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R428:The mobile laboratory: bringing high-quality testing, to the patient. 3rd WHO Global Forum on Medical Devices, Genève 2017
Biomedical Laboratory scientist, lecturer Susanne Andresen, Zealand University Hospital Køge.
Public health care in Denmark is free of charge and consists of three sectors: GP´s, regional hospitals and smaller health care units in the municipalities.
The healthcare is provided by either -
• Self-employed general practitioners (GP´s)
• Specialists paid by the regions
• Public hospitals owned and operated by the regions
Organisation of the hospitals i Denmark
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Each citizen in Denmark must choose a GP for basic examination, treatment and follow-up.
The GP acts as a gatekeeper to the hospitals. Elective patients need a referral from the GP to go to a hospital.
GP´s perform their work in their practice – not in hospitals. Clinics are open in the daytime on workdays with one prolonged workday during the week.
The GP´s are also responsible for basic services outside their opening hours.
General Practice
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
1. Senior Citizens are admitted three times more often than younger citizens
2. People 75 years and older use emergency rooms about twice as often as any other age group
3. Risks associated with hospitalization of elderly are hallucinations, agitation, anxiety, insomnia etc.
4. They are also subjected to bedrest diseases like pneumonia, hospital infections, urinary tract infections, falls fractures due to unfamiliar surroundings and bedsore
Danish conditions
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
In Denmark, the number of short hospital admissions has significantly increased.
Non-surgical medical conditions account for 40 % of admissions.
• Short hospital admissions increase
• Re-admissions increase
• 20 % of admissions could have been prevented
Danish conditions
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
20 -25 % Lung disorders
20-25 % Cardiovascular diseases
40-60 % of the diagnosis are preventable conditions such as
UTIs (urinary tract infections)
COPD (chronic obstructive pulmonary disease)
Dizziness
Dehydration
Diarrhea
Constipation
Infections (pneumonia, erysipelas, pyelonephritis, etc.)
Anemia
Terminal patients
Discharge Diagnosis
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
To provide both laboratory and medical assistance (nurse) outside the hospital in order to maintain chronically ill or elderly patients at home, in relief homes or in nursing homes.
A shared care model between general practitioners, Koege and Solroed municipalities and Zealand University Hospital, to prevent unnecessary hospitalizations and to prevent hospital re-admissions of newly discharged patient.
Mission of the mobile laboratory (MLU)
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
A project financed by the Region and the municipality of Koege and Solroed.
1. To perform blood tests and triage that allows the GP to make fast treatment decisions
2. To present an assay menu to the GP at the citizens´s home similar to the one available at the
hospital emergency
3. To build a mobile laboratory
4. To evaluate the robustness of the equipment and their performance outside the laboratory
5. To prevent unnecessary hospitalization among elderly citizens in the municipality of Koege and Solroed.
Goals
So far! Point 1-2. It´s possible Point 3. Done Point 4. The robustness is amazing Point 5. It´s still an ongoing project
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Equipment used by the nurse.
Monitor: BP, pulse, SAT, resp.
Frequency alcoholmeter
Thermometer
Bladder Scanning
Defibrillator
Port- a'neb (atomizer for bronchiedilating medicine)
Bladder catheters,
Peripheral vein catheters
Peak flow meter
To present an assay menu similar to the hospital emergency
Equipment used by the biomedical laboratory scientist (BLS). Radiometer ABL 90 Siemens Clinitek Statspin ABX Micros-CRP 200 ABX Pentra 400 Roche Cobas h232 Roche Coaguchek XS pro HemoCue WBC Diff (back up) ECG 2 PCs PTB printer Fax
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Hematology
Hemoglobin red blood cells lymfocytes
Hematocrit platelets monocytes
MCV white blood cells granulocytes
MCHC
Electrolytes, liver and kidney analyses
Alaninaminotranferase Calcium Urea
Albumin semi-reactive proteinCreatinine
Amylase Potassium LDH
Alcaline phosphatase Sodium Uric acid
Phosphat
Acid/base status
pH Glucose Hemoglobin
Lactat Potassium CO-Hemoglobin
pCO2 Sodium Meth-Hemoglobin
pO2 Chlorid
SAT Calcium-ion
Urine analyses
White blood cells Glucose Red blood cells
Nitrite Acetoacetat Proteine
pH
Haemostasis
INR
D-dimer
Electrocardiogram
Workflow in the Mobile Laboratory Unit.
