Support for interpretive skills in Sheffield haematology laboratories

Excellence in interpretive skills singles out the haematology laboratory services at the Royal Hallamshire and Northern General hospitals, part of the Sheffield Teaching Hospitals NHS Trust. This is further enhanced by the reputation they have in medical laboratory circles for the quality of their staff and the training they receive.

Underpinning their individual approach is the innovative way the teams manage their information technology resources that feed data to the analysers, and the technology on which the analysers themselves are based. “We put a high value on the scatter plots generated by the technology and use the information they provide to help refine and clarify the diagnostic possibilities for the medical teams,” explained Andy Ward, deputy laboratory manager in haematology at the Royal Hallamshire Hospital.

The set-up was designed by the laboratory staff, with the cooperation of partner Beckman Coulter, and is widely regarded as one of the most progressive examples of laboratory information technology in Europe.

Diagnostic information resource

The advanced use of laboratory informatics has enabled the haematology teams at both hospitals to take a more proactive role as a diagnostic information resource. In vitro testing already represents less than 5% of a hospital’s total spending, yet the information it generates plays a pivotal role in over 70% of healthcare decisions. Case studies show that up to 50% of direct hospital and out-patient charges can be reduced by making the most appropriate use of existing diagnostic information.1

Significantly, Sheffield has just implemented a centralised referral laboratory service for haematooncology disorders to meet National Institute for Health and Clinical Excellence (NICE) improved outcome guidance for haematological malignancies. In some laboratory departments, the concept of collaborative disease management is finally becoming a more realistic and professionally stimulating concept. As professionals, however, the team knows all this has to be done while maintaining total standard conformity, without sample contamination or any ambiguity of results reporting.

In Sheffield, workloads have increased steadily by 5-10% each year since 2000. Currently, each site handles around 1000 full blood count (FBC) samples each day, the majority of which reach the laboratories around the late afternoon peak, driven partly by the growing demand from external GP practices.

Approximately one-third of samples arriving at the 850-bed Royal Hallamshire Hospital are from local GPs, while the larger 1100-bed Northern General Hospital handles an even higher percentage of external GP requests.

Fast turnaround of haematology results

Despite increasing demand, the laboratories have been able to maintain and improve standards of service delivery, hitting a 95% target rate for result turnaround time (TAT), in part thanks to the capabilities of their data management resource. At the Royal Hallamshire, with both an expanding oncology department and a high proportion of out-patient test requests, they are able to deliver a TAT for urgent results of between 30 and 45 minutes.

The haematology teams have achieved their reputation by taking a creative approach to current NHS efficiency drives and demands for greater productivity and cost savings. As Andy Ward explained: “Modern laboratory life makes demands on managers quite outside traditional scientific skill sets; for example, budgeting and administrative duties and more complex staff training programmes.

“We decided that to handle these challenges successfully, and to free staff to manage the additional burdens we all face, we needed to utilise the right type of analysing and information technologies, and in the long-term to look towards a greater use of automation.”

At its most basic, robust information technology must assist in reducing paperwork, cutting down on test result review time and reporting, both of which help the laboratory make a greater contribution to improved patient care. For this to happen, however, the data management system has to be simple and easy to use, while offering a variety of problem-solving possibilities. Working alongside a traditional laboratory information system (LIS), which has numerous limitations, data management systems and other software solutions will speed the exchange of crucial information.

Top European site for information management

Remisol 2000 can eliminate a proportion of the manual review process with a system of auto-validation, based on user-defined decision rules. This is crucial when assessing urgent tests. By improving TAT through this system, the laboratory is able to provide critical test results more quickly. This will enable the medical teams to make more informed decisions faster – a benefit that measurably improves patient care.

With its advanced auto-validation capabilities, Remisol 2000 allows normal results to be processed and released quickly, based on user-defined criteria. Meanwhile, abnormal or unexpected test results that require urgent assessment are flagged for manual review. Samples flagged in this way can be located with just a single click of the mouse. Data can be retrieved numerically, alphabetically or even reverse alphabetically from any networked station.

What the Sheffield teams have achieved, with the cooperation of Beckman Coulter and the Remisol software, is something truly powerful. They have created a way of working with Remisol and the Coulter technology that maximises the potential of both, a challenge many other laboratories remain reluctant to tackle.

Each of the Sheffield sites has three Coulter LH 750 analysers, which feed information to a bank of Remisol 2000 computers – the largest set-up of its kind in Europe.

First, data from the analysers stream into the central Remisol server, which then directs specific data to five individual Remisol screens, two of which are used for the validation of results, with each of the remaining three located by a biomedical scientist at a microscope.

The set-up is replicated at each site, with a total of 12 Remisol units in total – two master servers and 10 individual monitors. “What is viewed under the microscope, and its implications for patients, is given fresh impetus when it is assessed alongside the scatter plots generated by the Coulter technology,” added Mr Ward.

User-defined rules

The laboratories review every result and utilise a traffic-light system, which acts as a visual trigger for abnormal results, keeping the validation process safe and efficient. Remisol gives the laboratory complete control over writing rules specific to its individual requirements.

It is this aspect that the Sheffield laboratories have exploited to the full. “When producing an audit trail, for example, we can write a rule that allows us to automatically record and identify the individual analyser involved – something we need to do for quality control purposes anyway,” explained Mr Ward.

In addition, Mr Ward believes that the VCS technology on which the Coulter LH 750 analyser is based has enabled the laboratories to extend their interpretive abilities. VCS technology (volume, conductivity and scatter) provides a powerful and precise tool for blood cell analysis, enabling the direct measurement of differential populations. Mr Ward cited the example of standard blood readings at the low end of normal.

“This is the most difficult diagnostic challenge, but when we look at the blood scatter patterns produced on the computer by the VCS technology we may see changes that suggest the early stages of disease,” he explained. Such has been their success with the Remisol 2000 network that the Sheffield Teaching Hospitals NHS Trust laboratories currently are working with Beckman Coulter to test a prototype of Advance, the next-generation Remisol, which has the capability of replacing many of the functions currently undertaken by a standard LIS.

Sheffield is the first laboratory service in the UK to work with the new Remisol Advance, a resource that Andy Ward believes will further increase their efficiency and expertise in delivering diagnostic possibilities to the city’s clinicians.

Neil Porter, lead laboratory manager in haematology, has encouraged this partnership approach between his automation team and Beckman Coulter. This provides added value in operational terms and ensures the innovative use of the technology, which has the potential to enhance diagnostic value in areas such as the haemato-oncology reference laboratory.

Reference

1 The Lewin Group. The value of diagnostics innovation, adoption and diffusion into healthcare. AdvaMed July 2005