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"UNNECESSARY" INVESTIGATIONS: THE JUNIORS' DEFENCE
724 CHEMICAL PATHOLOGY ON THE WARD
by the presidents of the Royal College of the Association of Clinical Pathologists, and the Association of Clinical Biochemists (Feb. 28, p. 487) providing guidelines for the performance of chemical pathology tests outside the laboratory and by non-laboratory staff is timely. The number of such tests has begun to increase significantly and this trend is likely to continue with technological development. SIR,-The
statement
Pathologists,
Quality assurance procedures are in wide use in the laboratory investigations of patients in the U.K. Such procedures involve all the precautions taken, from the requesting of an investigation, the preparation of the patient, and the collection of the specimen to the interpretation of the result, including the analytical procedure. An integral part of quality assurance is the use of internal quality control techniques to control the analytical quality of the laboratory result. In addition, external quality assessment must be used frequently as an overall check on the analytical performance of individual laboratories. External quality assessment of many of the tests carried out by chemical pathology laboratories in the U.K. is organised from this laboratory. Every fourteen days portions of the same lyophilised material are sent to 450 laboratories throughout the U.K. Performance is assessed and poor performance subjected to confidential scrutiny by representatives of the professional organisations concerned. similar schemes are organised for haematology, and several other types of laboratory investigation. microbiology, There is reason to believe that these schemes have played an imporAt other
centres
role in monitoring and improving analytical performance in clinical laboratories in the U.K. in the past decade.
tant
The presidents’ guidelines rightly emphasise the importance of the use of quality assurance in pathological investigations done outside the laboratory. A deterioration in the quality of patient care following the introduction of such investigations resulting from poor analytical quality would be unacceptable to all concerned. An important method of ensuring there is no such deterioration is to monitor the analytical performance in the investigations by both internal quality control and external quality assessment. The introduction of such monitoring techniques is not simple and skill has to be gradually acquired. Most importantly, when it has been decided that an analytical method is producing unsatisfactory results, solving the problem frequently requires considerable
background knowledge of laboratory procedures. Some may argue that the analytical techniques in use or proposed are so simple they do not require quality control. It has been my experience over the years that the simpler a technique appears to be the more it may be abused in terms of analytical care, and in these circumstances quality control is essential. I have been approached, as organiser of the U.K. External Quality Assessment Scheme in General Clinical Chemistry (UKEQAS), to supply materials direct to non-laboratory areas for external quality assessment. The problem was put to our steering committee, which advises the UKEQAS on policy, and it has been jointly decided that our policy will be to continue to survey only the main routine laboratories within a hospital complex. Our advice is that such laboratories should make arrangements for the external quality assessment of laboratory investigation in non-laboratory areas. When the routine laboratory is regularly participating in the UKEQAS it can directly link the results to the performance in nonlaboratory areas for the analyses surveyed. In addition we endorse the statement in the guidelines that the routine laboratory should also play an important role in the establishment and operation of quality control procedures. Our decision not to extend our external quality assessment scheme to non-laboratory areas is not a "political" decision but is based upon several practical problems. Amongst these are: the practical and financial difficulties of obtaining satisfactory quality assessment materials for such analyses as blood gases; the inability
obtain suitable materials for commoner analyses in larger quantities than at present; the wastage of material when only two or three types of analyses are performed by a participant instead of the fourteen normally surveyed for each distribution by most routine laboratories; the inevitable restriction on finance from central funds because considerable extra funding would be required. to
We believe that the proposed solution-namely, of fostering cooperation between those in the routine laboratory and clinical areas-will help to bring the clinician and laboratory worker closer together. They have complementary expertise and the common objective of quality in patient care. It would be most unfortunate if the introduction of these newer techniques strained such relationships ; both clinician and laboratory staff have the responsibility of ensuring that this does not happen. Wolfson Research Laboratories, Department of Clinical Chemistry, Queen Elizabeth Medical Centre, Birmingham B15 2TH
