An Effective Approach for Endocrine Dynamic Function Tests Workflow and Reporting Using Cerner Millennium®

Introduction/Objective Endocrine dynamic function testing (DFT), also known as hormone stimulation tests, are indispensable tools in the endocrine practice. Common pitfalls of ineffective testing and misdiagnosis are due to incorrect sample recordings, delay in sample collections and disorganized or confusing result presentation. Clinical and laboratory data deserves careful attention and discrepancies must be reviewed by a clinical biochemist before releasing results for proper patient diagnosis. The main objective of this Cerner DFT project is to design and implement Cerner Millennium applications for effective management and organized result reporting of hospital-wide DFT protocols. Methods/Case Report The DFT Cerner workflow is uniquely designed in-house and known as a pioneer build for Cerner Millenium. The design involves the use of Cerner Discern Analytics 2.0 and clinical modules to complete such a complex build. Five DFT panels are defined as care-sets with specific hormone discrete task assays (DTA). For each care-set, an ‘order sentence’ is created to produce the order priority rules. The DFT panels can only be requested as future orders in PowerChart and activated by the medical staff upon collection of the baseline sample. On Cerner PathNet, results are pre-verified by the medical technologists then auto-filtered in the clinical Review Queue (RQ) module for final verification and addition of comments by the biochemistry consultant. A word processing template is used to collate the results and present the summary of the DFT report where standardized canned comments are added using pre-defined codes. Results (if a Case Study enter NA) See Conclusion Section Conclusion The Cerner DFT project mproves the diagnosis and treatment of patients with hormone disorders. Before, there was a danger of misdiagnosis when samples are individually requested producing separate reports with no organized presentation. Report comments from the clinical biochemist consultant also served as good diagnostic guidance. This quality initiative has definitely improved the previous and long term issues of endocrine dynamic function tests.

DUTIES AND RESPONSIBILITIES OF CLINICAL BIOCHEMIST IN PSYCHIATRY HOSPITAL

The duties and responsibilities of Clinical Biochemists are evolving. Some of theclassical duties and responsibilities of Clinical Biochemists in a Tertiary Psychiatry hospital are basically in the area of research, education and service. Some general rules of success for younger Clinical Biochemist in his/her fieldare also important topic of discussion. We are living in very competitive timesand Clinical Biochemists mustlearn to adapt very quickly to the continuing changes in our discipline. We are yet to realize the best times of this exciting profession.

Case report of spuriously low sodium and calcium in a 36-year-old male in primary care

An unseparated serum specimen for a 36-year-old male was received from primary care. The specimen arrived in the laboratory at Cork University Hospital one day after collection, as documented on the paper request card, and was promptly centrifuged. Analysis was delayed for three days due to operational constraints and serum indices were run at the same time as the biochemical analyses. Results showed a moderately haemolysed specimen with remarkably low concentrations of both sodium (119 mmol/L) and total calcium (1.15 mmol/L), with all other parameters within their appropriate reference intervals (RIs). The complete report was released electronically and both sodium and calcium results were phoned to, and acknowledged by, the requesting general practitioner (GP). Discussion between the medical scientists and clinical biochemist on duty raised the possibility that the specimen was significantly older than initially thought. Further discussion of results with the GP clarified that the documented time of collection corresponded with specimen receipt by the courier, rather than the time of phlebotomy. Thus, the specimen was 7 days old when received in the laboratory and 10 days old when analysed. This case illustrates the dangers of multiple convergent preanalytical errors. Laboratories should be mindful of the stability of analytes in unseparated blood and unusual patterns of results which might suggest a specimen is “old”, and that this may coexist with erroneous request information. Any potential adverse effects on patient care were prevented in this case by laboratory vigilance.

