Biomedical subjects

Bruce A Jones

Publications and source records attributed to Bruce A Jones.

11 recordsLinked to original sources

PubMed2006

Hospital nursing satisfaction with clinical laboratory services: a College of American Pathologists Q-Probes study of 162 institutions.

CONTEXT: Monitoring customer satisfaction is an important and useful quality improvement tool and is required of most clinical laboratories in the United States. OBJECTIVE: To survey the level of nursing satisfaction with hospital clinical laboratory services. DESIGN: Participating laboratories provided information regarding laboratory demographics and practices. These laboratories then surveyed hospital nursing personnel regarding their level of satisfaction with defined aspects of laboratory service. SETTING: College of American Pathologists Q-Probes laboratory quality improvement study in 162 hospital laboratories. MAIN OUTCOME MEASURES: Nursing overall satisfaction score (ranging from 1, not satisfied, to 5, very satisfied) and satisfaction scores for 13 specific aspects of clinical laboratory services. RESULTS: One hundred sixty-two institutions submitted data from a total of 7033 nursing surveys. The overall satisfaction score for all institutions ranged from 2.5 to 4.6. The median overall score for all participants was 3.9 (10th percentile, 3.2; 90th percentile, 4.2). Nursing personnel were most satisfied with the accuracy of test results, phlebotomy courtesy toward patients and nursing staff, and notification of abnormal results. They were least satisfied with stat test turnaround time, laboratory management responsiveness and accessibility, phlebotomy responsiveness to service requests, and routine test turnaround time. The most important aspect of laboratory service reported by nursing personnel was stat test turnaround time. CONCLUSIONS: Most nursing personnel are satisfied with the clinical laboratory services that are provided to the patients in their care. Although test result accuracy is very highly regarded, there is room for improvement in several aspects of service, particularly in test turnaround time and laboratory management accessibility and responsiveness.

Clinical Laboratory Techniques↗

PubMed2005

Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors.

CONTEXT: In a survey performed 4 years ago, testing venues doing only point-of-care testing (POCT) made up 78% of sites for patient testing licensed under federal regulations. OBJECTIVES: To identify sources of POCT error, to present a classification of such errors, to suggest strategies to prevent errors, and to describe monitors that assess and reduce the frequency of errors. DESIGN: To identify sources of POCT error, large studies of error among US Federal Certificate of Waiver laboratories (CoWs) and practitioner-performed microscopy certificate holders were reviewed. To facilitate investigation and management of POCT error, a taxonomy of such errors (modified from a classification previously published by Gerald Kost) was used to identify 4 steps with error potential in each of the 3 phases (ie, preanalytic, analytic, and postanalytic) of the POCT process. To prevent observed POCT errors, 4 strategies are suggested: direct observation of instrument/method functionality, structured observation of method performance, proficiency testing/use of relevant test scenarios, and autonomation. To assess frequency of errors, a quartet of indices are introduced as detection monitors: order documentation, patient identification, specimen adequacy, and result integrity. RESULTS: Three sources of POCT error were identified: operator incompetence, nonadherence to test procedures, and use of uncontrolled reagents and equipment. Three other characteristics of many point-of-care tests amplify their risk of error: incoherent regulation, rapid availability of results, and the results' immediate therapeutic implications. Two members of the quartet of detection monitors, order documentation and specimen adequacy, are relatively difficult to measure and are controversial, but the other 2, patient identification and result integrity, are easier to assess and are relatively widely accepted. CONCLUSIONS: Point-of-care testing errors are relatively common, their frequency is amplified by incoherent regulation, and their likelihood of affecting patient care is amplified by the rapid availability of POCT results and the results' immediate therapeutic implications. The modified Kost taxonomy offers a reasonable approach to the identification of POCT errors. Direct observation of test functionality, structured observation of test performance, and testing the competence of POCT operators, as well as autonomation of devices, are strategies to prevent such errors. In this context, we suggest monitoring POCT order documentation, patient identification, specimen integrity, and result reporting to detect errors in this sort of testing.

Humans↗

PubMed2005

Robotic mitral valve repair: a community hospital experience.

