Author: Guo Xuping
Unit: Affiliated Hospital of Chongqing Three Gorges Medical College
At 14:30 p.m., I was preparing to leave work, and I was stopped by a colleague and asked if the critical value of this patient in the following figure could be reported?
The total number of white blood cells is normal, N% is significantly increased, 2 lines are significantly decreased (red, platelets), and HGB/HCT violates the critical value of this chamber (HGB
Suggest lymphopenia, anemia, thrombocytopenia, scatter plot and instrument results are more consistent, and this specimen in other instruments retested, the results are more consistent, when colleagues pick up the phone to report the critical value, I called pause, found some problems:
As we all know, before the critical value report, we must review the results, first understand the status of the instrument, whether the quality control is in control, the quality of the specimen, the quantity, etc., and then re-examine, for the blood routine must also be combined with manual classification, to understand the morphology, quantity, distribution, whether there are abnormal conditions under the microscopic cells, etc., to see whether the microscopic lines are roughly consistent with the results of the instrument.
Question 1: Push the specimen, St. Regis stained, low magnification under the ring for a week, no obvious abnormal large cells were found, so turned to the high magnification to count the 10 visual fields with relatively uniform cell distribution, the average of each field of field leukocytes 3-4/LP, no obvious abnormalities in morphology, mainly lobular nucleus; thrombocytopenia, scattered distribution, no aggregation phenomenon, and the instrument basically coincided; red blood cells were evenly distributed, the size was basically the same, there was no abnormality in morphology, no pallet enlargement of red blood cells, and no dot color red blood cells, polychromatic red blood cells, Howe's body, etc., that is to say, no obvious anemia was found from the microscope, but the results of the instrument showed obvious positive cell anemia; from the perspective of the compound film, the red blood cell results did not match the instrument.
Question 2: The patient is an orthopedic patient, listen to colleagues say that it is higher than the fall injury, multiple fractures, blood loss is inevitable, but the total number of white blood cells is not high, not very common sense, strenuous exercise will also make the total number of white blood cells several times higher than usual, not to mention the fall from a high place, and usually see the car accident injury, or other fracture patients have more leukocyte heightened phenomenon is not consistent, not to mention the patient is usually a healthy middle-aged man.
Question 3: The patient's multiple fractures will definitely bleed, causing a decline in red blood cells and hemoglobin, but this patient has dropped too much, is the liver and spleen ruptured? However, even if the liver and spleen rupture, it will only be red or at the same time the platelets will decline, and the granules will often increase significantly, except for the underlying diseases.
So the phone asked the current situation of the clinical patient, the clinical nurse said that the patient's general condition is fine, that is, feel the pain, from the nurse's general situation ok, I read out that this patient should not be so anemic, this critical value report results are estimated to be untrue. So ask the nurse, whether the infusion side of the blood collection, the nurse denies, ask whether the patient has a liver and spleen rupture, the nurse said that the case is not reflected, so talk to the nurse, HCV critical value, HGB critical value, the result is obviously inconsistent with the actual situation of the patient, if we report to the clinician, the clinician can not judge normally when it will be based on our results, resulting in patients not only can not get effective treatment, but also to the patient's body, property caused by huge losses. So the nurse told me that due to multiple fractures, the specimen collection was not smooth, so she closed the infusion tube, the blood collected from the needle, and also told me that the blood routine at 12:30 was also collected in this way, so I inquired about the previous results.
The first column of this figure is the result of 12:30 noon, the second column is the result of 9:30 a.m., from these three results, white blood cells, red blood cells, hemoglobin, hematocrit, platelets are getting lower and lower, the most likely reason is blood dilution, it is possible to reduce synchronously, so immediately ask the nurse to collect the contralateral unfused lower extremity venous blood, retest results, as follows:
Sure enough, as I expected, at this time it was really like a big white, the previous specimen was indeed diluted, and the previous report result including the critical value was wrong.
Later we also had an exchange with the patient's supervisor doctor, and the report at 9:30 a.m. was that the patient had multiple fractures before the infusion, the patient's hemochromatosis was not low, and the white blood cells were also high, considering hemoconcentration (the body's emergency response). At 12:30 noon, the patient infused for 3 hours (later learned, the nurse because of the difficulty of collection, from the second collection to take the infusion tube, directly to the blood vessel) The results changed greatly, the doctor wanted to find out the real bleeding situation of the patient, at 14:30 in the afternoon, he sent a blood routine, on the critical value report at the beginning of the article, if we send the critical value out, experienced clinicians are bound to question the reliability of our results, inexperienced doctors immediately issued an emergency blood transfusion notice, and it is bound to review the blood routine again If we don't communicate well with the nurse, the nurse won't tell the truth. Therefore, how important is the communication between testing and clinical.
Critical values and patients are not critical, deserve our high attention!
Start by clarifying what a critical value is and how to report it. Critical value definition: can prompt the patient's life in a dangerous / critical state of the examination data / results, at this time the clinic should immediately take urgent and appropriate rescue measures, it is possible to save the patient's life, otherwise there may be serious consequences, the loss of the best rescue machine.
