7834 
Supported by its partnership with Beckman Coulter UK, the largest single-site National Health Service hospital is benefiting from greater, overall efficiencies in its haematology service
Peter Manning
Haematology Operational Manager,
Queen Elizabeth Hospital Birmingham, UK
The Queen Elizabeth Hospital Birmingham (QEHB), UK, was the city’s first new acute hospital in over 70 years when it opened five years ago. The £545 million new, purpose-built environment was one and a half times bigger than the construction of the city’s world famous Bullring complex.
The challenge was to successfully combine the resources of two separate hospital centres into what is now the largest single-site National Health Service (NHS) hospital. It has 32 operating theatres; over 1200 beds including Europe’s largest 100-bed critical care unit, as well as Europe’s largest solid organ transplant programme.
Both its inspirational exterior design, and the ethos within the hospital, reflect the city’s spirit of ‘innovation, improvement and renewal’ – succinctly expressed in its motto, Forward. The NHS has designated QEHB, part of the University Hospitals Birmingham NHS Foundation Trust (UHB), as a Level 1 Trauma Centre as well as host to the UK’s £20m National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC). The Royal Centre for Defence Medicine (RCDM) is also based at the hospital. This treats seriously injured British and European military personnel wounded overseas. The QEHB is recognised worldwide for the excellence of its trauma care, and its ability to devise bespoke solutions for the ballistic and blast injuries of modern combat. In addition, the hospital is a regional centre of excellence, not only for trauma but also cancer, renal, plastic and burns care.
Innovative technology
The laboratory services were upgraded and expanded to be able to satisfy these new and increasingly complex and demanding clinician requirements, both now and over the next decade. By 2012, this saw the creation of a fully automated blood sciences laboratory. The original building programme, and the subsequent upgrading of the laboratory, placed ongoing demands on staff to maintain turnaround times. This was especially important during the transition period as the work transferred to the new hospital complex. Haematology operational manager Peter Manning explained: “It has been a process of evolution requiring a great deal of dedication from the staff. We have had to learn new ways of working, with new technologies.”
Beckman Coulter UK was appointed the lab’s haematology partner under a managed service contract. This has seen the lab switch to the UniCel® DxH 800 Coulter Cellular Analysis System – the company’s multidimensional, high definition flow cytometric technology that improves analysis of abnormal specimens. The changeover took place in stages, first installing four small footprint DxH 800 standalone modules and two Beckman Coulter DxH Slidemaker Stainers. The lab also chose Beckman Coulter’s high speed sorter, the AutoMate 2500, able to handle up to 1200 tubes an hour. Data management was driven by Beckman Coulter’s REMISOL Advance Information System; with the lab now using Version 1.7.
While an individual DxH 800 module can work successfully as a standalone unit, the full potential is realised when the units are linked up, enabling samples to be loaded at one or more entry points. In 2014, the lab became one of the first in Europe, and the first in the UK, to link the units together to create a UniCel DxH Connected Workcell system for added workflow improvements and advanced analytics. “The quality of the new DxH operational data management software has made a difference,” said Mr Manning.
Beckman Coulter designed the system so that a maximum of three DxH 800 modules and one DxH Slidemaker Stainer could be connected, to form a UniCel DxH 2401 Workcell. QEHB decided they needed two workcells, opting for the UniCel DxH 1601 combination, each consisting of two DxH 800 modules and one DxH Slidemaker Stainer.
Scalable solution
With the lab operational 24 hours a day, one workcell already handles a 20% higher workload than the other. Mr Manning explained: “When we selected Beckman Coulter as a partner we needed a scalable solution which had the flexibility to handle increasing workloads without taking up too much valuable lab space.
“Connectivity has made it possible to deliver what is, in effect, an integrated, compact, haematology sample tracking system. This automatically holds, waits and assigns the sample to the next available module and reroutes when necessary, all without manual loading and reduction in downtime. It is this factor that delivers the workflow improvements.”
The recent move to a workcell configuration and connectivity placed further demands on the staff. “While they understood the need for the changes, they had to adjust to new working practices,” explained Mr Manning. “Because the changes have been radical, with haematology tracking being removed and a more compact system installed, the team had to understand how the new technology worked before they could use it to maximum benefit.
“Ongoing training and support from Beckman Coulter has been essential both in the pre-connectivity stage and then helping the staff to adust to working with the workcells. However, the switchover to connectivity went smoothly with remarkably few problems.”
Streamlined workflow
Once the instruments were connected, workloads were more evenly distributed between the modules, increasing uptime over the life of the analysers.
