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Result Authorisation – Correct or Not? Julie RYAN FAACB Chair SRAC AACB Healthscope Pathology.

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Presentation on theme: "Result Authorisation – Correct or Not? Julie RYAN FAACB Chair SRAC AACB Healthscope Pathology."— Presentation transcript:

1 Result Authorisation – Correct or Not? Julie RYAN FAACB Chair SRAC AACB Healthscope Pathology

2  Background Information  Staff Result Validation Training in Biochemistry  Competancy evaluation  Process of Continuing Education Welcome

3  Pre Analytical Issues  Analytical Issues  Post analytical Issues  Focus on Potassium el al Plan of Action

4  Right result  Right Sample  Right Patient  Right Time Result Authorisation

5  Patient Identifiers  Sample Identifiers  Sample Suitability  Test suitability Pre Analytical Requirements

6 Example 1  75 y o female, in ward.  Date: 4,12 4,12 4,12  Time 03:00 06:00 08:35  Sodium 139 87 138 (135 - 145) mmol/L  Potassium 3.4 2.0 3.8 (3.5 – 5.2) mmol/L  Chloride 102 58 100 (101 - 110) mmol/L  Bicarbonate 26 17 25 (22 - 35) mmol/L  Urea 9.3 5.8 8.4 (3.5 - 10.0) mmol/L  Creatinine 119 71 115 (40 - 85) umol/L  Sample collected from IV site ? Dextrose infusion

7 Example 2  45 y o male, in ward.  Date: 27,3 27,3 26,3  Time 11:36 08:55 18:35  Sodium 137 135 138 (135 - 145) mmol/L  Potassium 5.4 5.5 3.8 (3.5 – 5.2) mmol/L  Chloride 102 105 100 (101 - 110) mmol/L  Bicarbonate 31 23 25 (22 - 35) mmol/L  Urea 11.0 8.7 8.4 (3.5 - 10.0) mmol/L  Creatinine 78 51 115 (55 - 110) umol/L  eGFR 79 >90 63 ml/min/1.73m2  Calcium 2.15 2.03 2.25 (2.10 – 2.60)mmol/L  Magnesium 0.81 0.57 0.87 (0.70 – 1.10)mmol/L  Phosphate 0.73 0.56 1.11 (0.80 – 1.40)mmol/L  Albumin 24 16 26 (35 – 50) g/L   Sample collected from IV site. Hb Change from 143 to 109 g/L also.

8 Example 3  86 y o male, in ward.  Date: 5,12 5,12 5,12  Time 23:00 06:54 02:24  Sodium 137 142 (135 - 145) mmol/L  Potassium 4.8 3.7 (3.5 – 5.2) mmol/L  Chloride 111 115 (101 - 110) mmol/L  Bicarbonate 17 20 (22 - 35) mmol/L  Urea 4.9 6.9 (3.5 - 10.0) mmol/L  Creatinine 80 111 (55 - 110) umol/L  Calcium 2.02 1.84 1.77 (2.10 – 2.60)mmol/L  Magnesium 1.24 3.79 0.73 (0.70 – 1.10)mmol/L  Phosphate 0.88 0.65 0.86 (0.80 – 1.40)mmol/L  Albumin 28 19 23 (35 – 50) g/L   Sample collected from IV site Mg infusion

9 Example 4  59 y o male, in ward.  Date: 21,11  Time 13:31  Sodium 164 (135 - 145) mmol/L  Potassium >30.0 (3.5 – 5.2) mmol/L  Chloride 151 (101 - 110) mmol/L  Bicarbonate 4 (22 - 35) mmol/L  Urea >107 (3.5 - 10.0) mmol/L  Creatinine >1000 (55 - 110) umol/L   Sample specimen check - Urine

10 Example 5  64 y o Female, in ward.  Date: 14,04  Time 11:22  Sodium 125 (135 - 145) mmol/L  Potassium 7.2 (3.5 – 5.2) mmol/L  Chloride 94 (101 - 110) mmol/L  Bicarbonate 22 (22 - 35) mmol/L  Urea 6.1 (3.5 - 10.0) mmol/L  Creatinine 61 (40 - 85) umol/L  TProtein 49 (60 – 80) g/L  Albumin 28 (35 – 50) g/L  Haemolysis 1+  Icterus 0  Lipaemia 3+   Sample specimen check – Intralipid Infusion

