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Sunday, May 15, 2011

More Rejection.

Sometimes rejection is a good thing, at least when thinking about laboratories protecting the quality of their work and output.  Rejection criteria are created to protect the laboratory, the clinician and the patient.    The laboratory protects itself from doing needless work and work with little chance of clinical utility.  The clinician is protected from receiving information that might be non-contributory, or worse, might lead to wrong decision making.  The patient is protected from spending money for additional tests and therapies that would not have been ordered had things been done right the first time.

In a litigious society working on poor quality samples has a higher probability of costing the laboratory more through legal fees than than it recovers in test revenues.


In the non-litigious society, reporting results that are either clinically-irrelevant  or clinically inappropriate damages the laboratory’s credibility.  Frequently we hear in laboratories in developing countries that the reason that so few samples are sent to medical laboratories is because the doctors don’t trust the results.  By tightening up on the quality of samples that are accepted for testing results in increased confidence in the results and increased samples being processed.  


But as with most things in life, rejection criteria are not a “one-size-fits-all” decision process.  I can give you a few examples as they appear in the microbiology laboratory.  

The first example is one where the sample is accepted, but the request is rejected.  Frequently we receive urine culture samples submitted with a requisition that says “test all organisms for antibiotic sensitivity” or “test all organisms for urease activity”.   Usually these requests are motivated chronic recurrent symptoms of infection or stone formation.  Well that sounds good and the information may be useful if the samples are pure (one isolate) or near pure (2 or 3 isolates).   But there is no value in testing every isolate in a polymicrobic sample with 4, 5 or 6 different isolates.  There is no reason to do high level testing that you know will not contribute relevant or useful information.  

There are many ways of dealing with this sort of rejection, and usually it requres having a conversation with the ordering clinician, but sometimes the clinician has to understand that extra testing is not going to get done.

Another example is what might be called  cascade rejection.  This is where the sample comes with a request for all isolates to be tested for susceptibility to satifloxacin. This is a situation where as soon as the “new drug” shows up in literature, requests for testing show up in the laboratory.  This is where antibiotic stewartship needs to kick in.  If the drug is not on the facility formulary list or the current laboratory list, it is not going to get tested, unless there is a research protocol to which the laboratory has agreed to participate,  and this information is not going to be available for random and regular use. 



Two last quick thoughts.  


First,  Most laboratories do not have the computer power to build rejection criteria into the laboratory sortware, which will be terrific when it happens.  When that happens all sorts of complex “if...then” layers can be implemented, and the system will label the sample and block steps all along the sample’s path of workflow.  Until that time comes, the application of rejection criteria falls to the memory of frontline workers with lots of work pressures. Creating straightforward criteria have a reasonable chance of being implemented.  Complex criteria are have little chance for success unless senior leaders personally insert themselves into the intervening process.  


The second quick thought is that proficiency testing programs can and should  provide programs to challenge rejection criteria.  More on this later.

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