Upon request by the GP the mobile laboratory drives from the hospital to the citizens home address.
It is staffed with a biomedical laboratory scientist (BLS) and an emergency nurse.
The requestor gives the nurse information about
-reason to referral
-comorbidity
-which observations and tests required.
To perform blood tests and triage that allows the GP to make fast treatment decisions
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Indication!
Pneumoni
Feber/infection
Dehydration
Generally unwell
Confusion
Cronic obstructive pulmonary disease (COPD)
Abdominalia
Comorbidity
Dementia
Alzheimers
Mentally ill
DM2
COPD in exacerbation
Reason to refferal – the most frequent causes
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
1. Requested blood samples are sent electronically from the GP to the MLU.
2. The nurse makes a triage of the patient according to ABCDE.
3. If the temperature is higher than 38,5 degrees, and if ordered by the GP, the BLS draws blood culture and urine culture.
4. The MLT collects the blood samples and carries the samples from the patient´s bed to the MLU parked outside the patients home.
5. Laboratory results are send electronically to the GP by broadband solution.
6. ECG is either faxed or sent by smartphone to the GP.
Additionel clinical information can be sent to the GP via smartphone.
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Workflow and communication
When results are ready, within 30 minutes, the nurse calls the GP and gives information of her triage values and test results for the blood sample. The GP decides whether the patient must be hospitalized, treated at home or no treatment.
Workflow
.
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Consciousness influence
Infection
Breathing symptoms
Pneumoni
UTI
Dehydration
But we have seen
- Severe sepsis
- 2. degrees AV block (drug poisining)
- Creatinine 673 µmol/L caused by dehydration
Conclusion after triage – the most frequent cuases
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Hospitalization / readmissions
O = Inpatient same day , 7 = Hospitalization within 7 days, N = No admission
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
0
50
100
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350
400
0 7 N
Nu
mb
ers
Days
Hospitalization/readmissions
Total
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Age distribution
Median age 80 years.
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Age
Total
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Sex
0
50
100
150
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350
F M
Nu
mb
ers
Sex
Total
F = Females, M= Males
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Time spent at the patient
Median = 40 minutes
0
10
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80
90
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15
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(to
m)
Nu
mb
ers
Minutes
Total
Building a mobile laboratory
Requirements.
Length of the van. Be able to drive down small residential streets
< 3500 kg. (> 3500 kg. a special
Driver´s license is needed)
Reversing camera
Parking in operation (special
Parking permission)
Diesel Generator (power supply)
Suspension (important for the
equipment)
Wifi
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Building a mobile laboratory
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
We had to decide: Size and weight of the equipment Effect and power consumption – for calculation of the capacity of the battery Design
Our two most fragile instruments (blood cell counter and clinical chemistry instrument)
underwent transport tests before being installed in the van.
I carried the hematology analyzer into my car, and the reagents from the biochemistry analyzer
(only the reagents, because the weight of the analyzer is 120 kg) and drove around the building
a couple of times to see if anything would happen. Subsequently we have had permeable lids to
the reagents.
Robustness
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
The validation of materials and methods was performed in the central laboratory. The
instruments in the MLU were validated using instructions of the central laboratory.
External control Retrospective monitoring Intermediate comparison
Validation and performance of the instruments
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
1. Older people are more relaxed and cooperative in familiar surroundings and thrilled to have a visit at home
2. Patients are more compliant and more open
3. A very important benefit is that we can see the environment in which the patient is living. Can be important information for the GP
4. If the citizen suffers from dementia, we can do the triage and blood sample without the citizen becoming more confused
5. Mentally ill citizens who cannot visit the GP gets help. A visit is made on their premises
Our experiences - benefits for the citizen
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
Common understanding of the job + completion
Testresults supports the clinical findings – other findings evolve
We are proud of what we accomplish together
Common sharing of knowledge
Respect for different competences
The impact of interdisciplinary cooperation– BLS and nurse
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."
1. Blood transfusion at home?
2. Patients receiving chemotherapy – starting and following up?
3. To discharge senior patients from hospital earlier that expected in order to continue
treatment at home under the supervision and responsibility of the hospital physician.
Which equipment/devices will that require? How many different analyses is enough? Are
we missing some analyses, or are we analyzing too many?
4. Would tests for Clostridium difficile at home be a benefit?
Other use – future?
Laboratory technician and lecturer Susanne Andresen. "The mobile laboratory: bringing high-quality testing to the patient."