Robotically assisted cardiac surgery has been presented as less invasive than conventional surgery, with shortened hospital stays and faster return to daily activities. We evaluated our experience with the da Vinci robot to determine whether we could in fact demonstrate those findings. All mitral and tricuspid valve repairs were performed by the same surgeon. Cardiopulmonary bypass was performed with femoral cannulation, antegrade cardioplegia, and transthoracic aortic cross-clamping. Multiple valve repair techniques were used, including quadrant resection, cord replacement, Alfieri leaflet coaptation, and ring annuloplasty. Access was by 2 ports and a 5-cm right anterolateral thoracotomy. All annuloplasty rings were secured using surgical clips. From October 2003 through September 2004, 32 patients underwent robotically assisted mitral valve repair. The mean age of our population was 676 years (range, 43-82 years). Four patients also underwent the 1st tricuspid valve repair using the da Vinci robot in the United States. There were 3 conversions for irreparable valves, 1 stroke, and 2 deaths. The average procedure time, cardiopulmonary bypass time, and aortic cross-clamp time were all reduced, when the first 20 patients were compared with the last 12. Length-of-stay also improved. One patient required early mitral valve replacement for recurrent regurgitation. Two patients required late (> 3 month) mitral valve replacement for recurrent regurgitation. We have shown that a dedicated nonacademic institute can develop a robotic cardiac surgery program and perform mitral and tricuspid valve repairs successfully. There is a several-case learning curve, and patient selection is paramount.

Aged↗

PubMed2004

Patient safety in point-of-care testing.

In the authors' view, the following four points compose the current state of the question of patient safety in point-of-care testing: The collision of definitions used in this article with actual practice in point-of-care testing is evidence for the likelihood of error in this genre of clinical tests. Uncovering of latent conditions conducive to error is the objective for investigations of this likelihood. A modified Kost classification serves as a basis for determining where latent conditions appear in the point-of-care testing process and as a framework in which to recognize these errors in an error classification process. Errors in point-of-care testing are likely to arise most frequently in the steps of patient identification, specimen collection, and result reporting. In the absence of an adequate evidence base, the authors recommend as measures to build a culture of patient safety in point-of-care testing the components of the standard model of safe laboratory testing. This model inculcates the laboratory ethos of test operator competence, procedure adherence, quality control, and result integrity. These objectives can be achieved by integrating operator training, program supervision, competence assessment, and proficiency demonstration into an institution's or practice's point-of-care testing program. Based on the authors' hypothesis that medical errors in point-of-care testing, which lead to preventable adverse events most often arise in three testing processes--patient identification, specimen collation, and result reporting--they recommend ongoing monitors of these critical steps. If they are wrong, such monitoring will disprove their hypothesis; if they are right, it will measurably reduce medical error in point-of-care testing.

Humans↗

PubMed2004

Biochemical markers of myocardial injury test turnaround time: a College of American Pathologists Q-Probes study of 7020 troponin and 4368 creatine kinase-MB determinations in 159 institutions.

CONTEXT: Rapid diagnosis of acute myocardial infarction in patients presenting to emergency departments (EDs) with chest pain may determine the types, and predict the outcomes of, the therapy those patients receive. The amount of time consumed in establishing diagnoses of acute myocardial infarction may depend in part on that consumed in the generation of the blood test results measuring myocardial injury. OBJECTIVE: To determine the normative rates of turnaround time (TAT) for biochemical markers of myocardial injury and to examine hospital and laboratory practices associated with faster TATs. DESIGN: Laboratory personnel in institutions enrolled in the College of American Pathologists Q-Probes Program measured the order-to-report TATs for serum creatine kinase-MB and/or serum troponin (I or T) for patients presenting to their hospital EDs with symptoms of acute myocardial infarction. Laboratory personnel also completed detailed questionnaires characterizing their laboratories' and hospitals' practices related to testing for biochemical markers of myocardial injury. ED physicians completed questionnaires indicating their satisfaction with testing for biochemical markers of myocardial injury in their hospitals. SETTING: A total of 159 hospitals, predominantly located in the United States, participating in the College of American Pathologists Q-Probes Program. RESULTS: Most (82%) laboratory participants indicated that they believed a reasonable order-to-report TATs for biochemical markers of myocardial injury to be 60 minutes or less. Most (75%) of the 1352 ED physicians who completed satisfaction questionnaires believed that the results of tests measuring myocardial injury should be reported back to them in 45 minutes or less, measured from the time that they ordered those tests. Participants submitted TAT data for 7020 troponin and 4368 creatine kinase-MB determinations. On average, they reported 90% of myocardial injury marker results in slightly more than 90 minutes measured from the time that those tests were ordered. Among the fastest performing 25% of participants (75th percentile and above), median order-to-report troponin and creatine kinase-MB TATs were equal to 50 and 48.3 minutes or less, respectively. Shorter troponin TATs were associated with performing cardiac marker studies in EDs or other peripheral laboratories compared to (1) performing tests in central hospital laboratories, and (2) having cardiac marker specimens obtained by laboratory rather than by nonlaboratory personnel. CONCLUSION: The TAT expectations of the ED physicians using the results of laboratory tests measuring myocardial injury exceed those of the laboratory personnel providing the results of those tests. The actual TATs of myocardial injury testing meet the expectations of neither the providers of those tests nor the users of those test results. Improving TAT performance will require that the providers and users of laboratory services work together to develop standards that meet the needs of the medical staff and that are reasonably achievable by laboratory personnel.