That is to say, the critical value report is closely related to life, and the timely and accurate examination and inspection report of the medical technology department can provide a reliable basis for the diagnosis and treatment of clinicians, and can better provide safe, effective and timely diagnosis and treatment services for patients[1]. It can be seen that the critical value should not only be timely, but also accurate, if not accurate, it will give the clinician a false prompt (especially when the diagnosis of the disease is vague in the clinic), medical over-treatment, bringing damage to the body and property of the patient, so the critical value is not the same as the child's play, must be highly responsible, combined with the clinical, the use of clinical thinking careful analysis, in accordance with the critical value reporting procedures (critical value item selection procedure, critical value report limit determination procedure, critical value identification and confirmation procedure, critical value report path selection procedure, Critical value review procedures, critical value confirmation/readback/record procedures, critical value reporting system assessment procedures, etc.) correct and timely reporting.
For example, if the above critical value results are real performance, then the clinician will increase the amount of blood, according to the conventional, each 200 ml of red blood cell suspension can increase up to 7-8 grams of hemoglobin, if you want to increase the hemoglobin to 100 grams, at least 1000 ml or so (provided that the patient does not lose blood again), as we all know, multiple fractures will at least bleed in surgery, then you have to prepare blood, the overall cost of 200 ml of suspension is more than 300, and allogeneic blood transfusion, For patients with sensitive constitutions, it will also bring different degrees of harm, so accurate results are clinical and how important they are to patients!
For the laboratory department, the reexamination of the critical value is an important factor to ensure the accuracy and reliability of its results, the re-examination, not only the simple and repeated operation of this specimen, but also the manual counting and staining microscopy as far as the blood routine is concerned, the quality control measures before the analysis, the analysis, the analysis and the analysis are perfect, the quality ability is fully guaranteed, the clinical laboratory can perform the first report, and review when the critical value is determined and the clinical non-conformity. In these cases, clinical laboratories are required to report critical values and ask for consistency between critical value outcomes and clinical practices [2]. From this point, it is not difficult to see that the critical value can be reported first, if it is inconsistent with the actual clinical situation and then re-examined, however, emphasizing the quality control measures before, during and after the analysis are perfect, the quality is guaranteed, and the clinical status must be asked at the same time.
Urgently needs to be solved
However, because the current laboratory work is relatively busy, heavy quantity, light quality of people abound, for abnormal results, only the repetition of the value of the audit, review results are consistent on the audit sent to the clinic, never analyze this result can be sent? Why not send it? Even too lazy to communicate, too lazy to read the film, what the instrument is out of what I do, you send unqualified specimens, I will send you the results, the victim is still the patient, can not get a clear diagnosis, the patient toss and turn in many hospitals. In fact, sometimes as long as we inspectors use a little snack, a small blood routine, can also diagnose major diseases. According to the survey, the percentage of reports of true and false critical values in different hospitals varies greatly, and the biggest reason is the quality problems before the test of the specimens, as well as the accidental or systematic errors in the inspection, the error review and Zhang Guanli Dai reported after the inspection, and the ability problems of the personnel.
Surveys have shown that in today's highly developed automation and informatization, the inconsistency between the test results and the clinic is mainly before the analysis, that is, the time when the specimen is transported to the laboratory, we cannot control its quality, the patient's state (fasting or after meals, drug situation, psychological factors, whether the self-sampling is taken in accordance with the regulations, etc.), whether the nurse is familiar with the collection specifications and processes (collection order, collection method, collection site, collection time, precautions, etc., as well as the transportation process of the specimen, etc.). For example, there are clear provisions on the collection time of blood collection for infusion patients: it is advisable to collect blood after 3 hours after the end of the infusion; if the infusion component metabolism is slow and seriously affects the test results (such as fat emulsions), it is advisable to collect blood before the next infusion. When blood must be collected during infusion in an emergency, it is advisable to collect blood at the distal end of the infusion point of the contralateral limb or posterior limb of the infusion and inform the examiner.
Nurses did not collect in accordance with the norms, and did not truthfully inform the laboratory department, resulting in repeated inspections, multiple tests, misleading inspectors to get wrong results, from this matter to remind the inspectors to often go to the clinic to preach, so that the collection and transportation of each test item is standardized, to ensure the reliability and correctness of the samples before analysis, to timely communication with the clinic for suspicious samples and suspicious results, to ensure the timeliness and correctness of the test data. At the same time, remind our laboratory workers and nursing workers that the work is not simply to complete the task, to be responsible, to continuously improve their business skills, broaden the scope of knowledge, can not be a robot, be the master of the instrument, improve the ability to analyze problems, solve problems, provide clinicians with the most valuable reports, provide valuable help for clinical diagnosis, truly help patients, let patients use the least amount of money, get the most effective treatment, so that the presence and sense of access of our medical staff are fully reflected.
【Reference】
Chinese Hospital Association. Patient Safety Goals (2014-2015)[J].China Health Quality Management,2014,18(10): 22.
[2] Chinese Journal of Laboratory Medicine, Vol. 39, No. 7, July 2016, ChinJ lab Med, July 2016. Vol. 39. No. 7
Editor: Ren Mileage Reviewer: Xiao Ran