Specimen Handling in the ED


July-August 2015 - Vol.4 No. 4 - Page #10

 

Q&A with Jennifer Granata, FNP-C, MSN, CEN, CPEN, CNML
Southern Maine Health Care, Biddeford, Maine


Medical Lab Management: How does your facility currently manage specimen collection and patient information capture in the emergency department (ED)?
Jennifer Granata: At Southern Maine Health Care, a not-for-profit health care system comprising two full-service medical centers in Biddeford and Sanford, Maine, positive patient identification and transfer of accurate patient information are among the top priorities. To ensure samples intended for analysis are always traceable to the correct patient, regardless of the sample’s or patient’s location in the facility, the organization employs an automated, bar-coded point-of-care (POC) system for patient specimen collection and tracking. This system uses a common labeling format and universal interface, so users can scan and read the labels throughout the facility. By extending this bar coding to the point of care, human error is virtually eliminated from the patient specimen collection process, and the potential for patient harm due to misidentification is substantially diminished.

As for the process itself, when a clinician orders a specimen for analysis, the order crosses automatically to a queue for nursing. The nurse attends to the patient and scans the patient’s bracelet to confirm identity using the PC-based system housed in each patient room. The software program outlines the tubes that need to be collected and the order of draw, and provides any special instructions (eg, place specimen on ice; no tourniquet).  At this point, the specimen labels print at the bedside. The nurse then collects the specimen, attaches the labels, and scans each specimen to mark it as collected in the system. Lastly, the specimens are bagged and sent to the lab, usually via pneumatic tube.

MLM: Do you use any other systems for specimens requiring special labeling or handling?
Granata: The facility has a special process for the handling of spinal fluid. In these cases, the patient sample still is labeled at the bedside and confirmed using dual identifiers (ie, name and date of birth), but the ordering, labeling, and transferring processes are done by hand. Because lumbar punctures are delicate procedures, the physician is present during the collection and hand writes the order using the patient’s chart labels. The tubes are labeled with specific instructions, and the order and samples are hand carried to the lab.

MLM: How does the ED generally deliver specimens to the lab? 
Granata: The ED utilizes a courier service, primarily because our in-house lab is smaller and, therefore, offers fewer services than our larger lab, which is approximately 15 minutes away. Tests that do not require an expedient turnaround time or are particularly esoteric often are sent to the main lab for analysis; however, all emergency testing is performed at our in-house lab. 

When using a courier, the process still is secured using the bar-coded tracking system. Staff members scan all samples when they leave the ED and when they arrive at the main lab, so the products can be tracked through the computer system. The universal interface throughout the health system allows both labs to use the same labels and nomenclature. 

MLM: Do you have any specific rules regarding the use of the pneumatic tube for transporting specimens from the ED to the lab?
Granata: In addition to not sending spinal fluids through the pneumatic tube, the general rule is if a specimen is particularly difficult to acquire, such as blood draws or straight catheterizations involving small children, the severely injured, or the immunocompromised, those samples are hand-delivered to the lab. Although the lab has not had any significant issues involving the integrity of samples sent through the pneumatic tube, hand-carrying samples is a judgment call made by the nurse based on the difficulty of a repeat procedure should the specimen be compromised.

MLM: How do you monitor the status of patient samples once they leave the ED?
Granata: As a complement to our automated specimen collection and tracking system, a tracker board runs through our electronic medical record (EMR). After collecting, labeling, and sending the patient samples to the lab, the nurse indicates in the EMR that these processes have been performed. This alerts the lab that the specimens are coming. In the ED, a large display board shows the status of each order sent to the lab. When an order is entered, the word LAB shows up in red on the board for that order. When the lab scans the specimens as received, the letter L in the word LAB turns green. This indicates to ED staff that the lab has received that specimen, but it has not been resulted. When the specimen is processed, the entire word becomes green; in this way, a quick glance at the board lets ED staff know when the results are available. 

MLM: How do you address workflow issues that impact specimen collection and handling?
Granata: Regular meetings with lab personnel have been an important part of achieving success with the POC identification and tracking system. When the system was first instituted, we met with members of the lab staff to establish a project implementation group. That evolved into a bimonthly meeting to discuss functionality and workflow problems. We have found that many operational issues can be resolved through collaborative meetings. For example, one issue that arose involved laboratorians noticing that ED nurses were sending a large number of patient samples to the lab with chart labels, instead of the labels generated by the automated system. Lab staff assumed that ED nurses were choosing not to use the automated system, thereby breaking protocol. Rather, it became clear that with 29 rooms in the ED, each housing PC-based scanning and printing units, technology breakdowns were inevitable. If a scanner malfunctioned in one room and a printer jammed in another, the nurses resorted to handwriting information on patient chart labels.

In meeting with lab and IT personnel, the team developed a process to quickly identify rooms with malfunctioning equipment and resolve issues as rapidly as possible. The process involves informing IT of the breakdown via an electronic ticket that is initiated at the PC in the patient room. Simultaneously, the lab is informed of the issue and, thus, is prepared for an uptick in hand-processed orders until the issue is resolved. Given the hectic environment of the ED, nursing often cannot wait for a repair before caring for a patient. Nevertheless, resolving issues as quickly as possible and reverting back to a fully automated process should be a priority. 

MLM: Do you plan to change or augment the specimen tracking system going forward?
Granata: Fortunately, we have been able to expand the automated system beyond the ED and incorporate it throughout our inpatient units. Some units use a handheld version of the system and others rely on the same desktop version that is used in the ED. The hardware choice depends on the individual needs of the unit and their workflow. Regardless, implementing a standardized, automated process is both ideal and necessary for interdepartmental collaboration between the lab and the ED. Both are heavily dependent on expeditious turnaround times, as well as precision and accuracy of results. The support system creates a closed loop for specimen tracking.

 


Jennifer Granata, FNP-C, MSN, CEN, CPEN, CNML, is the director of emergency services at Southern Maine Health Care in Biddeford, Maine. She received her bachelor’s degree in nursing from the University of Southern Maine and her master’s degree from Husson University in Bangor, Maine. Jennifer’s professional interests include ensuring patient safety through dual identification and patient throughput processes.

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