Differential diagnosis between bone relapse of breast cancer and lambda light chain multiple myeloma: role of the clinical biochemist

Purpose: The integration of expertise between oncologist and clinical biochemist for the monitoring and diagnosis of plasma cell dyscrasia is crucial. In some cases, medical laboratory scientists can provide an original contribution using the appropriate techniques to arrive at a diagnosis. Methods: We report a case of 67-year-old woman who was admitted to our hospital for bone pain. Imaging studies showed multiple diffuse bone lytic lesions, and a laboratory screen revealed anemia and altered creatinemia; serum capillary zone electrophoresis confirmed a monoclonal peak in the γ-zone that had been known since 2011, typed as immunoglobulin G kappa by immunosubtraction electrophoresis. The patient had undergone surgery for breast cancer in 2013, and based on her clinical history, the oncologist suspected the presence of bone metastases from the breast cancer and opted for relative therapy. Immunosubtraction, however, showed a very small reduction in lambda free light chains in the beta zone, but it was difficult to establish if was a monoclonal component, and consequently additional tests were performed. Discussion: A monoclonal component composed of only lambda free light chains was evidenced. This result in association with multiple diffuse bone lytic lesions observed led us to suspect multiple myeloma and not bone metastases from the breast cancer. Based on these observations, we encouraged the oncologist to conduct an osteomedullary biopsy, allowing us to make a diagnosis of low-grade stage II lambda light chain multiple myeloma. Conclusion: In this report, we show how the expertise of the clinical biochemist was instrumental in solving this case.

Elimination of 72-Hour Quantitative Fecal Fat Testing by Restriction, Laboratory Consultation, and Evaluation of Specimen Weight and Fat Globules

Background The 72-h quantitative fecal fat test has been mostly obsolete for many years. Our objective was to reduce and eliminate the use of this test, while providing suitable alternatives. Methods We assessed (2010–2016) utilization of the fecal fat test in Calgary, Central Alberta, and Southern Alberta, Canada. Alternatives were identified through literature review and consultation with gastroenterologist stakeholders. Logistic regression and ROC curves were used to characterize discrimination power of 72-h specimen weight on abnormal fat excretion. This was also examined in 91 subspecimens that were additionally tested for the presence of fat globules. Results As 69% of fecal fat tests (total, 106/year) were on adults (age ≥ 18), stakeholders agreed that adult specimens should not be tested until ordering physicians consulted with a clinical biochemist. This change reduced fecal fat testing by 81% to 20/year in 2015. The 72-h specimen weight was a significant predictor of abnormal fat excretion [P < 0.001; area under curve (AUC) = 0.75–0.79, n = 115–417] in historic fecal fat data. A similar result was observed among subspecimens (AUC = 0.70), which improved when additionally considering the presence of fat globules (AUC = 0.74). Stakeholders consented to replacing fecal fat with a comparison of specimen weight to cutpoints with 80% specificity for abnormal fat excretion, and the test for fat globules. Conclusion Through stakeholder engagement, we implemented changes that eliminated 72-h quantitative fecal fat testing in a large geographic region in Alberta, Canada. Future fecal fat orders would be reflexed to an assessment of 72-h specimen weight and a qualitative test for fat globules in stool.

ASSESSING THE FREQUENCY OF CA-125 MEASUREMENTS WITHIN HAMILTON HEALTH SCIENCES AND ST. JOSEPH’S HEALTHCARE

Objective: To determined if the number and frequency of CA-125 measurements per patient reflect the 2008 NACB (National Academy of Clinical Biochemist) practice guidelines. Methods: We collected data retrospectively on CA-125 over a period of one year as apart of our ongoing practice in monitoring the tumor markers for quality assurance, The number of CA-125 results per patient as well as the time interval between the 1st and 2nd measurements was noted. To enrich this population for the likelihood that the measurement of CA-125 was used for monitoring or for detection of recurrence, we divided the population into patients from the Jurvainski Cancer Centre (JCC) and the rest of the sites. Results: The JCC patients contributed the majority of CA-125 results, representing over 75% of all results (n= 3057 results from 998 patients), whereas the remainder of the sites only yielded 959 results from 920 patients. Further analysis of the JCC patients indicated 2 main subgroups: Group A – patients with 1 or 2 results (n=624 patients); Group B - patients with 3 or more results , Overall, less than 4% of patients at the JCC had a time interval between the 1st and 2nd specimens of less than 2 weeks. Discussion: This initial analysis would indicate that physicians are ordering CA-125 in agreement with the NACB guidelines. To further improve compliance to the guidelines and to prevent subsequent measurements of CA-125 too close, we propose restricting CA-125 orders that are less than 14 days apart to only those that receive Biochemist’s approval.