Academies and Institutes↗

PubMed2004

Comparative analytical costs of central laboratory glucose and bedside glucose testing: a College of American Pathologists Q-Probes study.

CONTEXT: One of the major attributes of laboratory testing is cost. Although fully automated central laboratory glucose testing and semiautomated bedside glucose testing (BGT) are performed at most institutions, rigorous determinations of interinstitutional comparative costs have not been performed. OBJECTIVES: To compare interinstitutional analytical costs of central laboratory glucose testing and BGT and to provide suggestions for improvement. DESIGN: Participants completed a demographic form about their institutional glucose monitoring practices. They also collected information about the costs of central laboratory glucose testing, BGT at a high-volume testing site, and BGT at a low-volume testing site, including specified cost variables for labor, reagents, and instruments. PARTICIPANTS: A total of 445 institutions enrolled in the College of American Pathologists Q-Probes program. MAIN OUTCOME MEASURE: Median cost per glucose test at 3 testing sites. RESULTS: The median (10th-90th percentile range) costs per glucose test were 1.18 dollars (5.59 dollars-0.36 dollars), 1.96 dollars (9.51 dollars-0.77 dollars), and 4.66 dollars (27.54 dollars-1.02 dollars) for central laboratory, high-volume BGT sites, and low-volume BGT sites, respectively. The largest percentages of the cost per test were for labor (59.3%, 72.7%, and 85.8%), followed by supplies (27.2%, 27.3%, and 13.4%) and equipment (2.1%, 0.0%, and 0.0%) for the 3 sites, respectively. The median number of patient specimens per month at the high-volume BGT sites was 625 compared to 30 at the low-volume BGT sites. Most participants did not include labor, instrument maintenance, competency assessment, or oversight in their BGT estimated costs until required to do so for the study. CONCLUSIONS: Analytical costs per glucose test were lower for central laboratory glucose testing than for BGT, which, in turn, was highly variable and dependent on volume. Data that would be used for financial justification for BGT were widely aberrant and in need of improvement.

Blood Glucose↗

PubMed2003

Analysis of inconclusive fine-needle aspiration of thyroid follicular lesions.

To evaluate all inconclusive fine-needle aspiration biopsy (FNAB) specimens from thyroid follicular lesions with subsequent histologic diagnosis at St John Hospital and Medical Center, Detroit, MI. The criterion for specimen adequacy used in our institution was also reexamined to determine whether it was too stringent. We reviewed 45 inconclusive FNAB samples. Only cases that underwent surgical intervention were considered. Specimen adequacy was determined by the presence of at least 8-10 tissue fragments of well-preserved follicular epithelium on at least two slides; each tissue fragment should have a minimum of 8-10 cells. Different cytologic characteristics-cellularity, cellular architecture, nuclear pleomorphism, inclusion/grooves, chromatin, Hürthle cell change, lymphocytes, macrophages, colloid, and multinucleated giant cells-were scored and compared with final surgical diagnosis. The surgical procedure performed was also analyzed. Review of these 45 surgical specimens found 28 (62.2%) multinodular goiters, 14 (31.1%) nodular hyperplasias, 2 (4.4%) follicular adenomas, and one (2.2%) with invasive follicular carcinoma. Forty-three (95.6%) of these cases were female and 2 (4.4%) were male. Cytologic review showed 2 acellular samples, 10 cases containing macrophages only, 10 aspirates with macrophages and an inadequate number of follicular cells, and 23 specimens with an inadequate number of follicular cells. Twenty-three patients underwent total thyroidectomy; 20, lobectomy; and 2, isthumusectomy. Almost 98% of the patients with inconclusive FNAB had benign lesions. This finding encouraged us to continue using our criteria for adequacy because of the importance of a negative report. Patients in our series, who underwent thyroidectomy after an inconclusive or nondiagnostic aspirate, had a malignancy rate of 2.2%, which was no worse than patients with a benign preoperative diagnosis. A balanced approach with careful follow-up for nondiagnostic cytology is prudent.

