Laboratory tests are essential for myeloma diagnosis and management, so, the tests requested and the way results are reported can make a difference to how patients are managed or referred. At Basingstoke and North Hampshire Hospital we carried out an internal audit and set up a multi-disciplinary collaboration to improve the pathway from initial request to long-term monitoring to improve patient pathways for myeloma.
The initiative
The International Myeloma Working Group (IMWG) has clear diagnostic criteria for myeloma, which we utilised for an internal audit. The audit highlighted two key improvement areas: many requests missed appropriate tests, and many inappropriate referrals were being made to secondary care haematologists – or indeed missed. As a result, a multidisciplinary myeloma working group was brought together to review the current pathway from start to finish.
The changes
The first significant improvement we made was to introduce an electronic request profile for service users which lists all required tests, sample types and instructions. This ensures the right test and samples are collected initially.
The next and largest task was writing a complete interpretation algorithm with supporting IT rules and a risk category escalation protocol. The wider algorithm followed three stepwise pathways based on serum protein electrophoresis results, serum immunoglobulin results and serum free light chain results. The aim of this task was to ensure that every sample had all tests analysed (reducing repeats), manual intervention was reduced, result turnaround times improved and variation in interpretation and action improved.
The IT build in the Lab Information Management System included result entry drop-down, auto-reflex testing rules, automatic generation of telephone limit actions and a way to electronically send critical result reports to the duty haematologist for immediate action. This has not only reduced paper use (previously manual forms were used) but has drastically reduced the time taken for patient review.
Another key aspect was the creation of coded interpretive comments that were concise, informative and referred clinicians to the most appropriate clinical guidance.
In addition to these large changes, several smaller IT improvements were introduced including patient flags, the ability to quantify multiple paraproteins and the use of antibody-based therapy flagging. A simplified version of the algorithm was written to enable biomedical scientists to conduct a ‘first read’ interpretation. Cascade training is underway.
On the back of this project, a quarterly Pathology Newsletter was started to enhance communication with our service users, which has been very well received.
The impact
- Patients: All urgent positive results are reviewed by a haematologist within 24 hours of result generation. A recent audit has demonstrated a 13% increase in first order request completeness minimising patient redraws and diagnostic delays.
- Clinicians: Since implementation, haematologists have noted a reduction in inappropriate secondary care queries and referrals. Positive feedback from local GPs has also been received noting improved confidence in appropriate requesting.
- Employees: Since the implementation of this algorithm several biomedical scientists have been upskilled on protein electrophoresis first read and interpretation. New skills have enhanced employee engagement and satisfaction.
- Associated costs: The use of requesting profiles and in-built minimum retesting intervals prevents inappropriate repeat requests and therefore associated costs.
Success relied heavily on expert opinion spanning three clinical disciplines and laboratory staff, with a significant amount of IT work. Having a strong project lead who brought together the relevant stakeholders into a shared space to agree key approaches, with an identified IT project support, was a key enabler.
If you would like to find out more about the service at Basingstoke and North Hampshire Hospital please contact the CSEP Team at csep@myeloma.org.uk
Written by Kate Fenna
Consultant Biochemist
Basingstoke and North Hampshire Hospital