Understanding Phleb (PDF)

CHAPTER 1 Past and Present and The Healthcare Setting KEY TERMS AHCCCS APC case manager certiﬁcation CLIA ’88 CMS communication barriers CPT exsanguinate HIPAA Do the Matching Exercises in the WORKBOOK to gain familiarity with these terms. OBJECTIVES Upon successful completion of this chapter, the reader should be able to: HMOs ICD-9-CM IDS kinesic slip kinesics MCOs Medicaid Medicare MLS PHI PHS phlebotomy polycythemia PPOs primary care proxemics reference laboratories secondary care tertiary care third-party payer 1 Deﬁne the key terms and abbreviations listed at the beginning of this chapter. 2 Describe the evolution of phlebotomy and the role of the phlebotomist in today’s healthcare setting. 3 Describe the traits that form the professional image and identify national organizations that support professional recognition of phlebotomists. 4 Describe the basic concepts of communication as they relate to healthcare and how appearance and nonverbal messages affect the communication process. 5 Describe proper telephone protocol in a laboratory or other healthcare setting. 6 Demonstrate an awareness of the different types of healthcare settings. 7 Compare types of third-party payers, coverage, and methods of payment to the patient, provider, and institutions. 8 Describe traditional hospital organization and identify the healthcare providers in the inpatient facility. 9 List the clinical analysis areas of the laboratory and the types of laboratory procedures performed in the different areas. 10 Describe the different levels of personnel found in the clinical laboratory and how Clinical Laboratory Improvement Amendment regulations affect their job descriptions. 4 UNIT I: THE HEALTHCARE SETTING OVERVIEW Healthcare today has evolved into an integrated delivery system offering a full range of services intended to ensure that the patient gets what is needed at the right time and in the right way. In addition to physicians, nurses, and patient support personnel, allied health professionals such as clinical laboratory personnel play a role in the delivery of patient care. The clinical laboratory serves a vital role in the healthcare system, providing physicians with some of medicine’s most powerful diagnostic tests. Before patient test results can be reported to the physician, specimens must be collected and analyzed. The phlebotomist has been a key player in this process for some time. In addition to blood collection skills, successful specimen collection requires the phlebotomist to demonstrate competence, professionalism, good communication and public relations skills, thorough knowledge of the healthcare delivery system, and familiarity with clinical laboratory services. An understanding of phlebotomy from a historical perspective helps the phlebotomist appreciate the signiﬁcance of his or her role in healthcare today. Phlebotomy: A Historical Perspective Since very early times, people have been fascinated by blood and have believed in some connection between the blood racing through their veins and their well-being. From this belief, certain medical principles and procedures dealing with blood evolved, some surviving to the present day. An early medical theory developed by Hippocrates (460–377 B.C.) stated that disease was the result of excess substance—such as blood, phlegm, black bile, and yellow bile—within the body. It was thought that removal of the excess would restore balance. The process of removal and extraction became the treatment and could be done either by expelling disease materials through the use of drugs or by direct removal during surgery. One important surgical technique was venesection (cutting a vein), used in the process of bloodletting. Venesection— which comes from the Latin words vena, “vein,” and sectio, “cutting”—was the most common method of general bloodletting. It involved cutting into a vein with a sharp instrument and releasing blood in an effort to rid the body of evil spirits, cleanse the body of impurities, or, as in Hippocrates’ time, bring the body into proper balance. It often meant withdrawing large quantities of blood from a patient to cure or prevent illness and disease. Venesection is another word for phlebotomy, which comes from the Greek words phlebos, “vein,” and tome, “incision.” Some authorities believe phlebotomy dates back to the last period of the Stone Age, when crude tools were used to puncture vessels and allow excess blood to drain out of the body. A painting in a tomb showing the application of a leech to a patient evidences bloodletting in Egypt in about 1400 B.C. Early in the Middle Ages, barber–surgeons ﬂourished. By 1210, the Guild of Barber–Surgeons had been formed; it divided the surgeons into Surgeons of the Long Robe and Surgeons of the Short Robe. Soon the Short Robe surgeons were forbidden by law to do any surgery except bloodletting, wound surgery, cupping, leeching, shaving, tooth extraction, and enema administration. To distinguish their profession from that of the Long Robe surgeon, barber–surgeons placed a striped pole, from which a bleeding bowl was suspended, outside their doors. The pole represented the rod squeezed by the patient to promote bleeding and the white stripe on the pole corresponded to the bandages, which were also used as tourniquets. Soon, handsomely decorated ceramic bleeding bowls (Fig. 1-1) came into fashion and were passed down from one generation to the next. These bowls, which often doubled as shaving bowls, usually had a semicircular area cut out on one side to facilitate placement of the bowl under the chin. During the 17th and early 18th centuries, phlebotomy was considered a major therapeutic (treatment) process, and anyone willing to claim medical training could perform phlebotomy. The lancet, a tool used for cutting the vein during venesection, was perhaps the most prevalent medical instrument of the times. The usual amount of blood withdrawn was approximately 10 mL, but excessive phlebotomy was common. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING 5 Figure 1-1 A bleeding bowl. Excessive phlebotomy is thought to have contributed to George Washington’s death in 1799, when he was diagnosed with a throat infection and the physician bled him four times in 2 days. It was because of Washington’s request to be allowed to die without further medical intervention that the physician did not completely exsanguinate him, or remove all his blood. During this same period, phlebotomy was also accomplished by cupping and leeching. The art of cupping required a great deal of practice to maintain the high degree of dexterity necessary to avoid appearing clumsy and thus frighten the patient away. Cupping involved the application of a heated suction apparatus, called the “cup,” to the skin to draw the blood to the surface. Then the capillaries in that area were severed by making a series of parallel incisions with a lancet or ﬂeam. The typical ﬂeam was a wide double-edged blade at right angles to the handle. Eventually, multiple ﬂeams (Fig. 1-2) were attached and folded into a brass case for easy carrying. The blades were wiped clean with only a rag; therefore, they readily transmitted a host of blood-borne infections from patient to patient. Fleams were used for general phlebotomy to open an artery or, more commonly, a vein to remove large amounts of blood. For more localized bloodletting, leeches were used. This procedure involved enticing the Hirudo medicinalis, a European medicinal leech, to the spot needing bloodletting with a drop of milk or blood on the patient’s skin. After the leech engorged itself with blood, which took about an hour, it was allowed to drop off. By the mid-18th century, leeching was widely practiced in Europe, especially in France. Leeches were kept in special vessels that were ﬁlled with water and had perforated tops, so that the leeches could breathe. Early leech jars were glass and later ones ceramic (Fig. 1-3). Within the last decade, leeches have made a comeback as defenders from the complications of microsurgical replantation. The value of leech therapy (Fig. 1-4) lies in the components of the worm’s saliva, which contains a local vasodilator (substance that increases the diameter of blood vessels), a local anesthetic, and hirudin, an anticoagulant (a substance that prevents clotting). Figure 1-2 Typical ﬂeams. (Courtesy Robert Kravetz, MD, Chairman, Archives Committee, American College of Gastroenterology.) 6 UNIT I: THE HEALTHCARE SETTING Figure 1-3 A leech jar. Phlebotomy Today The practice of phlebotomy continues to this day; however, principles and methods have improved dramatically. Today, phlebotomy is performed to: Obtain blood for diagnostic purposes and to monitor prescribed treatment Remove blood for transfusions at a donor center Remove blood for therapeutic purposes, such as treatment for polycythemia, a disorder involving the overproduction of red blood cells Phlebotomy is primarily accomplished by one of two procedures: Venipuncture, which involves collecting blood by penetrating a vein with a needle and syringe or other collection apparatus Capillary puncture, which involves collecting blood after puncturing the skin with a lancet THE CHANGING ROLE OF THE PHLEBOTOMIST IN THE EMERGING HEALTHCARE ENVIRONMENT Healthcare delivery systems are constantly changing. Advances in laboratory technology are making point-of-care testing (POCT) commonplace, and services that were once unique to the laboratory are now being provided at other locations. The development of teams and the Figure 1-4 A toe with leech. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING BOX 1-1 7 DUTIES AND RESPONSIBILITIES OF A PHLEBOTOMIST Prepare patients for collection procedures associated with laboratory samples. Collect routine skin puncture and venous specimens for testing as required. Prepare specimens for transport to ensure stability of sample. Maintain patient conﬁdentiality. Perform quality-control checks while carrying out clerical, clinical, and technical duties. Transport specimens to the laboratory. Comply with all procedures instituted in the procedure manual. Promote good relations with patients and hospital personnel. Assist in collecting and documenting monthly workload and recording data. Maintain safe working conditions. Perform appropriate laboratory computer operations. Participate in continuing education programs. Collect and perform point-of-care testing (POCT). Perform quality-control checks on POCT instruments. Perform skin tests. Prepare and process specimens. Collect urine drug screen specimens. Perform electrocardiography. Perform front-ofﬁce duties, current procedural terminology coding, and paperwork. sharing of tasks have become necessary as healthcare organizations attempt to ﬁnd the balance between cost-effective treatment and high-quality care. Work responsibilities have been revised, so that many types of healthcare professionals are cross-trained in a number of techniques and skills, including phlebotomy. Consequently the term phlebotomist is applied