Adult↗

PubMed2003

Type and screen completion for scheduled surgical procedures. A College of American Pathologists Q-Probes study of 8941 type and screen tests in 108 institutions.

CONTEXT: Market-driven changes in the timing of elective surgeries and admissions have introduced barriers to completing pretransfusion testing in a timely manner. Consequently, blood bank personnel may not have adequate time to identify appropriate blood products for scheduled surgeries. Incomplete pretransfusion testing can delay surgery and significantly compromise patient safety. OBJECTIVES: To identify the incidence of avoidable problems associated with obtaining timely samples for adequate pretransfusion type and screen (T&S) testing, to identify the practices and characteristics associated with improved rates of pretransfusion testing completed prior to surgery, and to determine the likelihood of antibody identification problems that affect the availability of blood. DESIGN: Participants in the College of American Pathologists (CAP) Q-Probes laboratory quality improvement program were asked to collect data on when a T&S was collected in anticipation of elective scheduled surgery, when the T&S was completed, when the surgery started, and the results of those T&S tests. Participants also completed questionnaires describing their facilities, procedures, and practices. SETTING AND PARTICIPANTS: One hundred eight public and private institutions participated in this Q-Probes Study, 97% of which were located in the United States. MAIN OUTCOMES MEASURES: Type and screen collection and completion relative to the start of surgery, and the results of those tests. RESULTS: Of the 8941 T&Ss, 64.6% were collected prior to the day of surgery. The median laboratory completed approximately 69% of their T&S testing for scheduled surgeries at least 1 day prior to the surgery. Of those T&S tests that were collected on the day of surgery, the median laboratory completed almost 23% after the start of surgery. For 10% of participants, more than 75% of all T&Ss collected on the same day as surgery were not complete until after the start of surgery. When red blood cell-directed antibodies were identified, 78.7% were considered clinically significant, and 95.2% were alloantibodies. Positive antibody screens were significantly associated with delayed surgery and special efforts needed to obtain blood. Of those institutions with a specific protocol in place to collect T&S samples prior to hospital admission, the median laboratory completed the T&S at least 1 day prior to surgery 74% of the time. When the institution coupled the T&S collection protocol with T&S collection earlier than 3 days prior to surgery, the median laboratory completed the T&S at least 1 day prior to surgery almost 87% of the time. Type and screen collection less than 3 days prior to surgery resulted in special efforts needed to obtain blood more than 1% of the time. Type and screen collected on the same day as surgery directly resulted in a surgery delay 0.8% of the time. CONCLUSIONS: Patients are unnecessarily being placed at risk by inadequate mechanisms to ensure available blood for surgery. All T&Ss were collected for scheduled surgeries with adequate opportunity for a T&S to be completed in advance of the surgery. Specific protocols helped improve the performance in terms of completing the T&S prior to surgery, as did mechanisms that permitted T&S collections in advance of the admission. Type and screen collection time relative to surgery was significantly associated with the incidence of surgery delay due to unavailable blood; the less time between collection and surgery, the less likely blood was available.

Accreditation↗

PubMed2002

Cryptococcus neoformans myositis without dissemination.

We report a case of isolated cryptococcal myositis involving the paraspinal muscle without evidence of disseminated disease in a patient with a large B-cell lymphoma diagnosed at the time of presentation. Biopsy of the muscle involved grew a pure culture of Cryptococcus neoformans and periodic acid-Schiff staining showed numerous budding yeast consistent with Cryptococcus spp. The patient responded to systemic antifungal therapy with complete resolution of his infection. We also present a review of 5 previously published cases of cryptococcal myositis.

Adult↗

PubMed2002

Routine outpatient laboratory test turnaround times and practice patterns: a College of American Pathologists Q-Probes study.

