Brain to Brain Cycle

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Brain to Brain Cycle

• Dr. Bill Bartlett
• Consultant Clinical Scientist
• Dept Clinical Biochemistry Immunology
• Heart of England NHS Foundation Trust
• Birmingham B9 5SS

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Our Business -
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Importance of Laboratory Medicine

• 70 to 80 of decisions in diagnosis based on
  laboratory outputs.
• 70 80 of the interactions of health care
  professionals involve laboratory outputs.

Our Work and the Quality of Our Work Under pins
the Delivery of High Quality Health Care
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What do we do for a living?

• We save lives.
• We help diagnose, monitor treat disease
• We screen for disease
• We carry out and support RD
• We teach

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How do we do these things

• We Measure

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Brain to Brain Cycle
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What Is It?

• Phrase was first used by George Lundberg in the
  context of laboratory testing.
• (JAMA 19812451762-1763)
• Refers to a process that ideally links a
  clinical problem to an appropriate action, taken
  on the patients behalf, based on the results of
  laboratory tests.
• Question - Answer - Interpretation -Action.

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Knowledge
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The Process -

• Ask the right questions.
• Interpret the answers.
• Collate the information.
• Arrive at working diagnosis.
• Request -
• Pathology
• Radiology
• Other Opinions
• Admit?
• Wait

I dont feel well Doc!
What is the nature and cause of his disease?
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Pathology Request to Result What is the Process
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9 Steps
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Value in Understanding the Cycle

• manage the process to reduce complexity.
• remove the choke points, consolidate and
  automate
• become pro-active in helping clinicians to -
• use the laboratory services appropriately.
• use the product of the process which is
  information.

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How will managing the cycle impact on healthcare?

• Delivery of a more efficient diagnostic process
  -
• better targeting of resources
• shorter bed stays?
• faster processing of patients?

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• Brain to Brain Cycle
• Complex.
• Applies to every request
• Every cycle results in costs outside of pathology
  (e.g. longer bed stays?)
• Any error reinitiates cycle
• Information flows and accuracy are critical.
• Complex analytical processes time
• Repeat cycles cost!
• Need to use information generated. Failure to
  do so unnecessary cost
• Wrong results or misinterpretation cost

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Managing the Cycle
How do we dispose of the complexity and increase
effectiveness?

• Understand Process and simplify

• Direct skills into value added processes.

Diagram Courtesy of Dr CG Fraser, Dundee
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Requesting ReportingThe Key to a Patient Focus?

• Need to help users -
• Ask the right questions.
• Provide the right inputs.
• Apply the outputs effectively.
• We need to -
• deliver the required outputs to the right place
  within the required time frame.

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To Be Effective We Need To Ensure That -

• the correct questions are asked.
• the correct inputs are provided.
• valid analytical processes are applied.
• useful outputs are delivered in an appropriate
  time frame.
• our outputs are applied effectively.

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Asking the right questions.

• Requestors have varying degrees of knowledge,
  experience, expertise. (Nurse/Pharmacist/Doctor).
• Tools -
• Brain - limited capacity/ exposure
• Books, Journals - Volume
• Protocols (NSFs) - Volume
• Triage systems Presentation panels (Headache,
  gut ache etc, chest pain)
• Expert systems
• Additional inputs, previous results, Hx, Rx

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User Education

• Less emphasis on laboratory medicine in medical
  curricula
• Exponential rise in the size medical evidence
  base.
• Fewer people with increased demands on their
  time.
• More protocol driven processes required?

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Evidence into practice?

• Job of the lab medicine specialist to work with
  clinicians to turn evidence into practice.
• Take the evidence and build it into the
  requesting interface.
• Integrate systems with expert systems

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Education Communication

• Push v Pull
• Medium
• Web sites
• Critical mass
• Granularity
• Paper
• Built into processes, requesting/reporting
• Decision Aides
• Update sessions

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Electronic/Intelligent Requesting

• Accurate flows of information.
• Time efficient.
• Linking requesting with results.
• Linking requesting with care pathways.
• Ability to see outstanding requests.
• Building in protocols and links to information
  sources.
• Enable the partially informed requestor.
• Closing the loop between electronic systems.

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Brain to Brain Cycle
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Big Expensive User
And for my next request, I would like to tick all
the boxes.
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Whats in a Request?

• Decide what is to be measured
• Decide in what sample to measure it, (blood,
  urine, faeces, tissue, CSF, etc)
• Apply knowledge about the stability of the
  analyte (requirement for sample stabilisers,
  preservatives, cold transport etc)
• Decide where to sample from (e.g. arterial versus
  venous sampling, swabs from which areas to
  identify infections)

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Whats in a Request?

• Identify the most appropriate time to take the
  sample (knowledge of biological rhythms, effects
  of drugs on analysis, effects of feeding on
  analytes (e.g. blood glucose))
• When to involve and inform the people who know
  how to measure the analyte
• Initiate the request for analysis
• Take the appropriate samples
• Ensure that the samples and relevant information
  are passed to the laboratory

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Pre-analytical Phase

• Critical Phase
• Garbage in Garbage out
• Labour intensive
• Complex Processes
• Errors
• Choke Points
• Automation

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Automation
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Current Analytical Configuration

• Heartlands Automation Lab
• Roche 2 x PPE SWAs
• 2 x Organon Technika MDA II
• 2 x ADVIA 120
• Solihull
• SWA (Modular PE)
• Advia 120
• MDA I

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Current Capacity

• Heartlands 6800/hr Chemistry 340/hr
  immunoassay -
• Solihull 1700/hr chemistry, 170/hr immunoassay
  -
• SWA/ Modular PE

• ISE 900/1800 module
• ISE tests (Na, K, Cl)
• ISE 900 up to 900 tests/h
• P 800 module
• Photometric tests
• Throughput up to 800 tests/h
• 22-44 channels, (reagent slots)
• flexible setting

• E 170 module
• Immunology, ECL technology
• Throughputup to 170 tests/h
• 25 channels (reagent slots)

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Mass Spectrometry
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Near Patient Testing
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What is acceptable performance?

• Accuracy
• Imprecision
• Short/Long term
• Within lab/between lab
• Within organisation
• Turn around time
• Failure rates

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Fitness for purpose -

• How do you assess this?
• Analytical Goals
• Method design and validation against goals
• Analytical goals
• Clinical decision limits
• Reference change values
• Practicability
• Process design and validation against goals

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Apply Outputs Effectively.

• Combine information, data and knowledge to
  provide a meaningful report to the point of care.
• Enriched reports to aide medics.
• Disease probabilities based on nosology
• Graphical representations
• Novel reporting formats based on pattern
  recognition?
• Hyperlinks to data sources decision aides.
• Automatic referral to areas of expertise
  (local/national)
• Information for patients.

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Pacific Knowledge Systems

• www.pks.com.au.
• Tailors the report to the patient

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The Beginning Or The End