to any individual who has been trained in the various techniques used to obtain blood for laboratory testing or blood donations. A competent clinical phlebotomist must have good manual dexterity, special communication skills, good organizational skills, and a thorough knowledge of laboratory specimen requirements and departmental policies. A selection of common duties and responsibilities associated with the role of phlebotomist are listed in Box 1-1. Regardless of which member of the healthcare team performs phlebotomy techniques, quality assurance demands that the highest standards be maintained and approved procedures followed. Consequently there is a standardized educational curriculum with a recognized body of knowledge, skills, and standards of practice for the phlebotomy profession. Many hospitals, vocational schools, and colleges offer structured phlebotomy programs that not only train students in phlebotomy procedures, but also prepare them for national certiﬁcation or state licensure. These programs, which can apply for approval by the National Accrediting Agency for Clinical Laboratory Sciences (NAACLS), typically include classroom instruction and clinical practice. According to Laboratory Medicine: A National Status Report – 2007, phlebotomy training programs have increased sixfold from 1987 to 2003. OFFICIAL RECOGNITION Certiﬁcation Certiﬁcation is a voluntary process by which an agency grants recognition to an individual who has met certain prerequisites in a particular technical area. Certiﬁcation indicates the completion of deﬁned academic and training requirements and the attainment of a satisfactory score on an examination. This is conﬁrmed by the awarding of a title or designation. Phlebotomist certiﬁcation is signiﬁed by initials that the individual is allowed to display after 8 UNIT I: THE HEALTHCARE SETTING TABLE 1-1 Phlebotomist Title and Initials Awarded by Certiﬁcation Agency* Certiﬁcation Agency Certiﬁcation Title Certiﬁcation Initials American Medical Technologists Registered Phlebotomy Technician RPT(AMT) American Certiﬁcation Agency Certiﬁed Phlebotomy Technician CPT(ACA) American Society for Clinical Pathology Phlebotomy Technician PBT(ASCP) National Center for Competency Testing National Certiﬁed Phlebotomy NCPT(NCCT) National Healthcareer Association Certiﬁed Phlebotomy Technician CPT(NHA) Mailing and e-mail addresses and telephone numbers for the Certiﬁcation Agencies listed can be found in R. McCall, Phlebotomy Exam Review, 4th ed. Baltimore: Lippincott Williams & Wilkins, 2012. his or her name. Examples of national agencies that certify phlebotomists, along with the title and corresponding initials awarded, are listed in Table 1-1. Licensure Licensure is the act of granting a license. A license in healthcare is an ofﬁcial document or permit granted by a state agency that gives legal permission for a person to work in a particular health profession. Without a license, it would be against the law for a person to practice that profession in that state. Typically, the individual must meet speciﬁc education and experience requirements and pass an examination before the license is granted. The license indicates competency only at the time of examination. As a demonstration of continued competency, states normally require periodic license renewal, by either reexamination or proof of continuing education. Some states have several levels of licensure for certain professions. For example, California offers three levels of phlebotomy licensure: Limited Phlebotomy Technician (LPT), Certiﬁed Phlebotomy Technician I (CPT I), and Certiﬁed Phlebotomy Technician II (CPT II). Continuing Education Continuing education is designed to update the knowledge or skills of participants and is generally geared to a learning activity or course of study for a speciﬁc group of health professionals, such as phlebotomists. Many organizations, such as the American Society for Clinical Pathology (ASCP), the American Society for Clinical Laboratory Sciences (ASCLS), and the American Medical Technologists (AMT), sponsor workshops, seminars, and self-study programs that award continuing education units (CEUs) to those who participate. The most widely accepted CEU standard, developed by the International Association for Continuing Education and Training (IACET), is that 10 contact hours equal one CEU. (International Association for Continuing Education and Training. Retrieved April 14, 2010, from http://www. iacet.org/content/continuing-education-units.html.) Most certifying and licensing agencies require CEUs or other proof of continuing education for renewal of credentials. These requirements are intended to encourage professionals to expand their knowledge base and stay up to date. It is important for phlebotomists to participate in continuing education to be aware of new developments in specimen collection and personal safety. PATIENT–CLIENT INTERACTION As a member of the clinical laboratory team, the phlebotomist plays an important role in how the laboratory is portrayed to the public. The phlebotomist is often the only real contact the patient has with the laboratory. In many cases, patients equate this encounter with the caliber of care they receive while in the hospital. Positive “customer relations” involves promoting goodwill and a harmonious relationship with fellow employees, visitors, and especially CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING 9 patients. A competent phlebotomist with a professional manner and a neat appearance helps