OBJECTIVES: To determine baseline parameters for routine outpatient test turnaround time (TAT), to identify influential factors, and to study the impact of managed care on this testing. METHOD: Using forms supplied by the College of American Pathologists Q-Probes program, laboratories conducted a self-directed study of routine outpatient TATs over a 4-week period. Data requested included various times of day associated with the collection, laboratory receipt, and result verification of specimens, as well as details on the drawing location and ordering and delivery methods for up to 3 tests, namely, a complete blood cell count (CBC), biochemical profile, or thyrotropin test. For the CBC, an indication was requested if a manual differential was performed. Additionally, practice-related questions were asked, including several about whether the laboratory was associated with a managed care organization (MCO). The main outcome measures included the components of the TAT process and related factors.Participants.-Six hundred nineteen laboratories from those enrolled in the 1997 College of American Pathologists Q-Probes program. RESULTS: Data were submitted by 614 participants, most US hospitals, and represented 30 240 CBCs, 25 683 biochemical profiles, and 14 801 thyrotropins. Collection to verification TATs increased for specimens received later in the day for all analytes, but the magnitude of the increase was greatest for thyrotropin. Collection to laboratory receipt TAT was similar for all analytes, but the time and distribution increased with time of day. Testing time (receipt to verification) was similar for the CBC and biochemical profile, but was greatly increased for thyrotropin. Most participants tested the CBC and the biochemical profile as they arrived, but many delayed testing for thyrotropin. Most (70%) outpatient specimens were collected within the institution; only about 10% came from local physicians' offices. A median 46.7% of hospital testing involved outpatients. Only 10% of laboratories operated under an MCO; these laboratories reported a median of 45% of specimens coming from their MCO. Being associated with an MCO increased TAT for the CBC and biochemical profile. CONCLUSIONS: Outpatient testing comprises about half of all hospital testing, yet systems are not optimized. Preanalytic TAT increases during the day, which indicates increasing delays in the collection and transport stages. Imposition of a test schedule on thyrotropin results in a delay pattern that is very different from the CBC and biochemical profile, which are tested on arrival. A laboratory's association with an MCO had a weak impact on TAT.

Ambulatory Care↗

PubMed2002

Q-tracks: a College of American Pathologists program of continuous laboratory monitoring and longitudinal tracking.

CONTEXT: Continuous monitoring of key laboratory indicators of quality by hundreds of laboratories in a standardized measurement program affords an opportunity to document the influence of longitudinal tracking on performance improvement by participants focused on that outcome. OBJECTIVE: To describe the results of the first 2 years of participation in a unique continuous performance assessment program for pathology and laboratory medicine. DESIGN: Participants in any of 6 modules in the 1999 and 2000 College of American Pathologists (CAP) Q-Tracks program collected data according to defined methods and sampling intervals on standardized input forms. Data were submitted quarterly to CAP for statistical analysis. Interinstitutional comparison reports returned in 6 weeks provided each laboratory with its performance profile of key indicators and its percentile ranking compared with all participants in that quarter. This also included longitudinal comparisons of performance during previous cumulative quarters. Control charts graphically displayed data with flags identifying performance points that were out of statistical control. SETTING: Hospital-based laboratories in the United States (98%), Canada, and Australia. PARTICIPANTS: Voluntary subscriber laboratories in the CAP Q-Tracks performance measurement program: roughly 70% from hospitals of 300 occupied beds or fewer, 65% from private, nonprofit institutions, slightly more than half located in cities, one third from teaching hospitals, and 20% with pathology residency training programs. MAIN OUTCOME MEASURES: Each module measured several major and additional minor quality indicators and unbenchmarked individualized data for internal use. RESULTS: Participants in 4 of 6 Q-Tracks continuous monitors demonstrated statistically significant performance improvement trends in 1999 and 2000, which were most marked for laboratories that continued participation throughout both years. These monitors were wristband patient identification, laboratory specimen acceptability, blood product wastage, and intraoperative frozen section consultation. CONCLUSIONS: Key continuous indicators chosen on the basis of a decade's experience in the CAP Q-Probes quality improvement program are useful measurement and benchmarking tools for laboratories to improve performance. In general, measures in which there is a broad range of demonstrable performance initially are most optimal for subsequent improvement using continuous monitoring. These studies have shown that quality is not static, but rather is a moving benchmark of performance as seen in the redefinition of benchmarks over time by participants in the first 2 years of the CAP Q-Tracks program.

Accreditation↗