The UniCel DxH 1601 configuration is capable of analysing up to 100 samples an hour for each unit with a throughput of up to 140 smears per hour. Most days, QEHB would expect each instrument to be analysing 70 FBCs an hour, with this split between CBC/Differential/NRBCs (80%) and CBC/Differential/NRBC/Retics (20%). In addition, each unit is capable of 100 smears an hour for a CBC and differential profile and 90 per hour for CBC/Differential/NRBC.
In contrast to many NHS labs, GP requests take less than a third of the daily workload, approximately 28%. “Due to the high volume and complexity of the type of patients we care for in the hospital, both on the wards or as outpatients, approximately three quarters of test requests come from the hospital itself,” explained Mr Manning. “This places particular pressure on turnaround times and consistency throughout the day, from the moment demand goes up late morning, it stays high.”
The lab handles an average of 8000 specimens a day, which include (on weekdays) 1800 full blood counts (FBC), 200 erythrocyte sedimentation rate tests (ESRs) and 450 HbA1c tests for diabetes. Since 2012, FBC requests have risen about 12% with glucose testing up over 50%. However, automating processes has enabled the lab to maintain turnaround time (TAT) levels for all its requestors. For example, more than 90% of FBC requests from the Emergency Department are reported in less than 60 minutes.
Low differential review rates
The addition of the automated Beckman Coulter Slidemaker Stainer within the configuration has made a particular contribution to lab efficiency. Being able to accurately detect and count abnormal cells, particularly if they occur in low frequency, depends on the quality of the blood films produced. The instrument provides a more reliable and consistent smear quality regardless of the blood consistency. With the Slidemaker Stainer (SMS) it is easy to make and stain smears from both capped whole blood sample tubes and open top tubes. This can be done via an automatic cassette or when in single-tube mode. The SMS also requires very little maintenance and is easy to configure.
While FBC workloads have steadily increased over the last two years, differential review rates are down. The lab carries out more than 525,000 FBCs a year with less than 3.5% now requiring further review. The lab already constantly monitors referral criteria to ensure they accurately reflect the hospital’s unique patient demographics. “In just over 12 months, our increased emphasis on referral monitoring, alongside the SMS smear quality, has seen a 27% reduction rate in films needing to be re-examined by visual microscopy,” commented Mr Manning. “This both improves efficiency and means we can make better use of valuable staff time.”
Other SMS benefits include:
- “Load ‘n’ go” feature allows staff to load up to 180 slides
- Small sample volume of 90 μl makes up to four slides
- Up to twelve slides from a single presentation
- Staining protocols can easily be adjusted
- Staff time released by automated post analytical sorting and archiving.
With its ability to automatically handle up to 1200 tubes an hour, most core labs use the Beckman Coulter high- speed sorter, the AutoMate 2500, at both the pre- and post-analytical stage. Manual sample processing delays at this point significantly affect overall workflow and TAT rates. The haematology team at the QEHB prefers to concentrate the sorter’s high speed capabilities on solving post analytical sorting demands, both to maintain workflow performance and TAT, and also simplify archiving.
As samples are being loaded, the AutoMate 2500 automatically checks there are no outstanding test requests before the sample is archived. If there are any outstanding tests, samples are rapidly placed in the area designated for that test. This makes it easy for the staff to identify where the samples are to go next, before being stored.
Improved data management
The latest DxH data management system (Version 3.0) consolidates information for order entry and results review (up to 90,000 results) and quality control management (with a storage capacity for 30 control files, each with 150 runs per instrument). For the SMS, the DxH’s internal ‘rules’ tell the instrument exactly which films are needed so that it can then make slides to the lab’s specification.
Further capability is added by Beckman Coulter’s REMISOL Advance Information System (Version 1.7). User-defined decision rules for auto-rerun and reflex testing make it possible to add further tests, such as blood films or reticulocyte counts, post analysis. This further improves workflow and helps reduce TAT. Critical STAT samples or body fluids can be added while the system is running, without needing to interrupt routine sample testing. REMISOL Advance also simplifies archiving by consolidating multiple sample types into a single archiving system.
Supported by its partnership with Beckman Coulter UK, the QEHB haematology service is benefiting from greater, overall efficiencies, with valuable staff time put to maximum benefit.
In spite of increasingly complex demands from clinicians, turnaround time targets are being maintained or exceeded. The lab needed the right technologies and advanced data management in place to improve overall workflow and performance, providing a fast and consistent response to test requests, without compromising on safety, and regardless of workload pressures.
