Monday, June 27, 2011

Two sides of the Clinical - Laboratory divide.

I saw with appreciation Charlie’s reminiscences of having phlebotomy duties and how it was such an important connector to the patient behind the bar label.  I agree.  It was then and could still be today an important way to link the disconnected laboratorian back to the reason that many of us got involved in health care.   In many respects it was a triple-win strategy.  The laboratorian collected the sample they needed for testing having connected directly with the patient.  Since the laboratorian was more aware of the specifics with respect to sample volume and timing and transport conditions, the patient benefited from the increased likelihood of a correctly collected sample.  This created the conditions for minimized risk of pre-examination error.

My background was similar, but from the opposite direction and with the exact opposite effect because it create the greatest risk for examination error, over and over and over.  In the sixties’ and seventies’ and a little into the eighties’ hospitals seeking to keep their laboratory budgets down required interns and residents to perform laboratory tests, rather than have technologists do them, especially in the Emergency Rooms (ER) and in the evenings and on weekends. 

The ER would have a broom-closet converted to a cubby-hole laboratory with a centrifuge, a microscope, a urinometer, and a hemoglobinometer and a counting chamber.  Usually the room was full of tons of junk and debris and old samples dating back for the several weeks, creating an indelible odour of stale urine and God knows what else.   The available stain reagents were contaminated and loaded with crystal shards.  There we would do our own urinalysis, and haemoglobin and white counts and gram stains.  On evenings we would plant our own urine cultures. 

I know that this sounds like much less than what we see the house staff doing on the television show House, but it was a total waste of time.  (It is probably an equal waste on House as well!)  First none of us had any real training, and even if we did, the microscope and centrifuge and urinometer were so badly cared for, the chance that we could perform any test accurately was essentially zero.  And what was scary was that we actually used to make clinical decisions based upon those results.   The risk of examination error was near 100 percent.
The justification for all this was said to be that we were learning skills invaluable for being a clinician, but the real reason was that we were cheap labour.  And the clinical consequences of erroneous testing never showed on anyone’s radar.    Fortunately over time the cubby-hole reverted back to being broom closets. 

Over the last 10 years we have seen these mini labs return with a vengeance with more-and-more point of care testing.  We are told that the situation is totally different because the equipment is self-controlling and “idiot-proof”.  Not only that, but there are international standards (ISO 22870:2006) that dictate the appropriate quality requirements when operating point-of-care equipment.  Maybe that’s all true, but if facilities have not learned the lessons of ensuring competency and training for point-of-care testing, then they deserve all the incumbent risks.  At our recent Quality Weekend Workshop, one of our presenters showed data demonstrating the bias and the degree of deviation on duplicate testing with several point-of-care instruments.

Manufacturers sell on simplicity of use, but they also work from a quality of use perspective.  It is not in their interest when poor usage by inexperienced or untrained personnel gets results that lead to negative outcomes.

The message here is not that laboratorians should be venturing into the clinical arena but clinicians should stay out of the laboratory.  I see a too many advantages to addressing the gap between these two spheres of activity. 

But can we agree that training and competency and commitment to Quality have to not only be a part of the process, they have to be the process.


  1. Randox manufacture a point of care instrument, the Evidence Multistat which has in built QC, but we also manufacture specific point of care liquid quality controls to help this issue you have raised, but I agree that thorough training in this is necessary.

  2. There are various processes in clinical laboratory that has to be assessed properly. This will avoid potential problems.


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