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07/03/2016
1
1
Transfusion Medicine Transformation
at Vancouver Coastal Health (VCH)
Heather Mah, Regional Technical Practice Lead VCH Vancouver, Canada
Immucor User Group 2016 Oakland California
Effective Use of Automated Capture® Panels and ImmuLINK™
for Cross-Site Antibody Identification
Province of British Columbia
• 357,000 sq miles
( California 163,700 sq miles)
• 4.5 million pop.
• Six Government funded Health Authorities administer health services
Vancouver Coastal Health
2
Vancouver Coastal Health
PRGH
PHC
SMH
RH
VGH
LGH
UBCH
Whistler
SGH
Vancouver Coastal Health
07/03/2016
2
Service Delivery Model
4
Vancouver General Hospital
VGH serves as a hub site for 10 facilities
Lions Gate Hospital
• Average travel time from LGH for urgent
antibody investigation samples is 67
minutes via the Lions Gate Bridge
Richmond Hospital
46,000 T/S annually 7,000 T/S annually
7,000 T/S annually
• More effective automation for large hub site
• Lean workflow
• Scalable automation appropriate for community hospitals
• Centralized data management
• Efficient cross-site antibody identification
VCH TM Transformation Goals 2013/14
5
Better Automation at VGH
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• Expanded test menu including testing of AI panels (T/S, ABR1, XM, panels, donor
unit confirm,)
• Large through-put
• Continuous access to load and unload samples and reagents at any time
• Dynamic scheduling - run tests in any order
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3
LEAN Principles Application VGH
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Original State
LEAN Principles Application VGH
LEAN = Eliminating waste, cycle time reduction for STAT Group and Screen Testing
• Create a value-stream map of the original state
• Develop new workflow to reduce non-value added time
• Redesign bench configuration and analyzers’ placement
• Move NEO®s to new location /Add Echo®
• Measure various parameters to assess benefits.
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LEAN Principles Application VGH
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ECHO
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4
LEAN Principles Application VGH
10
LEAN Principles Application VGH Parameter Original State Renewed State
Total travel distance
433 sq ft 145 sq ft
Employee travel time to check results
1.25 hrs/day 0 hrs/day
TAT for T/S from ER
1 hr 10 min (average for first 8 months)
1 hr 5 min (average since repositioning of NEOs)
11
TAT increased at implementation
Scalable Automation
12
ECHO® • Efficiency gains at LGH
and RH
• Improved standardization of test set up and reading
• Opportunity to shift some Antibody Identification testing closer to patient
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5
Centralized Data Management
13
ImmuLINK™
ImmuLINK™
• ImmuLINK™ middleware allows web-based review of data from multiple instruments
Centralized Data Management
14
ImmuLink
serverSunquest
VNEO1
VNEO2
LECHO1
RECHO
VIMLNK
LIMLNK
RIMLNK
NEO® and Echo®
(Immucor) Analyzers
ImmuLINK™ Implementation Process
15
VCH MULTI-SITE TMS ANALYZER IMPLEMENTATION TIMELINEDates: May 1, 2013 to July 31, 2014
List of Activities Days Jul/13 Jan/14 Jul/14
Implementation Processes at VCH
NEO/ECHO Installation and Validation - VGH/LGH 98
ImmuLINK Installation and Setup 49
Sunquest Software Development 63
ImmuLINK and Sunquest Configuration/Testing 49
Document Creation - Operating Procedures 161
Document Creation - Test Scripts 56
NEO and ImmuLINK Training - VGH 56
ECHO and ImmuLINK Training - LGH 119
ImmuLINK Virtualization at KDC 49
Security and Privacy Review Process 133
KDC ImmuLINK Server Installation and Validation 66
ECHO Installation and Validation - RH 28
ECHO and ImmuLINK Training - RH 64
* VGH - Vancouver General Hospital LGH - Lions' Gate Hospital RH - Richmond HospitalRH - Richmond Hospital
VGH/LGH Analyzers & ImmuLINK LIVE
18-Nov-2013
ImmuLINK @ KDC LIVE20-Mar-2014
2
3
4
1
RH ECHO LIVE15-Jul-2014
07/03/2016
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ImmuLINK™ Implementation Challenges
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• ImmuLINK Virtualization – Kamloops Data Center (KDC)
• Lack of redundancy, backup, and support on ImmuLINK server hardware – Initiate plans to virtualize the server to KDC
• Application to HSSBC privacy office for review to fulfill security and privacy concerns
• Re-validation of ImmuLINK™ at KDC
4
17
Effective Use of Automated Capture® Panels and ImmuLINK™
for Cross-Site Antibody Identification
Reagent Panels • Pre-dispensed
• Stable for 120 days from manufacture
• 3 different solid phase panels
• Easy to use on automated platform (automated panels)
• Assay TAT = 27 minutes on Echo
• 69% of investigations can be completed using only these panels
Efficient Antibody Identification
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Automated Panels for AI
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• Antibody investigations – Can be performed using
only automated panels 69% of the time (N=489)
• ImmuLINK™ middleware allows web-based review of data from multiple instruments
ImmuLINK™
20
ImmuLink
serverSunquest
VNEO1
VNEO2
LECHO1
RECHO
VIMLNK
LIMLNK
RIMLNK
NEO® and Echo®
(Immucor) Analyzers
ImmuLINK™ - Multiple Sites
21
Test site LGH - panel results viewed at VGH
01:35
02:12
07/03/2016
8
ImmuLINK™ - Multiple Sites
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Report from ImmuLINK™
- Test site LGH (02:12)
- Retrieved & interpreted at
VGH (02:30)
ImmuLINK™ - Multiple Sites
23
Report from ImmuLINK™
- Anti-Fya interpretation at VGH (3:20 AM phone report to LGH)
Sample arrives
at VGH 02:45
LEAN Principles Application VCH
LEAN = Eliminating waste, cycle time reduction for STAT Group and Screen Testing
• Create a value-stream map of the original state
• Develop new workflow to reduce non-value added time and incorporate technology enhancement
• Implement new workflow at LGH and VGH
• Measure TAT for urgent antibody investigations for 10 weeks to assess the benefit.
