Mahanagar Hospital

Abstract

Dr. Satish Kumar, Director of the Pathology Laboratory at Mahanagar Hospital, was reviewing the annual report of his lab performance prepared by the hospital’s quality control department. This report was prepared at the request of Dr. Satish himself in anticipation of a proposed visit by an NABL team following the accreditation of his lab three years ago. Dr. Satish was concerned about some of the observations in the report related to pre-analytical activities and the possible consequences on the turnaround time for report generation and patients’ health. With increasing dependence on clinical lab test reports by the hospital physicians, the reliability of laboratory testing and reporting was critical.

This case was prepared for inclusion in Sage Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.

2024 Sage Publications, Inc. All Rights Reserved

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Resources

Exhibit 1. Organogram of the Lab Department: Mahanagar Hospital Chief Pathologist and Laboratory Director (1)

Figure

*One of the senior technicians is the sectional head

Exhibit 2. Load on Lab Department: Mahanagar Hospital

Section Name

From: 01/01/2007 to 31/12/2007

From: 01/01/2008 to 31/12/2008

From: 01/01/2009 to 31/12/2009

Count

Count

Count

Biochemistry & Immunoassay

117194

132871

137133

Hematology

39287

45221

49770

Blood Storage Centre (Test Performed)

4819

5860

5995

Blood Storage Centre (Product Issued)

10063

13145

13593

Clinical Pathology

10117

11864

12028

Histopathology & Cytology

1964

2320

2667

Microbiology

8622

8686

9306

Outsourced Test

1915

1720

1517

Lab profiles (Department Code: 30)

3646

4337

5108

Lab Profiles From Health Check Up Department

8682

11338

9506

Total

206309

237362

246623

Exhibit 3. IP Request Slip: Mahanagar Hospital

IP Request slip is a computer printout of tests ordered by a consultant for indoor patients. Each request slip has a unique ID number, known as Request number, also called Encounter Number. Every time a consultant orders lab tests for an inpatient, a new request slip is generated and therefore a new encounter number by the HMS.

Figure

*One of the senior technicians is the sectional head

Exhibit 4. IP Sectional Worksheet: Mahanagar Hospital

A Worksheet gives all the necessary information to the phlebotomist for drawing sample(s) from patients. If samples had to be sent to different sections in the lab for analysis (biochemistry section, hematology section etc), the HMS automatically generated sectional worksheets for each.

Figure

*One of the senior technicians is the sectional head

Figure

*One of the senior technicians is the sectional head

Exhibit 5. OPD Requisition Slip: Mahanagar Hospital

Figure

*One of the senior technicians is the sectional head

Exhibit 6. OPD Cash Memo: Mahanagar Hospital

Figure

*One of the senior technicians is the sectional head

The cash memo for each outpatient is printed for the receptionist to collect the payment in cash for the investigations ordered.

Exhibit 7. Materials kept in the phlebotomy box (Red Box) : Mahanagar Hospital

Sr. No

Materials

1

Syringes

2

Needles (for vacuum & normal syringe): Mostly 22 G needle used.

3

Tubes (for blood collection)

4

Spirit Swab

5

Gloves

6

Scalp Vein

7

Capillary

8

Heparin Bulb

9

Belt/Strap

10

Bandage

Annexure 1. Pre-Analytic Phase in Pathology Lab Management

Pathology laboratories perform a number of clinical diagnostic procedures ordered by the physicians/consultants. Timely collection of samples and delivery of reliable accurate test results are therefore important quality indicators of performance of any laboratory.

Laboratory procedures are divided into three phases: Pre-Analytical, Analytical, and Post-Analytical phases:

  • Pre analytic phase starts from the time the lab receives a request for investigations ordered by a consultant/physician and ends when the samples are handed over to the lab sections, such as biochemistry, hematology etc for analysis.
  • Analytic phase involves testing, examination, analysis and interpretation of the investigations.
  • Post-analytic phase deals with reporting the results of investigations to the physicians and to their patients or patients’ relatives. The physician’s reaction to the report and interpretation of results would impact the future course of treatment and care.
Pre-Analytic Phase

It is well known that more than sixty percent of all lab errors occur at the pre-analytical phase, as sample collection calls for interaction with a number of people: physicians/consultants, nurses, lab receptionist, lab assistants, phlebotomists, patients and their relatives, lab analysts and so on.

This phase starts with the phlebotomists picking up their work orders from the lab receptionist, preparing bar-coded labels, collecting samples from patients, and submitting the samples to the analytic section of the lab for testing. This phase is known to account for almost 70% of all lab errors, often leading to sample rejection. Hemolysed 1 blood is the most common reason (as high as 55%) for sample rejection. Other major reasons for sample rejection are insufficient sample quantity (20%), incorrect samples (15%), and lipemic 2 , icteric 3 , and clotted blood samples [Bonini PA, et al 2002].

Sample collection requires strict adherence to safety procedures (safety to the phlebotomists and the patients), use of appropriate needles and well established procedures for drawing blood as well as correct identification of patient samples. Sample collection is followed by transportation of the samples to the lab for analysis. One of the major challenges in managing a pathology lab is to minimize the pre-analytic lab errors, so as to submit test worthy samples for analysis.

Table 1. Pre-Analytic Phase

Phase

Sl no

Activity

Pre-pre analytic

1

Physician/clinician orders tests for investigation Orally

2

Physician/clinician orders tests for investigation Hand written

3

Lab receptionist does not highlight “URGENT” work orders

Pre Analytic

4

Phlebotomist’s habit of picking up work orders

5

Preparation of bar-coded labels for sample collection, identification

6

Patient identification

7

Use of gloves

8

Site selection for drawing blood

9

Site Preparation

10

Use of the tourniquet correctly

11

Identifying the order for sample collection

12

Vacutainers vs syringes, appropriate container for sample collection

13

Use of appropriate needle of gauge 21 or 22 if using a syringe

14

Sample collection

15

Proper mixing

16

Sample identification: Paste the bar-coded labels

17

Dispose off all used materials

18

Submit the samples to the lab for testing

Notes

1. Hemolysis is the breakage of red blood cells causing the release of hemoglobin and other internal components into the blood serum or plasma. It can occur both in-vitro and in-vivo. In-vitro hemolysis happens mostly as a result of inappropriate blood collection practices, and is easily detected by the presence of pink or red color specimens in the serum/plasma after centrifugation. Causes for in-vivo hemolysis are many including hereditary, acquired and iatrogenic conditions such as autoimmune hemolytic anemia and other hemo globinopathies. Hemolysis is a very undesirable condition that influences the accuracy and reliability of lab tests.

2. Lipemia indicates the presence of fat in the blood serum, and is an inherent characteristic of the patient’s blood. Lipemic sample can arise due to sample collection after heavy meals or the presence of some metabolic disorder. Lipemic samples become turbid making it difficult for investigation.

3. Icterus blood means jaundiced blood and cannot be used for testing.

This case was prepared for inclusion in Sage Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.

2024 Sage Publications, Inc. All Rights Reserved

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