|
Here's the problem:
1 We want very high consistency in glycated haemoglobin analysis across
the patch: primary, secondary and tertiary care.
2 We are considering assaying glycated haemoglobin, total and HDL
cholesterol, triglycerides and creatinine during the clinic visit for
patients with diabetes. This could be at three sites,
3 Capital and revenue costs need to be as low as possible
4 Relentless increase in requests for glycated haemoglobin analysis
from primary care
Because of 1 my first thought was "laboratory-type" analysers for
glycated haemoglobin on trolleys which could be used in the laboratory
and wheeled down and used PoCT in the clinics. This would give high
consistency and low cost but won't give the extended repertoire.
Air tubes + in-laboratory analysis alone won't solve the problem
because one site doesn't have an on-site laboratory and another doesn't
have enough air tubes.
Will we inevitably end up with different methods used in the laboratory
and clinic?
I have a feeling we are not alone in having this problem. Does any one
have good solutions they could share?
Thanks
Jonathan
And here are the responses (I may not be any wiser, but I'm much better
informed):
....
We (xxx Pathology Network)use a mix of laboratory Tosoh analysers and
Bayer DCA NPT GHb analysers with good agreement up to 10% (above 10%
DCA has an increasingly negative bias). We don't see a need to provide
other NPT services, but one proposal is to bleed all GP diabetics when
the Eye Screening van visits the practice and transport all the samples
back to the lab for analysis of creatinine,lipids and GHb.
...
We have 2 menarini instruments at a small lab in the Diabetes Centre
and we
take over non-clinic samples for analysis between clinic patients and
overnight (all results networked, of course). It has the advantage that
we
provide an on-site service for the clinics daily, and use exactly the
same
instruments for primary care. It has the disadvantages that you need a
BMS
presence in the Centre every day, and the increasing primary care
workload
is making the ferrying of samples tedious and the capacity for overnight
running barely sufficient.
Not sure about the necessity for in-clinic lipids and creatinine,
though.
...
The most rational solution is to centralise laboratory service
provision and for blood samples to be sent to the lab 2-3 days prior to
clinic appointment. Unfortunately this rational solution is politically
unacceptable as it is against "the one stop shop concept" that is
infesting the NHS. So we end up with DCA analysers in diabetic clinics
and GP surgeries and an HPLC analysers in the laboratories, producing
inevitably inconsistent results. Centralisation of clinical services at
least in secondary care and utilising an efficient air tube system is
another rational approach, if there is the political will to do it.
...
Our Diabetic Day Care Centre sends a letter to patients about a month
before
they are due for their annual review clinic. The patients can take this
either to their own GP surgery or to the phlebotomist in our
out-patients
department. The letter lists the assays which are required and should
act
as a request form.
It doesn't always work - we get boric acid containers for the
microalbumins
which we knock back. Also the surgeries don't always use the letter as
a
request form but write out fresh forms, but with their surgery as the
address for the report.
On Monday afternoons the secy in the diabetes centre FAXes a list to
the lab
of patients for whom she has no lab results. We print off copies of
anything that the GPs or other hospital departments have requested
recently
and she picks up the reports around coffee time the following morning.
This
latter stage in the process should be avoidable soon with the roll out
of
web-browser which should allow the diabetes centre staff access to both
hospital and GP results.
The vast majority of the patients have results in the diabetes centre's
computer system by the time they are seen for their annual review.
...
Years ago I put an odd analyser in the diabetic clinic because the
consultant wanted urea, creat, total chol and trigs on selected patients
along with HbA1C. We used an Abbott centrifugal analyser, name escapes
me, primarily as it did HbA1c by affinity chromatography. After 5 years
we removed it because it had never been used for any test but HbA1c !
...We also request a pre-visit to either GP or hospital phlebotomy
service with
a pro-forma PAS letter which serves as a clinic reminder with a tear-off
"lab request form" for renal, lipid, glycHb and urine alb:creat.
This is not so good for the non-ambulants, so we have a Primus PDQ
analyser
in the Diabetes Unit maintained by the lab, but run by the trained DU
staff
with results recorded and reported back to our lab LIS. This picks up
the
stragglers and is also used for finger/ear-prick samples from kids in
the
paediatric clinic.
The lab system is also PDQ but with barcode reading autosampler.
Feedback from DU is "large majority of patients have results available
and
patients mostly satisfied"
...
For many years we have provided biochemistry services in the Diabetes
Clinic here, with a repertoire of glucose, cholesterol, triglyceride
and creatinine. All assays are performed on a Mira analyser (which will
be replaced shortly by a new discrete analyser) using plasma from
capillary blood taken from a fingerprick. Blood is collected by a MLA
and a BMS operates the analyser. We adapt the methods in use on our
main analysers (Roche Modular) for use on the Mira.
We used to do fructosamine alongside these other assays, but now do
HbA1c on a Tosoh G7 system, which lives in the clinic. We have another
G7 in the lab, on which non-clinic specimens are analysed so the
results are comparable.
I think we are fortunate that the service has been clinic-based for
over 15 years. There would be cosiderable outlay in terms of instrument
and staff to set it up from scratch.
....
The Bayer DCA 2000 performs very well, has excellent
EQA (actually better than the lab Menarini!)is
portable and easy to use in clinic situations. We have
used this for some time, correlation with laboratory
results is good and its use has revolutionised patient
care in the clinics. Go for it!
...
There seems to be an trend whereby GPs are becoming increasingly
reluctant
to bleed their own patients prior to a hospital visit. There seems to be
several reasons for this. Firstly, they can be overun by these requests.
Secondly, they feel it makes them (or their practice nurse) a lackie
for the
pompous hospital consultant. Thirdly, providing this phlebotomy is an
'enhanced service' under the new GP contract, so it has certainly been
discussed that by withdrawing the service now it means they can
introduce it
at a later date and get rewarded for it!
...
Menarini responded:
I believe that Menarini Diagnostics could help with the scenario as
outlined in your e-mail of 26th May which was noticed on the ACB
bulletin board.
Firstly, you mentioned 'laboratory type' A1c analysers which could be
used in the POCT clinics. Menarini have a new generation of HPLC
analysers, the HA-8160. This analyser will offer you the same quality
of results as the HA-8140 which is currently in use in the Biochemistry
Department at the JR; but unlike the 8140, the 8160 analyser is a
single contained unit, which can easily be put onto a trolley and
wheeled to the clinic. In fact I am aware of sites who currently use
the 8160 in a busy clinic setting.
With regard to your consideration to assay total HDL, cholesterol,
triglycerides and creatinine during the clinic visit, Menarini can also
offer a small portable POCT dry chemistry analyser for these assays.
Shortly, we will be launching a connectivity package called NetCare,
this will enable you to de-centralise your laboratory tests, whilst
still maintaining control within the laboratory.
...
And today, in response to a similar question:
We use an airtube and the same analyser we have in the lab - It
minimises variation...
------ACB discussion List Information--------
This is an open discussion list for the academic and clinical
community working in clinical biochemistry.
Please note, archived messages are public and can be viewed
via the internet. Views expressed are those of the individual and
they are responsible for all message content.
ACB Web Site
http://www.acb.org.uk
List Archives
http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
List Instructions (How to leave etc.)
http://www.jiscmail.ac.uk/
|