T. P. WHITEHEAD, Organiser, UKEQAS for General Clinical Chemistry
"UNNECESSARY" INVESTIGATIONS: THE JUNIORS’ DEFENCE
SIR,-Every year (and 1981 is no exception) the journals abound with articles on unnecessary investigations ordered by junior staff. I feel it is time we presented our case. junior’s point of view, there are two reasons for ordering investigation-firstly, to confirm or support a tentative diagnosis or to help in management (e.g., serial electrolytes in diabetic ketoacidosis) and, secondly, to have the result available when a senior asks for it. Every junior doctor knows or has an inkling of what is going to be asked for on the ward round, and only if the "chief positively questions why a test was ordered or criticises its From a
an
request will the junior adjust his habits. There are other points to our defence. We do not enjoy asking for investigations, least of all emergency ones. Picturethe scene: a child hot, vomiting, coughing, irritable (as most are when hot and vomiting with a cough). The poor junior would dearly love to admit the child, ensure oral fluid intake and antipyretics, rest on his diagnosis of upper respiratory tract infection (hospital language for common cold), and get back to bed. However, he cannot because he knows that the registrar will ask why a lumbar puncture was not done, the senior registrar will be interested in the white cell count, and the consultant may want to know the urea and electrolytes and see the chest X-ray. The people who complain of overinvestigation seem out of touch with the fact that to order the above investigations involves not only obtaining blood and CSF but also filling out the wretched forms, labelling specimen bottles, and making at least four telephone calls. Mixed with suffering the wrath of the technicians because of their rude awakening, finding that a technician has just left the hospital from a previous call and remembering to ring him again ten minutes later, talking to the parents, and answering the call from a family
doctor who would like to admit a two year old child who is hot, coughing, vomiting, and seems a little irritable, this is not without its frustration. A frustration added to by "sod’s law" which dictates that if you have a patient whose electrolytes you are diligently investigating every other day, the chief will ask for the serum potassium only on the days when you have not done it.
This, of course, is paranoia, and some of us bring work and justified criticism upon ourselves. I have known colleagues ask for erythrocyte sedimentation rates as an emergency investigation and complain at the technician’s reluctance. However, most juniors do think twice about investigations. Research into their motives, financial incentives, and papers documenting the inappropriateness of tests are nothing beside the respect paid to the guidance of the consultant and other senior doctors involved with the individual case.
Royal Hospital for Sick Children, Edinburgh EH9 1LF
NEIL WILSON
by the presidents of the Royal College of the Association of Clinical Pathologists, and the Association of Clinical Biochemists (Feb. 28, p. 487) providing guidelines for the performance of chemical pathology tests outside the laboratory and by non-laboratory staff is timely. The number of such tests has begun to increase significantly and this trend is likely to continue with technological development. SIR,-The
statement
Pathologists,
Quality assurance procedures are in wide use in the laboratory investigations of patients in the U.K. Such procedures involve all the precautions taken, from the requesting of an investigation, the preparation of the patient, and the collection of the specimen to the interpretation of the result, including the analytical procedure. An integral part of quality assurance is the use of internal quality control techniques to control the analytical quality of the laboratory result. In addition, external quality assessment must be used frequently as an overall check on the analytical performance of individual laboratories. External quality assessment of many of the tests carried out by chemical pathology laboratories in the U.K. is organised from this laboratory. Every fourteen days portions of the same lyophilised material are sent to 450 laboratories throughout the U.K. Performance is assessed and poor performance subjected to confidential scrutiny by representatives of the professional organisations concerned. similar schemes are organised for haematology, and several other types of laboratory investigation. microbiology, There is reason to believe that these schemes have played an imporAt other
centres
role in monitoring and improving analytical performance in clinical laboratories in the U.K. in the past decade.