11 Example 6  55 y o male, in AE  Date: 14,4  Time 11:23  Sodium 143 (135 - 145) mmol/L  Potassium 4.0 (3.5 – 5.2) mmol/L  Chloride 109 (101 - 110) mmol/L  Bicarbonate 28 (22 - 35) mmol/L  Urea 5.2 (3.5 - 10.0) mmol/L  Creatinine 59 (55 - 110) umol/L  Calcium 2.10 (2.10 – 2.60)mmol/L  Magnesium 0.69 (0.70 – 1.10)mmol/L  Phosphate 0.87 (0.80 – 1.40)mmol/L  Albumin 38 (35 – 50) g/L   Sample issue ?

12 Example 7  15 y o Female, in AE. Abdominal Pain  Date: 11,03  Time 14:15  Sodium 138 (135 - 145) mmol/L  Potassium 10.7 (3.5 – 5.2) mmol/L  Chloride 105 (101 – 110) mmol/L  Bicarbonate 28 (22 - 35) mmol/L  Urea 2.9 (3.5 - 10.0) mmol/L  Creatinine 57 (40 - 85) umol/L  Glucose 2.6 (3.5 – 8.0) mmol/L  Calcium 2.43 (2.10 – 2.60)mmol/L  Albumin 28 (35 – 50) g/L  BhCG <2.0 (0 – 5.0) IU/L  Haemolysis 1+  Icterus 0  Lipaemia 0

13 Example 8  41 y o Female, in AE.  Date: 15,12  Time 03:10  pH 7.13 (7.35 – 7.45)  pCO2 24 (35 – 45) mmHg  pO2 33 (101 – 110 mmol/L  Bicarbonate 8 (22 - 35) mmol/L  Sodium 138 (135 – 145) mmol/L  Potassium 4.5 (3.5 – 5.20 umol/L  Chloride 111 (101 – 110) mmol/L  Glucose 27.0 (3.5 – 8.0) mmol/L  Cooximetry no results  Sample specimen check – Lipaemic Sample

14 Example 8  41 y o Female, in AE.  Date: 15,12  Time 03:10  Sodium 133 (135 - 145) mmol/L  Potassium 4.2 (3.5 – 5.2) mmol/L  Chloride 104 (101 - 110) mmol/L  Bicarbonate 8 (22 - 35) mmol/L  Urea 4.2 (3.5 - 10.0) mmol/L  Creatinine 81 (40 - 85) umol/L  TProtein 46 (60 – 80) g/L  Albumin 36 (35 – 50) g/L  Haemolysis 1+  Icterus 0  Lipaemia 4+   Sample specimen check – Lipemia

15  Order of Draw  Correct Tube use  Site of Collection  Sample Mixing Post Collection Sample Collection

16 Sample Tube Result Variation

17  Due to Instrument Failure  Due to Sample preparation issues  Due to Calibration issues  Due to QC issues Analytical Issues

18 Example 1  49 y o Female, in AE.  Date: 29,01 29,01  Time 10:01 09:38  pH 7.43 7.75* (7.35 – 7.45)  pCO2 43 19 * (35 – 45) mmHg  pO2 63 42 * (101 – 110 mmol/L  Bicarbonate 28 26 (22 - 35) mmol/L  Sodium 118 118 (135 – 145) mmol/L  Potassium 3.2 3.2 (3.5 – 5.20 umol/L  Chloride 82 82 (101 – 110) mmol/L  Glucose 6.2 6.8 (3.5 – 8.0) mmol/L  Lactate 4.2 3.6 (<1.3) mmol/L  iCalcium 1.07 1.22 (1.15 – 1.27)mmol/L   Sample speciman check – * Clot Detected in Sample