to put the patient at ease and establish a positive relationship. Recognizing Diversity Despite similarities, fundamental differences among people arise from nationality, ethnicity, and culture as well as from family background, life experiences, and individual challenges. These differences affect the health beliefs and behaviors of both patients and providers. Culturally aware healthcare providers enhance the potential for more rewarding interpersonal experiences. This can lead to increased job satisfaction for them and increased patient satisfaction with the healthcare services they provide. Critical factors in providing healthcare services that meet the needs of diverse populations include understanding the: Beliefs and values that shape a person’s approach to health and illness Health-related needs of patients and their families according to the environments in which they live Knowledge of customs and traditions related to health and healing Attitudes toward seeking help from healthcare providers KEY POINT By recognizing diversity, the phlebotomist promotes goodwill and harmonious relationships that directly improve health outcomes, the quality of services, and public relations. State how each quality contributes to professional attitude in the Knowledge Drill 1-6 activity in the WORKBOOK. Professionalism Professionalism is deﬁned as the conduct and qualities that characterize a professional person. As part of a service-oriented industry, persons performing phlebotomy must practice professionalism. The public’s perception of the phlebotomy profession is based on the image created by the phlebotomist’s conduct and appearance. In fact, general appearance and grooming directly inﬂuence whether the phlebotomist is perceived as a professional. It has been said that people form opinions of a person within the ﬁrst 3 seconds of meeting, and this judgment on the superﬁcial aspect of a person sets an image in the observer’s mind that can affect the interaction. Conservative clothing, proper personal hygiene, and physical well-being contribute to a professional appearance. It should be noted that healthcare institutional policies for attire are inﬂuenced by a federal standard that requires employers to provide protective clothing for laboratory workers, including phlebotomists. Besides displaying a professional appearance, a person performing phlebotomy is required to display attitudes, personal characteristics, and behaviors consistent with accepted standards of professional conduct. Some of the personal behaviors and characteristics that make up this professional image, are as follows: Self-Conﬁdence A phlebotomists who exhibit self-conﬁdence has the ability to trust his or her own personal judgment. Your perception of yourself has an enormous impact on how others perceive you, and “perception is reality.” The more self-conﬁdence you have, the more professional you appear. Many factors affect being perceived as self-conﬁdent; for example, erect posture, professional appearance, courage, and tactfulness in communication. Integrity Integrity as a concept has to do with a personal feeling of “wholeness” deriving from honesty and consistency of character; this can be seen in the person’s actions, values, and beliefs. Professional standards of integrity or honesty require a person to do what is right regardless of the circumstances and in all situations and interactions. For example, a phlebotomist often functions independently and may be tempted to take procedural shortcuts when pressed for time. A phlebotomist with integrity understands that following the rules for collection is essential to the quality of test results; therefore, he or she respects those rules without fail. 10 UNIT I: THE HEALTHCARE SETTING Compassion Compassion is a human emotion prompted by others’ experiences and concerns; it is considered to be one of the greatest of virtues by major religious traditions. It is differentiated from empathy only by the level of emotion, as it tends to be more intense. Compassion means being sensitive to a person’s needs and willing to offer reassurance in a caring and humane way. A phlebotomist may show compassion by appreciating the fear that illness or the unknown generates, by using empathy to sense others’ experiences, and by demonstrating a calm and helpful demeanor toward those in need. Self-Motivation A person with motivation ﬁnds the workplace stimulating no matter what the tasks may entail. Motivation is a direct reﬂection of a person’s attitude toward life. A phlebotomist who exhibits self-motivation takes initiative to follow through on tasks, consistently strives to improve and correct behavior, and takes advantage of every learning opportunity that may come along. A phlebotomist who is motivated makes every effort to provide excellence in all aspects of patient care in which he or she is involved. Dependability Dependability and work ethic go hand in hand. An individual who is dependable and takes personal responsibility for his or her actions is extremely refreshing in today’s environment. A phlebotomist who works hard and shows constant, reliable effort and perseverance is a valuable asset to a healthcare organization. This set of values makes a person a desirable candidate for new job opportunities and ultimately promotions in the healthcare setting or anywhere. Ethical Behavior A phlebotomist should know that there are policies designed to regulate what should or should not be done by those who work in the healthcare setting. This system of