterial resistance and recently published their findings. The report notes that a post-antibiotic era isn’t a dystopian fantasy but, in fact, a real possibility in the 21st century. Dire? Yes, but if you’ve been following the news, unsurprising.

The press release is here.

You can download or order the report here.

You can read a summary of the report here.

 

 

Should Laboratory Personnel’s Total Work Hours be Regulated?

In the past decade, a higher number of medical laboratory personnel work more than one job due to the medical lab personnel shortage situation nationwide and the depressed global economy overall. With more of the baby boomers retiring now, the threat of increasing lab personnel shortages is imminent. Healthcare organizations face challenges in recruiting lab personnel, especially in the highly specialty areas such as microbiology and blood banking. Alarmingly (but perhaps not surprisingly) in metropolitan areas a significant number of clinical personnel work two full-time jobs – that means these employees are working for a minimum of 16 hours per day! If travel time is considered, these employees could have less than 5.5 hours sleep per day. How many people can function long term with such limited sleep? While federal laws do govern how many slide reviews a cytotechnologist can perform per day, there are none that govern the number of hours per day laboratory professionals can work.   Should such laws exist?

In December 2011, the Joint Commission (JC) published a very important Sentinel Event Alert (SEA) Issue on “Healthcare worker fatigue and patient safety.” The publication addressed the effects and risks of an extended workday and cumulative days of extended work hours beyond 12.5 hours. The SEA cited the 2004 study that when nurses worked more than 12.5 hours, they were three (3) times more than likely these personnel created errors in patient care. This alert raised awareness that fatigue could jeopardize patient safety. Transcription errors or reading a patient ID number incorrectly can occur when personnel are fatigue or sleep deprived.

Are efforts to reduce or prevent the errors jeopardized by allowing laboratory professionals to work long hours? Should clinical personnel’s total hours be regulated for patient safety protection? Regardless of the answers to the above questions, healthcare leaders should start planning on how to perform root cause analysis on the medical errors pursuant to the best practices guideline. It is crucial to identify whether or not sleep deprivation and fatigue are a contributing factor and then implement strategies to mitigate the risks on patient safety.

 

Information on policies or practices are solely from my personal experience ONLY and have NO relation to my affiliation with any regulatory or government agency.

satyadi

-Caroline Satyadi, MT(ASCP), SM, DLM, SLS, MBA, MS, CQA (ASQ) has been a laboratory management professional for over 25 years. She has worked with several different medical industries for CLIA/CMS, FDA/ICH/ISO, TJC/CAP/COLA/HFAP accreditation survey readiness.

 

Notification After the Fact

What does your lab do when you are notified about instrument/reagent problems after the fact? Let me give you two recent examples.

A vender sends a recall notice that goes back 6 months on one of their reagents. There has been a problem with a reagent for 6 months, but you are just now being notified. You look and determine that you have run 1000 tests on patients using that reagent during the problematic time period. What do you do?

Or another example, a reference laboratory changes their units of measure and you miss the notification. 23 patients had results come back from the reference lab and the values were entered into the computer with the incorrect units of measure and reference interval in place. The mistake is discovered on the 24th patient.

Laboratories work to have systems in place to prevent these scenarios. We try to carefully watch for changes from reference labs, and we hope that recall notices will not affect many patients. However, despite our best efforts, relatively large-scale lab errors like these happen. Laboratories need to have systems in place for dealing with these events. A few steps that are helpful when this happens include:

1) Determine whether the error is on-going
  a. Are immediate process changes necessary?
2) Fix the error so no new patients are affected
3) Determine the extent of the damage
  a. Often involves a Root Cause Analysis
  b. How many patients were affected
  c. How serious was the effect (changed treatment vs no effect at all)
  d. Do healthcare-providers need to be notified, and if so, who and how to notify
4) Notifications
  a. Healthcare-providers
  b. Hospital/laboratory Quality and/or Risk Departments
  c. Other clients
5) Documentation
6) Is there a way to turn this into an opportunity for improvement?

Occasionally an error can cause more headache than harm. For example, if you report a value of 35 mg/dL with a reference interval is 20 – 80 mg/dL, the result is normal. If the units of measure are supposed to be mg/L on both instead of mg/dL as reported, this is simply a clerical error because the result will still be normal if you change the units on measure on both the result and the reference interval. Unfortunately, it may still result in a corrected report on each patient, which depending on your system, may still flag your ordering physician. If you make this correction on a high volume test, a lot of irate physicians will be calling you regarding the number of corrected reports on their patients. Thus the error causes more headache than harm, but still requires that a procedure be in place to investigate and deal with it. All labs should have such a procedure.

