Speeds up and increases accuracy

We purchased CellaVision because of the problems listed below, i.e. we believed in the importance of being able to create a networked, centralized service for blood morphology which would help us address the growing challenges of skill shortages and cost pressures while preserving patient safety.

We have met these goals along with the additional benefits of improving patient care through reduced turn around times and improved detection rates of blast cells; patient care has been advanced! The Hamilton Regional Laboratory Medicine Program (HRLMP) serves six hospitals, including a large cancer centre, for a population of over 2.2 million people in Ontario, Canada. Five multidisciplinary laboratories perform peripheral blood cell morphology testing, i.e. the microscopic analysis of blood cell shape, size, type and number. As a routine component of most clinical care, the laboratories receive over 1500 samples per day, of which 30% require manual review by a technologist.

The five sites performing morphology in the HRLMP independently developed site-specific methods for preparing blood smears and reporting results. As a consequence, blood samples taken from the same patient at different sites could not be reliably compared. Furthermore the 51 technologists had varying degrees of experience and competency in identifying abnormal cells and synthesizing the results. In some cases, the need to have findings verified by a senior technologist or haematologist resulted in reporting delays and prolonged turnaround times (TATs) up to 15 hours. Since inconsistent and delayed results often translate to suboptimal patient care, the decision was made to standardize and centralize morphology testing across the HRLMP.

Assessment and Cause Analysis
To quantify the problem, managers and technical staff completed comparisons of site procedures and processes, results of competency assessments, and turnaround times. Analysis of this data confirmed the existence of widely varying procedures and outputs across the sites.  A strategic plan to correct the identified deficiencies was then developed with input from all stakeholders, including administration, managers, and staff. To reduce individual variability, all morphology testing would be standardized using CellaVision DM Systems (Sweden), an automated digital cell morphology system that classifies, displays, and stores cell images using an artificial neural network. Blood smears could be uniformly and consistently processed and loaded onto CellaVision at all sites, however, since the automated interpretation must be confirmed by an experienced morphologist, final reporting was centralized to a single dedicated haematology laboratory.

Strategy for Change
Project Management was implemented using a project charter developed and signed by all stakeholders. On-going communications forums occurred and sought input from physicians and staff. Change management sessions emphasizing strategies for transitioning through the change were held for the staff involved. Steering (stakeholders with a vested interest) and technical (site specific key operators) teams were formed to manage the implementation which occurred over a nine month period.

Measurement of Improvement
Standardization of smear preparation was measured through competency assessment, stain preparation and staining through quality control and quality assurance guidelines, and, resulting and reporting through an audit of the CellaVision and Laboratory Information System (LIS) build standardization. TATs were audited by site using LIS data.  Sensitivity of CellaVision was determined comparing manual with automated specific cell findings.

Effects of Change
Morphology procedures were standardized across the HRLMP in accordance with current international guidelines. Final interpretation and reporting of results were centralized and now capitalize on a critical mass of morphology expertise, shortening TATs by 39% (from mean of 4.8 to 3.0 hours).  Malignant cells were detected through CellaVision in 14 out of 300 patients which were not detected in our normal manual slide reading process.  As a result, physicians now receive more accurate, reproducible, and timely reports that can be reliably used to guide patient care.

Lessons Learnt
Hospital-wide participation of stakeholders and good change management strategies were essential to project success.  CellaVision technology, implemented effectively has delivered improvements in patient care including enhanced detection of malignant cells.

Message for Others
Standardizing and centralizing morphology testing and reporting utilizing CellaVision technology can reduce the potential for errors, delays in subsequent patient care, improve malignant cell detection and thereby improve patient safety. Crucial to the success of the project was a thorough assessment of the problem and an organized approach to change management.

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