19 Example 2  81 y o Male, in AE.  Date: 30,11 30,11  Time 00:40 03:46  pH 7.33 7.30 (7.35 – 7.45)  pCO2 37 36 (35 – 45) mmHg  pO2 18 35 (101 – 110 mmol/L  Bicarbonate 20 18 (22 - 35) mmol/L  Sodium 137 137 (135 – 145) mmol/L  Potassium 4.7 4.3 (3.5 – 5.20 umol/L  Chloride 103 107 (101 – 110) mmol/L  Glucose 24.1 18.9 (3.5 – 8.0 mmol/L  Lactate 4.9 6.2 (<1.3) mmol/L  Haemoglobin 107 122 (117 – 174) g/L  Haematocrit 32 37  Sample Speciman check – Mixing of Sample

20 Example 3  66 y o Female, in ICU.  Date: 01,03 01,03  Time 17:54 07:56  pH 7.34 7.42 (7.35 – 7.45)  pCO2 29 38 (35 – 45) mmHg  pO2 74 50 (101 – 110 mmol/L  Bicarbonate 16 25 (22 - 35) mmol/L  Sodium <100 145 (135 – 145) mmol/L  Potassium 2.5 3.9 (3.5 – 5.20 umol/L  Chloride 65 116 (101 – 110) mmol/L  Glucose <0.2 9.4 (3.5 – 8.0) mmol/L  Lactate 0.9 1.7 (<1.3) mmol/L  Haemoglobin 100 130 (117 – 174) g/L   Sample Speciman check – Gas taken from IV site

21 Example 4  86 y o male, in ward.  Date: 03,06 03,06  Time 23:00 10:45  Sodium 133 (135 - 145) mmol/L  Potassium 4.4 (3.5 – 5.2) mmol/L  Chloride 98 (101 - 110) mmol/L  Bicarbonate 28 (22 - 35) mmol/L  Urea 5.4 (3.5 - 10.0) mmol/L  Creatinine 59 (55 - 110) umol/L  Calcium 2.34 1.57 (2.10 – 2.60)mmol/L  Magnesium 0.82 (0.70 – 1.10)mmol/L  Phosphate 0.98 (0.80 – 1.40)mmol/L  Albumin 37 41 (35 – 50) g/L   Instrument Error. Sample Repeated

22 Example 5  42 y o Male, in ICU.  Date: 21,01 21,01 21,01  Time 01:56 01:49 01:33  pH 7.28 7.25 7.25(7.35 – 7.45)  pCO2 41 43 43(35 – 45) mmHg  pO2 121 132 140(101 – 110 mmol/L  Bicarbonate 19 19 19(22 - 35) mmol/L  Sodium 134 134134(135 – 145) mmol/L  Potassium 6.6 6.66.9 (3.5 – 5.20 umol/L  Chloride 109 105 108(101 – 110) mmol/L  Glucose 15.1 16.2 16.7(3.5 – 8.0) mmol/L  Lactate 6.5 7.0 7.6(<1.3) mmol/L  Haemoglobin 110 111 110(117 – 174) g/L   Blood Gas Repeated ? Why

23 Example 5  42 y o male, in ICU.  Date: 21,01 21,01 21,01  Time 01:30 22:30 20:15  Sodium 140 138 139 (135 - 145) mmol/L  Potassium 7.0 4.7 4.7 (3.5 – 5.2) mmol/L  Chloride 109 111 105 (101 - 110) mmol/L  Bicarbonate 20 15 23 (22 - 35) mmol/L  Urea 8.8 7.9 9.0 (3.5 - 10.0) mmol/L  Creatinine 148 140 152 (55 - 110) umol/L  eGFR 39 42 38 ml/min/1.73m2  Calcium 1.83 1.60 (2.10 – 2.60)mmol/L  Magnesium 0.63 0.61 (0.70 – 1.10)mmol/L  Phosphate 2.19 1.92 (0.80 – 1.40)mmol/L  Albumin 21 9 31 (35 – 50) g/L   Post AAA Transfusion Packed Cells.

