On a daily basis medical laboratory professionals receive orders to perform laboratory tests that are appropriate as well as inappropriate with respect to providing clinicians with information that adds value to their decision making. Improving healthcare quality and patient safety requires addressing the effectiveness of laboratory testing–limiting overuse, underuse and misuse of laboratory testing1. Effectiveness of laboratory testing can only be improved through the use of evidence.
In the not so distant past laboratory professionals relied upon physicians’ routine or standard orders based upon a patient’s location within the healthcare setting, such as performing a Complete Blood Count (CBC) daily on each inpatient or performing a CBC and Erythrocyte Sedimentation Rate (ESR) and urinalysis on each patient who visited the Emergency Department (ED). Other practices no longer in employed include performing a differential microscopically with each CBC and microscopically examining each urine sediment after completing the biochemical analysis. A significant percentage of those test results were either within the reference range or identified little change from the most recent test result, providing no additional information for the patient’s treatment. Improvements and advancements in technology incorporated into hematology analyzers were the impetus to change the practice of microscopically performing a white cell differential with each CBC. Working with clinicians, laboratorians employed evidence demonstrating that white cell differentials counted using hematology analyzers were clinically effective.
Employing evidence-based laboratory practice (medicine)–the fifth healthcare professional competency identified by the National Academies of Sciences, Engineering and Medicine (formerly the Institute of Medicine (IOM))–includes three components: research evidence, clinical expertise and patient values.2 Although randomized control trials are considered the gold standard for clinical research, other quantitative and qualitative methodologies provide valuable evidence for developing practice guidelines. A laboratory professional’s clinical expertise serves as the first clue that laboratory testing is inappropriate at the point of test ordering and then when test results are reviewed. Information identified from clinical expertise provides the foundation to gather further evidence before embarking on a quality improvement project. Lastly, evidence identified and used to create testing protocols must be considered within the context of the patient perspective.
As testing has become more complicated and expensive—e.g. genetic testing and molecular testing–clinicians require more support for both ordering the correct test as well as its interpretation. One way to provide this support is the use of Clinical Laboratory Utilization Committees.3 Membership on these committees is interprofessional, composed of laboratory professionals, pathologists, clinicians of various disciplines and often individuals from information services. Committees work together to develop ordering protocols for expensive genetic tests, evaluate high volume testing and monitor blood utilization. Incorporating evidence into all of their decisions, utilization committees are improving healthcare quality and patient safety.
Employing evidence on the use (or lack of use) of laboratory testing is critical to improving the effectiveness of laboratory test information and healthcare delivery. As providers of information that impacts up to 70% of healthcare decisions, use of evidence is vital to the practice of clinical laboratory science.
References:
Committee on Quality of Health Care in America. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press; 2001.
Committee on Quality of Health Care in America. Institute of Medicine. Kohn L, Corrigan J, Donaldson M., eds. To err is human: building a safer health system. Washington DC: National Academy Press; 2000.
College of American Pathologists. Examples of Clinical Laboratory Utilization Committees. Retrieved from: http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution%20Folders/WebContent/pdf/examples-clinical-laboratory-utilization-committees.pdf. Accessed May 30, 2016.