24
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9
Cross-Site AI: Original State
Complete Forms
Notify VGH
Package & and
Send out Sample
First Antibody ID Panel by Manual GEL
Secondary Panels
Pheno- typing
Report to LGH
25
Start
1 hour
2 hours
3 hours
4 hours
5 hours
Travel time = Waste
Mean TAT for urgent cross-
site antibody investigations
was 4.6 hours. Target TAT is
4 hours.
LGH Activities VGH Activities
New Positive
Antibody Screen
Cross-Site AI: Improved TAT
First Antibody ID
Panel
Notify VGH
Package & and
Send out Sample
First Panel Secondary
Panels - typing
Report to LGH
26
Start
1 hour
2 hours
3 hours
4 hours
5 hours
LGH Activities
VGH Activities
New Positive
Antibody Screen
First Panel
Print Immu-LINK
report
First Panel
Exclu-sions
Secondary Panels
Pheno- typing
Report to LGH ImmuLINK™ Report
Change in mean TAT to 3.3 hours from 4.6
hours for original state
07/03/2016
10
• 34 urgent antibody investigations with cross-site collaboration
• Specificity assigned in 59% of cases as indicated in table
Measure cont’d
28
SPSA = pan-reactive, negative DAT, negative PEG
Unidentified = exclusions complete, unexplained
reactions in solid phase and/or PEG
• 38% of the cases had nonspecific reactions (mean TAT for this group 3.1 hours)
• Immucor acknowledged higher rates of equivocal and unexpected results with Capture™ reagents
• Potential impact on patient care and additional resources
• Negates some of the benefits of panels and ImmuLINK™ for cross-site AI.
Measure cont’d
29
SPSA = pan-reactive, negative DAT, negative PEG
Unidentified = exclusions complete, unexplained
reactions in solid phase and/or PEG
Conclusions
30
Benefit of new workflow and technology was a change in mean TAT to 3.3 hours from 4.6 hours for original state
1st panel results available to VGH via ImmuLINK™ shortly after referral by LGH and before arrival of sample
Opportunities to further decrease TAT by testing with additional Ready-ID® panels at referring sites
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11
Conclusions
31
LGH staff is pleased to have more
involvement in the AI process and
have ability to perform preliminary
analysis of the first panel
VGH staff noted a reduction in
hands-on time and TAT to complete
the investigations
32
NEW Positive Antibody
Screen requiring STAT
AI Process
Run Ready-ID on ECHO STAT
Order VAI* Test in
Sunquest
Complete Referral AI
Request Form
Ensure timing of Panel
Completion is recorded
Fax & Phone request for STAT AI to
VGH
Order Additional Samples if
needed
Package Samples for
Sendout
Send out samples via
CAB or COURIER
Print Panel & Screen Report
from ImmuLINK
Perform Exclusions and
Initial Conclusion
If Additional Solid Phase Panels are...
Arrived
NOT Arrived
Contact RH / LGH
to perform panel testing
Receive Call and run
requested panel onto ECHO STAT
Phone VGH when testing
complete
Samples arrive at VGH
PhoneRH / LGH with Final
Results
RH / LGH to order
Phenotyped Units if
required
Crossmatch Units,
Phenotyping as required
Fax & Phone received from
RH / LGH, note time of
Panel Completion
RH
/ L
GH
Pro
cess
VG
H P
roce
ss
Complete AI Process
Not RequiredWait for
Samples to arrive
Required and if Samples
have...
SAMPLES
If Patient still at RH / LGH...
* RH use STAT priority LGH use Urgent priority
Referral Antibody Investigation Flow
• More effective automation for VGH √
• LEAN workflow √
• Scalable automation appropriate for LGH & RH √
• Centralized data management - ImmuLINK™ √
• Efficient cross-site antibody identification √
Transformation Goals Accomplished
33
07/03/2016
12
Issue: • Files with multiple Master
Lists (ML) • Each of the 3 sites may
have different Capture-R® Ready-ID® panels in use
• Potential for error when selecting (ML) on which to transcribe results from ImmuLINK™ report
• Time consuming to transcribe results
Working Collaboratively with Immucor
34
Proposed ImmuLINK™ enhancements:
1. Panel Identification
• System selects lot number of panel
• ImmuLINK report results print on Master List
2. Algorithm for rule outs
3. Manual panels
• Save and store in data base
• Useful for select cells
Working Collaboratively with Immucor
35
Acknowledgements
36
Executive Sponsor Richard Walker
Medical Leads Dr. Kate Chipperfield, Dr. Kristine Roland
Technical Supervisor (VGH) Pam Danesin
Project Managers Ellie Sheng (LIS) Heather Mah (Lab)
LIS Steve Arai
Technical Support/Trainer Luca Rizzetto
Technical Support/ImmuLINK Lawrence Sham
LEAN Project Margaret Walsh
K/O – Trainers, Site Champion Pam Danesin, Kate Chan, Shelley Tapp (LGH) Teresa Sharp (RH)
Learning and Ideas All staff!