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Clinical Pathology Selected Abstracts, 4/14

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Clinical pathology abstracts editor: Deborah Sesok-Pizzini, MD, MBA, associate professor, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and medical director, Blood Bank and Transfusion Medicine, Children’s Hospital of Philadelphia.

Intervention to improve timing of vancomycin levels

Samples drawn for therapeutic drug monitoring are sometimes drawn too early, which can cause inaccurate results that lead to a potential dosing error. One approach to reducing such errors is to create an information technology tool to assist clinicians in determining the best timing for a sample draw. The authors conducted a study at Brigham and Women’s Hospital, Boston, in which the investigators used both an educational and electronic intervention to reduce the number of vancomycin collection timing errors. The information technology-based intervention provided educational instructions to nurses. The authors then determined, for 27 months before and 14 months after the intervention, the percentages of levels drawn too early. They also conducted interviews with nurses and investigated the cause of the mistimed collected levels. The authors discovered that the percentage of vancomycin timing errors decreased from 39 percent to 32 percent, but this decrease was not statistically significant using time series analysis. The study also found that only 33 percent of the nurses used the instructions provided as an educational reminder, despite the requirement to acknowledge receipt of the instructions in the electronic medication administration record. A common error resulted when some of the nurses timed the levels too early or delayed the next vancomycin dose until the levels were reported. Phlebotomy draws were also associated with a higher rate of early vancomycin levels. The authors noted the importance of communicating appropriate level timing with care team members who are not ordering or scheduling vancomycin levels. To improve workflow and reduce errors, the authors suggested the need for the electronic medical record to adjust the originally scheduled time for the vancomycin dose when the previous dose was given later than anticipated. They also recommended developing an information technology solution that would integrate various IT subsystems, including computerized provider order entry, medication administration, specimen collection, and the laboratory information system.

Melanson SEF, Mijailovic AS, Wright APM, et al. An intervention to improve the timing of vancomycin levels. Am J Clin Pathol. 2014;140:801–806.

Correspondence: Dr. Stacy Melanson at semelanson@partners.org

Health care medicine’s ‘big hairy audacious goal’

Jim Collins, author of Built to Last and Good to Great, noted that goals are the key to driving companies toward change, improvement, innovation, and renewal. Collins coined the term BHAG—big hairy audacious goal—to define a goal that drives progress and can make an organization or nation achieve remarkable feats. Health policy expert Ezekiel J. Emanuel, MD, PhD, compared health care reform to a BHAG and noted the five characteristics of these goals: They must be clear, measurable, have a well-defined time frame, represent a stretch, and have a reasonable probability of success. Dr. Emanuel argues that the U.S. health care system needs a new BHAG, and universal health coverage alone is not it. His concern is that by the end of the decade, health care costs per person will not grow faster than the economy as a whole, and, therefore, health care’s goal should be financial. Some may argue that this goal is too money oriented and that quality should be the goal. However, Dr. Emanuel notes that if quality is the goal, focusing on a few metrics may not be transformative enough to change the delivery and cost of care. Dr. Emanuel proposes that it is necessary to limit per capita cost growth to gross domestic product plus zero percent by 2020. Doing so, he says, “will organize and focus energies and skills in a way that will permanently transform health care for the better.”

Emanuel EJ. Going to the moon in health care medicine’s big hairy audacious goal (BHAG). JAMA. 2013;310:1925–1926.

Correspondence: Dr. Ezekiel J. Emanuel at vp-global@upenn.edu

Group O vs. non-group O premature infants receiving group O RBC transfusions

At some institutions, only group O packed red blood cells are administered to neonates to simplify the practice of neonatal transfusion. Although the amount of plasma in such cells is minimal, there are small amounts of residual anti-A, anti-B, and anti-A,B. At least one study reported an increase in necrotizing enterocolitis in group AB neonates receiving only group O packed red blood cells, attributing it to hemolysis of the neonates’ RBCs, resulting in the release of free hemoglobin, hypercoagulability, and bacterial growth from free iron. The authors examined transfusions in their hospital’s neonatal intensive care unit (NICU) to determine if their results showed similar findings. They evaluated 724 premature infants who were in the NICU’s database from 2005 through 2008. The infants were compared for severity of illness, number of infections, length of stay, and death rates to determine if transfused patients who were non-group O had worse outcomes than patients who were group O. All infants received group O transfusions according to the hospital’s policy. The authors found no significant difference in adverse outcomes, including complications from infection, between the group O and non-group O patients who received transfusions. The authors concluded that a mandated policy of transfusing only ABO-specific RBCs to neonates would raise policy and logistical issues. Furthermore, acquiring and maintaining ABO-identical special RBC units for each blood type would be time-consuming for NICUs. However, because there are more nuances to the picture of whether ABO-specific RBCs should be transfused to premature infants, additional studies of transfusion practices in the NICU may be warranted.

Boral LI, Staubach ZG, De Leeuw R, et al. Comparison of outcomes of group O vs. non-group O premature neonates receiving group O RBC transfusion. Am J Clin Pathol. 2013;140:780–786.

Correspondence: Dr. Leonard Boral at libora2@email.uky.edun


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