Medicina di laboratorio in urgenza/emergenza I perché dell’integrazione routine-urgenze Davide Giavarina (Vicenza) Laboratorio ‘Urgenze’: perché? Fornire una via preferenziale a campioni ‘urgenti’, per ottenere una risposta più rapida • ASAP: As Soon As Possible • STAT: dal latino statim, immediatamente, subito • TAT: Turn Around Time D. Giavarina 1999: dal laboratorio urgenze al Continuous Patient Reporting Laboratorio Routine (25 TLB fte) Laboratorio Urgenze (9 TLB fte) CORELAB D. Giavarina Problemi del «Laboratorio Urgenze» • Doppia gestione amministrativa – Test routine e test STAT • Aumento del numero delle richieste • Strumentazione e aree analitiche diverse – Allineamento – Qualità • Personale dedicato – Conflitti nell’equipe • Aumento delle risorse necessarie / costi D. Giavarina IL CONTESTO D. Giavarina Urgenze: integrazione o separazione? • Quanti esami urgenti sul totale? D. Giavarina D. Giavarina Cosa non è urgente? Pazienti «interni» • Acuti • Monitoraggio • Rapidità di decisione e trattamento – Clinica – Organizzazione – DGR Pazienti «esterni» • Post acuti • Patologie croniche, gestite in gran parte sul territorio • Terapie di supporto per pazienti complicati non ospedalizzati • Decisioni sempre più legate agli esami di laboratorio • Attese dei pazienti D. Giavarina TAT LABORATORIO E TERAPEUTICO D. Giavarina Emergency Laboratory Tests • EMERGENT (sec to min) • POCT – glucose, Hb/Ht, blood gases • URGENT (<1hour) – glucose, Hb/Ht, blood gases • STAT LAB ? – CBC, cardiac markers, PT, electrolytes, CSF, ammonia, osmolality, pregnancy test, toxicology, therapeutic drugs • NON-URGENT (>1hour) – chemistry panels, urinalysis, hCG, group A streptococcal screen, KOH preparation, Gram stain, cell count on body fluids – CBC, cardiac markers, PT, electrolytes, CSF, ammonia, osmolality, pregnancy test, LAB toxicology, therapeuticLAB drugs • ROUTINE LAB – chemistry panels, urinalysis, hCG, group A streptococcal screen, KOH preparation, Gram stain, cell count on body fluids Page 10 Evoluzione del Laboratorio Clinico Domanda di Turn Around Time 1980 2 Hr 1990 2000 2010 STAT – Urgent ASAP 0.5 Hr Page 11 Nuove Necessità TAT: start & end Time • Robert C Hawkin. Laboratory Turnaround Time D. Giavarina D. Giavarina Quale TAT? D. Giavarina Page 15 TAT: start & end Time • Robert C Hawkin. Laboratory Turnaround Time D. Giavarina Door to Needle: the «golden hour» for evaluating and treating acute stroke D. Giavarina 10 key best practice strategies associated with faster DTN • Advance hospital notification by Emergency Medical Services (EMS) • Rapid triage protocol and stroke team notification • Single call to active stroke team • Stroke tools • Rapid acquisition and interpretation of brain imaging • Rapid laboratory testing and point of care (POC) test • Mix rt-PA medication ahead of time • Rapid access to intravenous rt-PA • Team-based approach • Rapid data feedback D. Giavarina SITS-WATCH Follow-Up Report SITS – WATCH study was initiated in 2011. The aim of the study is to reduce the delay between arriving at hospital and initiation of thrombolysis (door-to-needle time, DNT) to median below 40 minutes, i.e., for at least half of all patients. D. Giavarina Reccomendation • Laboratory and radiology staff members are alarmed during the transport and waiting for the patient in the CT room. • Lab personnel draw blood while you are examining the patient • Implement point-of-care INR, do not wait with the decision until regular INR is ready in case POC INR<1.7. • Do not wait for other laboratory results, especially if you have knowledge on recent laboratory findings. D. Giavarina AUTOMAZIONE D. Giavarina Definition • The concept of “STAT” (from Latin statim, meaning immediately) tests in clinical setting is a time-honored tradition • When specimen analysis was slow and tedious, it was logical to give a special attention to those specimens that were urgent • Today’s technology has made it possibile to treat stats as routine specimens, provided the process time is made so short that all results are being returned quickly R. Moore, Handbook of Clinical Automation, 1996 Page 22 Traditional Workflow POST PRE ANALYTICAL ROUTINE Ore: Page 23 6 7 8 9 10 11 12 13 14 New paradigm Page 24 Continuous Patient Reporting Chek-in PRE ANALITICA POST PRE ANALITICA PRE POST ANALITICA PRE POST ANALITICA PRE POST ANALITICA PRE POST ANALITICA PRE POST ANALITICA POST Reporting ROUTINE STAT PRE Ore: Page 25 6 7 8 Dfd 13d31 1bdbòlmàò ngnf lgps k 5rhhrh h 6 gbgh jnhr554 645 vngn rhhrh gfbgfg f df65 f g bgbfgh155 5 gg332 iiijnpiig 32gd32 dff fwthg 3216g gwggg 9 Dfd 13d31 1bdbòlmàò ngnf lgps k 5rhhrh h 6 gbgh jnhr554 645 vngn rhhrh gfbgfg f df65 f g bgbfgh155 5 gg332 iiijnpiig 32gd32 dff fwthg 3216g gwggg 10 Dfd 13d31 1bdbòlmàò ngnf lgps k 5rhhrh h 6 gbgh jnhr554 645 vngn rhhrh gfbgfg f df65 f g bgbfgh155 5 gg332 iiijnpiig 32gd32 dff fwthg 3216g gwggg 11 ANALITICA Dfd 13d31 1bdbòlmàò ngnf lgps k 5rhhrh h 6 gbgh jnhr554 645 vngn rhhrh gfbgfg f df65 f g bgbfgh155 5 gg332 iiijnpiig 32gd32 dff fwthg 3216g gwggg 12 13 POST 14 Dfd 13d31 1bdbòlmàò ngnf lgps k 5rhhrh h 6 gbgh jnhr554 645 vngn rhhrh gfbgfg f df65 f g bgbfgh155 5 gg332 iiijnpiig 32gd32 dff fwthg 3216g gwggg Desirable Features for Automated Hospitals Instruments • • • • • • • • • • • Stat interrupt capability 24-h availability Large on-board menu Long-term calibration Random-access processing Short dwell time Primary-tube sampling Bar coding (reagent and sample) Ease of use Automatic diagnostics and on-line help Minimal maintenance, preferably automated M. S. LIFSHITZ, Handbook of Clinical Automation,1996 Page 26 Page 27 TRASPORTO Page 28 INFORMATICA Page 29 D. Giavarina ORGANIZZAZIONE D. Giavarina Quali esami? Specimen Processing Automated Instrumentation Semiautomated Instrumentation Manual Procedure D. Giavarina Compartmentalized Laboratory D. Giavarina TAT Driven Laboratory Compartmentalized Laboratory D. Giavarina TAT Driven Laboratory Consolidated Diagnostics TAT Driven Laboratory D. Giavarina Consolidated Diagnostics TAT Driven Laboratory D. Giavarina Davide Giavarina [email protected] D. Giavarina
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