24  15/09/2010 Results as follows:  Digoxin3.1nmol/L(0.6 – 1.0)  16/09/2010:  Digoxin>7.5nmol/L(0.6 – 1.0)  Rx with Digibind Example 6

25  Reference Intervals  Reporting Format  Collection Details Post Analytical Issues

26 Example 1  81 y o Male, in ICU.  Date: 30,01 30,01 30,01 30,1  Time 13:56 12:49 10:33 09:43  pH 7.15 7.19 7.19 7.25(7.35 – 7.45)  pCO2 30 34 42 35 (35 – 45) mmHg  pO2 249 114 24 106(101 – 110 mmol/L  Bicarbonate 10 13 16 15(22 - 35) mmol/L  Sodium 131 132137 135(135 – 145) mmol/L  Potassium 7.5 6.85.2 4.9 (3.5 – 5.20 umol/L  Chloride 107 106 109 109(101 – 110) mmol/L  Glucose 17.4 16.1 13.1 13.2(3.5 – 8.0) mmol/L  Lactate 6.9 4.6 4.0 3.9(<1.3) mmol/L  Haemoglobin 92 106 84 87 (117 – 174) g/L   Blood Gas Repeated Note pH K Lactate & Hb changes

27 Example 2  81 y o male, in ICU.  Date: 27,06 27,06 26,06  Time 23:50 03:50 20:15  Sodium 148 144 149 (135 - 145) mmol/L  Potassium 3.6 4.0 4.3 (3.5 – 5.2) mmol/L  Chloride 106 105 110 (101 - 110) mmol/L  Bicarbonate 28 26 24 (22 - 35) mmol/L  Urea 6.3 6.6 6.3 (3.5 - 10.0) mmol/L  Creatinine 112 90 114 (55 - 110) umol/L  eGFR 79 >90 63 ml/min/1.73m2  Calcium 2.23 2.27 2.05 (2.10 – 2.60)mmol/L  Magnesium 0.72 1.28 0.74 (0.70 – 1.10)mmol/L  Phosphate 0.83 0.93 1.93 (0.80 – 1.40)mmol/L  Albumin 47 43 38 (35 – 50) g/L   Report Printed 27,06 09:55

28 Example 2  81 y o male, in ICU.  Date: 27,06 26,06 26,06  Time 03:50 23:50 20:15  Sodium 144 148 149 (135 - 145) mmol/L  Potassium 4.0 3.6 4.3 (3.5 – 5.2) mmol/L  Chloride 105 106 110 (101 - 110) mmol/L  Bicarbonate 26 28 24 (22 - 35) mmol/L  Urea 6.6 6.3 6.3 (3.5 - 10.0) mmol/L  Creatinine 90 112 114 (55 - 110) umol/L  eGFR >90 79 63 ml/min/1.73m2  Calcium 2.27 2.23 2.05 (2.10 – 2.60)mmol/L  Magnesium 1.28 0.72 0.74 (0.70 – 1.10)mmol/L  Phosphate 0.93 0.83 1.93 (0.80 – 1.40)mmol/L  Albumin 43 47 38 (35 – 50) g/L   Report in Correct order

29  Pre Analytical Issues  Important Analyte  Critical values Potassium

30  Venepuncture technique  Sample Container appropriate  Transport at correct temperature  Storage at correct temperature Pre analytical Issues K

31  Due to Instrument Failure  Due to Sample preparation issues  Due to Calibration / QC issues  Due to Patient Conditions Analytical Issues K

32 Example 1  79 y o male, in AE.  Date: 7,06 21,05 20,05  Time 09:50 13:50 10:15  Sodium 137 142 145 (135 - 145) mmol/L  Potassium 7.9 4.4 4.3 (3.5 – 5.2) mmol/L  Chloride 107 106 110 (101 - 110) mmol/L  Bicarbonate 19 31 29 (22 - 35) mmol/L  Urea 3.2 3.8 3.3 (3.5 - 10.0) mmol/L  Creatinine 75 70 114 (55 - 110) umol/L  Calcium 2.24 2.21 2.15 (2.10 – 2.60)mmol/L  Magnesium 1.75 0.78 0.74 (0.70 – 1.10)mmol/L  Phosphate 1.80 1.22 1.13 (0.80 – 1.40)mmol/L  AST 56 23 33 (35 – 50) g/L   HAEMOLYSED 4+