 

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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.

 

The Importance of Manual Urine Microscopy

Research presented today at the National Kidney Foundation spring clinical meeting indicates that manual microscopy surpasses automated analyzers when assessing kidney injury. The abstract is titled “Manual Microscopy: Not a Lost Art” and says, in part: “In this study, we examined if a significant difference exists between the reported ranges of granular and muddy brown casts using manual microscopy as compared to an automated urine analyzer in an acute kidney injury cohort.”

According to one of the abstract’s authors, Dr. Sharda, “What our research has been able to show so far is that the automated system under reported the value of granular casts in our patient cohort of acute kidney injury. The automated system still has utility as a screening test, but manual microscopy should be done in all cases of abnormal kidney function, as accurate quantification of casts could have some prognostic benefit to patients.”

The poster is available online. The authors are currently writing a paper on their research; their contact information is here.

So, What Does MLPW Mean to Me?

So, I’m going to continue the thread from my previous blog post next week since this is Medical Laboratory Professionals Week (or what we affectionately refer to as Lab Week). Coincidentally, for a public health-oriented person like me, Earth Day (April 22) is also during this week; globally, some celebrate the entire week as Earth Week. So, I encourage you to celebrate both.

Pathology can be a hidden or invisible profession to many, even more so on the lab side. Even though we are dependent on lab results to guide clinical care (at least 70% of clinical decisions are guided by lab results), it’s easy to forget that there are lab professionals and pathologists working assiduously, sometimes late into the night, behind the scenes to make sure we receive timely and accurate, lab results for our patients.

So, what exactly is Lab Week? It’s the time each year when we celebrate and recognize these lab professionals and pathologists, a time where we recognize them as more than nameless faces but as team members who vitally and equally contribute to patient care. Many hospitals and health care centers will highlight the work of those in their clinical labs with poster sessions and talks on relevant topics this week. Some will also cater Lab Week celebrations for their staff as a thank you for all their diligent work that often goes unrecognized or taken for granted during the rest of the year.

So, as we residents, what can we do? Well, first, we can get to know our lab professionals and this week in particular, personally thank them for all their hard work. I’m pretty sure it’ll bring a smile to their faces if you make a deliberate effort to recognize and say “thank you” this week. We can learn their names and get to know them on a personal level and not just when we need a test result or to troubleshoot a lab related issue.

I’m on pretty friendly terms with most of the lab techs from my clinical rotations. They have invited me to department holiday celebrations (even when I’m not on their rotation), gave great feedback about me to my rotation director/attending (trust me, they often do get to comment on how you perform during a CP rotation), and gave me a heads up to help me out of potentially difficult situations. I’ve learned a lot from them and they’re always happy when we show interest in their work. Plus, I never treat anyone in a formal hierarchical manner (no one calls me “Dr. Chung” but rather “Dr. Betty” or just by my first name). I acknowledge that there is always something that they teach me and that I believe that we are colleagues working together on a team…not that I am the doctor and they are not. And often, lab professionals will be the first to detect a potential patient clinical issue, even if they have limited patient history access, so I totally give them props when they help me out in this way. And having a good attitude with your lab staff, as I mentioned, can go a long way for both your learning and advancement on the rotation.

As residents, CP rotations are often when we have the opportunity (as opposed to surgpath) to take vacation time and many look at these rotations as unofficial boards study time. But spending physical time in the lab is still learning. And for me, I learn better by doing as opposed to sitting in a lecture or sitting at my desk reading a textbook. The lab regulatory policies and management issues (and even the basic science concepts) we need to know to pass boards, we can learn more efficiently if we spend actual time IN the lab working alongside our lab professionals on these very issues. In the lab, we can also serve as consultants for our referring physicians on the intricacies and appropriateness of specific lab tests and help with regulatory (CAP/CLIA) inspections – even if your rotation doesn’t specifically require this, you can still ask to be more involved – trust me, you’ll learn more this way (and it is boards studying).

So, how are you planning to celebrate Lab Week and acknowledge those in the clinical labs this week? While you’re at all, you can help contribute to Earth Day/Earth Week as well by committing yourself to being more environmentally conscious (don’t forget to recycle!) from this week forth.

 

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.