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Coagulation Corner

Wednesday, September 3, 2008

Maximize your time and minimize your problems!

The MAYO conference in August was dedicated to the memory of Dr. Walter Bowie. He passed away in March of this year. He was a pioneer in coagulation and a very gentle soul. Dr. Bowie loved limericks- so I dedicate this as well as this month's column to him:
Dr. Bowie was dedicated to the science of clots
To hear him lecture, you would end up knowing lots
He had a passion for Lupus and Protein C's
Dr. Bowie taught with a cascade that was made up of fleas!

Maximize your time and minimize your problems in the coagulation laboratory:
Troubleshooting tips:

I have had both the honor and the privilege of lecturing to clinical laboratory scientists and visiting their laboratories from New York, to Jackson Hole Wyoming, to Ponce in Puerto Rico, and even Vincenzia in Italy. Technologists all struggle with the daily routine of balancing work, dedication, conflicts with turn around time and producing quality results. The complexity of coagulation is difficult enough, it is compounded with trying to get qualified personnel, training them (which I might add takes 2 years), and retaining them. From all corners of the earth, laboratories are faced with this dilemma. So, what we need are options, we need to maximize time and minimize problems!

You know those days - someone calls in sick, the phone hasn't stopped ringing, the floor needs a factor VIII NOW, your QC is due and it isn't even 8am. Well, you can so forget about lunch!
So what do you do to keep problems to a minimum? These are the days you want to cut corners, but in fact you need to slow down, take a deep breath, and proceed with caution. Here are some tips that can be used on any day to maximize your time and minimize your problems.

1. Make sure all your reagents are fresh. That one day old bottle of APTT reagent, don't take a chance, get a new bottle.
2. Make sure your maintenance is done on your analyzer. Check all you consumables, your reagents, and your water - make sure they are filled. There is nothing worse than losing precious time because you need to load some type of consumable, worst yet- reinitialize!
3. Get those controls cooking - let them sit for the correct amount of time- or they might just compound your problems. Make sure you use GOOD, FRESH, Type I or sterile water; you can halt many problems by this one little good laboratory practice.
4. Organize your work, ELISA testing can wait, things like factor assays, heparin levels, HIT assays need to be performed. For the staff that has braved the day, put your strongest person in their strongest testing place - and really schedule those breaks, you are going to need them, walking away for a cup of coffee sometimes makes the difference between finding a problem and going for a hammer!
5. You can always do the "Lets Make a Deal" - if a physician wants a full hypercoagulable workup, try to work through a rational plan with them, maybe the Protein C is more important then the Protein S, or even worse the patient is on heparin! The results of these assays are going to be affected by anticoagulation, besides the expense to the patient, and the time it will take, the answer really isn't reflective of what may be the root cause.
6. What if everyone wants factor VIII's right away? Can you give them 1 point with the rest to follow, as a preliminary, knowing if they suspect an inhibitor, it might be higher, and it is not likely to be lower if you run it at a 1:10 dilution. They might need to if it is just greater than 50%. Only use this when the clinician is fully aware of the implications of getting 1 point, and the rest will follow shortly.
7. Okay, so even before you get that far, your controls for the factor assay are out- what do you do? Lots of people just go to running a new curve, it may actually take less time in the long run - Lets take a minute to look and see what is "out"-
a. Did you run both PT and APTT based assays? Was just one- say factor IX out, if just one level is out, I would rerun that control.
b. If both levels are out on the Factor IX only, I would cut to the chase and rerun the curve.
c. If all APTT based assays are out, I would discard APTT reagents, and start again. (Once I was helping and reconstituted a reagent with 5mls instead of 10 mls, not much of a help!}
d. If all the controls are out, I would get new controls. (maybe new reagents, even new buffers!)
e. If you can't get anything to work, power down, restart, say a prayer, and maybe it will reset.
f. If you run a curve and controls are still out-, look at the points on the new curve, how do they compare to the previous curve. Sometimes only 1 point needs to be re- run, this will save a lot of time.
g. Then there are the times where the points look exactly alike- and the controls still won't work. You can try different types of controls, run them as patients so they don't mess up your QC files, MAKE SURE YOU HAVE DOCUMENTATION, or you can use proficiency testing material in the control ranges. This will also help you to troubleshoot, and if you need to call service, it will be good information to give to the company. Left over proficiency samples are gold, they are peer evaluated material, and you know how they ran in your laboratory, so they can really provide good information. Don't have any PT material, what about previous patients that are in the range needed? Again these were performed on your instrument/reagent combination and can give great insight as to what is going on.

Sometimes in the laboratory investing a little time, can help to decrease time in the long run- and with inspections now a surprise, everything always needs to be perfect, not that is wasn't before... some of my best tips are:
1. Color code shorted dated reagents by expiration date with a big DOT and a corresponding log: for example
Red dot for reagents that expire in October
Blue dot for reagent that expire in November
When you have to check inventory or discard expired reagents- just a quick
visual will let you know what has to be removed
2. Make sure everyone is aware of changes, post changes, and document it, because if it isn't documented, it wasn't done.
3. Use your proficiency tests to help establish competency, great way to do it, and to accomplish 2 tasks at once.
4. Try to minimize the controls that you use, they should be multipurpose and stable, make up more than 1 vial if you need it for more than one analyzer, sometimes spending a little more on utilization of a control, will save more time than waiting for a control to be run on one analyzer, then another and holding up test results.
5. Listen to the techs, allow all techs to have input in the running of the laboratory, if they can make suggestions as to a worksheet that will make it easier, or a computer function that will improve how they work and minimize errors, or they can improve a procedure, look at it, and listen to them. Allowing people to "own" processes make them more willing to adhere to standard operating procedures.

So, you have survived yet another stressful day in the coagulation laboratory. No patient will even know what you did, or how dedicated you are to their care. Yes, we will still continue to be portrayed on TV as the ones with the lost samples, or the ones having coffee, someone has to be blamed! However, you will know what you have done, other techs know what you have done, and occasionally even a physician will know what you have done. And guess what, you will come back tomorrow, and do it again- you love it, you know you do!

Donna Castellone

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Donna Castellone,  MS, MT(ASCP)SH

Donna Castellone,

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