33 Example 2  80 y o male, in AE  Date: 15,10  Time 07:23  Sodium 150 (135 - 145) mmol/L  Potassium 9.7 (3.5 – 5.2) mmol/L  Chloride 114 (101 – 110) mmol/L  Bicarbonate 19 (22 - 35) mmol/L  Urea 42.2 (3.5 - 10.0) mmol/L  Creatinine 386 (55 - 110) umol/L  Calcium 2.19 (2.10 – 2.60)mmol/L  Magnesium 1.18 (0.70 – 1.10)mmol/L  Phosphate 3.58 (0.80 – 1.40)mmol/L  Albumin 33 (35 – 50) g/L  CRP 125.4 (<8) mg/L  Haemolysis 3+  Sample Intravascular Haemolysis and Renal Impairment. Hb drop from 105– 64g/L

34 Example 3  43 y o male, in ICU.  Date: 21,01 20,01  Time 01:01 23:38  pH 7.25 7.10 (7.35 – 7.45)  pCO2 43 42 (35 – 45) mmHg  pO2 382 503 (101 – 110 mmol/L  Bicarbonate 19 13 (22 - 35) mmol/L  Sodium 134 134 (135 – 145) mmol/L  Potassium 6.9 4.3 (3.5 – 5.20 umol/L  Chloride 108 108 (101 – 110) mmol/L  Glucose 16.7 22.2 (3.5 – 8.0) mmol/L  Lactate 7.6 10.9 (<1.3) mmol/L  Haemoglobin 110 68 (115 – 170) g/L   Patient Post Transfusion

35 Example 4  80 y o male, in AE  Date: 16,02  Time 09:23  Sodium 144 (135 - 145) mmol/L  Potassium 6.6 (3.5 – 5.2) mmol/L  Chloride 112 (101 – 110) mmol/L  Bicarbonate 20 (22 - 35) mmol/L  Urea 33.4 (3.5 - 10.0) mmol/L  Creatinine 276 (55 - 110) umol/L  eGFR 18 ( >90 )  Calcium 2.19 (2.10 – 2.60)mmol/L  Phosphate 2.58 (0.80 – 1.40)mmol/L  Albumin 29 (35 – 50) g/L  CRP 461 (<8) mg/L  WCC 176.0 ( 4.0 – 11.0) x10^9/L  Sample High WCC. Serum Used

36 Example 7  48 y o Female, in AE. Muscle Weakness  Date: 28,08  Time 08:55  Sodium 139 (135 - 145) mmol/L  Potassium 1.8 (3.5 – 5.2) mmol/L  Chloride 104 (101 – 110) mmol/L  Bicarbonate 22 (22 - 35) mmol/L  Urea 0.4 (3.5 - 10.0) mmol/L  Creatinine 91 (40 - 85) umol/L  Calcium 1.83 (2.10 – 2.60)mmol/L  T Protein 49 (60 – 80) g/L  Albumin 23 (35 – 50) g/L  Lactate 9.3 ( 0.5 – 2.2) IU/L  Haemolysis 0   Patient with Anorexia Nervosa

37 Example 8  52 y o Female, in AE.  Date: 26,08  Time 09:55  Sodium 125 (135 - 145) mmol/L  Potassium 2.0 (3.5 – 5.2) mmol/L  Chloride 74 (101 – 110) mmol/L  Bicarbonate 35 (22 - 35) mmol/L  Urea 3.8 (3.5 - 10.0) mmol/L  Creatinine 68 (40 - 85) umol/L  T Protein 57 (60 – 80) g/L  Albumin 30 (35 – 50) g/L  T Bilirubin 30 ( <18 ) umol/L  GGT 391 ( <40 ) U/L  Haemolysis 0   Patient with Vomiting

38  Urine Spot  Na <10 mmol/L  K 7.0 mmol/L  Cl <15 mmol/L Example 8

39  Presentation a first look at Issues in Authorisation  Provide some guidance about the common pitfalls of result verification  Comparison with healthy patient results an invaluable tool  Understanding of the processes involved in result production in the Biochemistry Laboratory  All working towards: Final Comments

40  Right result  Right Sample  Right Patient  Right Time Final Comments

41  Many thanks to the numerous people who have assisted in training Biochemists throughout the industry  This includes representatives from the RCPA, AACB, various companies who produce and maintain the complex instrumentation used, and also the Educational Institutions providing graduates to staff Laboratories  All invaluable to the Industry Acknowledgements

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