tant
The presidents’ guidelines rightly emphasise the importance of the use of quality assurance in pathological investigations done outside the laboratory. A deterioration in the quality of patient care following the introduction of such investigations resulting from poor analytical quality would be unacceptable to all concerned. An important method of ensuring there is no such deterioration is to monitor the analytical performance in the investigations by both internal quality control and external quality assessment. The introduction of such monitoring techniques is not simple and skill has to be gradually acquired. Most importantly, when it has been decided that an analytical method is producing unsatisfactory results, solving the problem frequently requires considerable
background knowledge of laboratory procedures. Some may argue that the analytical techniques in use or proposed are so simple they do not require quality control. It has been my experience over the years that the simpler a technique appears to be the more it may be abused in terms of analytical care, and in these circumstances quality control is essential. I have been approached, as organiser of the U.K. External Quality Assessment Scheme in General Clinical Chemistry (UKEQAS), to supply materials direct to non-laboratory areas for external quality assessment. The problem was put to our steering committee, which advises the UKEQAS on policy, and it has been jointly decided that our policy will be to continue to survey only the main routine laboratories within a hospital complex. Our advice is that such laboratories should make arrangements for the external quality assessment of laboratory investigation in non-laboratory areas. When the routine laboratory is regularly participating in the UKEQAS it can directly link the results to the performance in nonlaboratory areas for the analyses surveyed. In addition we endorse the statement in the guidelines that the routine laboratory should also play an important role in the establishment and operation of quality control procedures. Our decision not to extend our external quality assessment scheme to non-laboratory areas is not a "political" decision but is based upon several practical problems. Amongst these are: the practical and financial difficulties of obtaining satisfactory quality assessment materials for such analyses as blood gases; the inability
obtain suitable materials for commoner analyses in larger quantities than at present; the wastage of material when only two or three types of analyses are performed by a participant instead of the fourteen normally surveyed for each distribution by most routine laboratories; the inevitable restriction on finance from central funds because considerable extra funding would be required. to
We believe that the proposed solution-namely, of fostering cooperation between those in the routine laboratory and clinical areas-will help to bring the clinician and laboratory worker closer together. They have complementary expertise and the common objective of quality in patient care. It would be most unfortunate if the introduction of these newer techniques strained such relationships ; both clinician and laboratory staff have the responsibility of ensuring that this does not happen. Wolfson Research Laboratories, Department of Clinical Chemistry, Queen Elizabeth Medical Centre, Birmingham B15 2TH
T. P. WHITEHEAD, Organiser, UKEQAS for General Clinical Chemistry
"UNNECESSARY" INVESTIGATIONS: THE JUNIORS’ DEFENCE
SIR,-Every year (and 1981 is no exception) the journals abound with articles on unnecessary investigations ordered by junior staff. I feel it is time we presented our case. junior’s point of view, there are two reasons for ordering investigation-firstly, to confirm or support a tentative diagnosis or to help in management (e.g., serial electrolytes in diabetic ketoacidosis) and, secondly, to have the result available when a senior asks for it. Every junior doctor knows or has an inkling of what is going to be asked for on the ward round, and only if the "chief positively questions why a test was ordered or criticises its From a
an
request will the junior adjust his habits. There are other points to our defence. We do not enjoy asking for investigations, least of all emergency ones. Picturethe scene: a child hot, vomiting, coughing, irritable (as most are when hot and vomiting with a cough). The poor junior would dearly love to admit the child, ensure oral fluid intake and antipyretics, rest on his diagnosis of upper respiratory tract infection (hospital language for common cold), and get back to bed. However, he cannot because he knows that the registrar will ask why a lumbar puncture was not done, the senior registrar will be interested in the white cell count, and the consultant may want to know the urea and electrolytes and see the chest X-ray. The people who complain of overinvestigation seem out of touch with the fact that to order the above investigations involves not only obtaining blood and CSF but also filling out the wretched forms, labelling specimen bottles, and making at least four telephone calls. Mixed with suffering the wrath of the technicians because of their rude awakening, finding that a technician has just left the hospital from a previous call and remembering to ring him again ten minutes later, talking to the parents, and answering the call from a family
doctor who would like to admit a two year old child who is hot, coughing, vomiting, and seems a little irritable, this is not without its frustration. A frustration added to by "sod’s law" which dictates that if you have a patient whose electrolytes you are diligently investigating every other day, the chief will ask for the serum potassium only on the days when you have not done it.
This, of course, is paranoia, and some of us bring work and justified criticism upon ourselves. I have known colleagues ask for erythrocyte sedimentation rates as an emergency investigation and complain at the technician’s reluctance. However, most juniors do think twice about investigations. Research into their motives, financial incentives, and papers documenting the inappropriateness of tests are nothing beside the respect paid to the guidance of the consultant and other senior doctors involved with the individual case.
Royal Hospital for Sick Children, Edinburgh EH9 1LF
NEIL WILSON