Tuesday, June 26, 2012

EQA and Continuing Education: saving lives?

One of the challenges of the clinical laboratory is that most samples received in the laboratory are routine, beyond routine.  In the microbiology laboratory the vast majority of samples are urine samples from women and the elderly, throat swabs from young kids, and genital samples mainly from the folks hoping they have dodged an unappreciated bullet (most of them have).  The reality is that within this group there are few samples of life-altering significance.   

The challenging samples where a stain analysis reading error or a faulty culture can potentially have a lot of significance include Cerebral Spinal Fluid (CSF) or joint fluid and maybe blood cultures, but these samples are not very common; indeed they are rare, especially in the smaller laboratories.  And in the rural laboratories what makes the challenge worse is that the technologists (and pathologists) tend to have very little exposure and experience to samples from patients with true examinable and interpretable diagnostic samples.

What can make this situation worse is the intervention of politics.  In these days of laboratory consolidation there are those that see great advantage in moving all the microbiology testing to a single site, and if a critical specimen (as in CSF or Joint Fluid)  comes up in the middle of the night, well the available Chemistry technologist will stain and examine it or ship it down to the main facility.  Take the least trained person and put them in the situation of having to stain, read and interpret and report the most critical sample.  That always seems to make a lot of sense (said with great sarcasm!)

So it was in that context that we at our proficiency testing program set up a supplemental program to provide samples that simulate joint fluid and CSF as a way to increase their amount of exposure to these samples.  After 20 years (plus) of creating these samples we have become really slick at creating really good simulations with the right number and type of cells and appropriate concentrations of bacteria, some easy to read, and some not so much.  On a scale of 1-10 (where 1 is you don’t actually need a microscope to read the slides and 10 is that skilled persons still find some of them very difficult). I would estimate the challenge value of the samples is close to 8 or 9.  There are not enough samples that the laboratories will become over-burdened, but enough that when the real samples come in the have enough exposure and expertise that they can read and report them with more confidence.  Where there may be 1 or 2 samples a year, we can raise the number up closer to 2 every 3 months.

So the program has now been running for about 2 years and we have just completed our first customer satisfaction survey; and the message appears to be “thank you”.   That by itself is a pretty big accomplishment.  Folks don't tend to say a lot of positives about proficiency testing. 

Most of the slides are rated as  "acceptable" or better and the readers see them as looking like and staining like real samples.  The educational material appreciated and rated highly.  And they would like us to extend the program to other uncommon but high risk samples.  

What I didn’t ask, but probably should have, was along the line of if the program has increased personal confidence in reading true critical slides.  In truth the responses would have been highly subjective and difficult to analyze, but I think it will have to be a part of a follow-up questionnaire, perhaps examinable within a word cloud.

So here is my bottom line: providing practice materials for laboratorians put in the terrible position of having to read high pressure samples with little experience and expertise is providing a service to the laboratorians and their patients.  The laboratorians comment positively about the program and I think it reduces the risk of reading error.  

While I can’t prove it, in my opinion and bias is this is a very important service, and it might even in some instances save a life.  

To see a critique with performance, evaluation, education and photograph visit: 


More later.

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