policies or principles is called a code of ethics. Ethics are centered on an individual’s conduct. Ethical behavior means making the right personal choices that help to maintain a high level of respect for you, the phlebotomist, and for the profession in which you work. In healthcare, ethical behavior requires conforming to a standard of right and wrong conduct so as to avoid harming patients in any way. A code of ethics, although not enforceable by law, leads to uniformity and deﬁned expectations for the members of that profession. Professional organizations, such as ASCP, have developed codes of ethics for laboratory professionals. The Hippocratic oath includes the phrase primum non nocere, which means “ﬁrst do no harm.” The primary objective in any healthcare professional’s code of ethics must always be to safeguard the patient’s welfare. A guide to working with that principle in mind is a document of accepted quality-care principles developed by the American Hospital Association and the related patient rights. Patients’ Rights A patient has rights and must be informed of these rights when care is initiated. The patient must sign a statement that these rights have been explained, and the signed statement must be made a part of the patient’s health record. It has been found that patients who are informed about their treatments and prognoses and are considered in the decision-making process are more satisﬁed with their care. A decade ago, the federal government recognized the need to strengthen consumer conﬁdence in the fairness and responsiveness of the healthcare system. The result was The Patient Bill of Rights in Medicare and Medicaid. Medicare now requires that patients be informed of their rights, including the right to know what treatment they can expect, who will be treating them, the right to refuse treatment, and the right to conﬁdentiality. To afﬁrm the importance of a strong relationship between patients and their healthcare providers, the American Hospital Association (AHA) publishes and disseminates a statement of patient rights and responsibilities. The AHA brochure with this statement or a similar pamphlet is often provided to consumers during inpatient admission procedures as evidence of patient advocacy or support. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING BOX 1-2 11 THE PATIENT CARE PARTNERSHIP What to Expect during Your Hospital Stay High-quality hospital care A clean and safe environment Involvement in your care Protection of your privacy Help when leaving the hospital Help with your billing claims Reprinted from American Hospital Association, The Patient Care Partnership, retrieved April 14, 2010 from http://www.aha.org/aha/content/2003/pdf/pcp_english_030730.pdf. See that document for more details. The latest revision approved by the AHA Board in 2003 is entitled The Patient Care Partnership. This easy-to-read brochure replaces the AHA’s Patient Bill of Rights and is designed to help patients understand their expectations during their hospital stay with regard to their rights and responsibilities. It states that the ﬁrst priority of all healthcare professionals, including phlebotomists, is to provide high-quality patient care in a clean and safe environment, while also maintaining the patient’s personal rights and dignity by being sensitive to differences in culture, race, religion, gender, and age. Expectations listed in the brochure are summarized in Box 1-2. Conﬁdentiality Patient conﬁdentiality is seen by many as the ethical cornerstone of professional behavior in the healthcare ﬁeld. It serves to protect both the patient and the practitioner. The healthcare provider must recognize that all patient information is absolutely private and conﬁdential. Healthcare providers are bound by ethical standards and various laws to maintain the conﬁdentiality of each person’s health information. KEY POINT The maintenance of conﬁdentiality is such an important issue in testing for HIV that the patient must sign a consent form before the specimen for the test can be collected. Any questions relating to patient information should be referred to the proper authority. Unauthorized release of information concerning a patient is considered an invasion of privacy. In 1996, a federal law was passed requiring all healthcare providers to obtain a patient’s consent in writing before disclosing medical information such as a patient’s test results, treatment, or condition to any unauthorized person. That law is the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA As a person’s health information has become more easily transferable from one facility or entity to the next through electronic exchange, a growing problem with a person’s rights and conﬁdentiality has arisen. The HIPAA law was enacted in order to more closely secure this information and regulate patient privacy. HIPAA provisions protect a broad range of health information. Safeguarding the conﬁdentiality of protected health information (PHI) is one of the primary aims of the HIPAA privacy rule. The law deﬁnes PHI as “individually identiﬁable health information that is transmitted by electronic media; maintained in any medium described in the deﬁnition of electronic media or transmitted or maintained in any other form or medium.” The law established national standards for the electronic exchange of PHI and states that patients must be informed of their rights concerning the release of PHI and how it will be used. Penalties for HIPAA violations include disciplinary action, ﬁnes, and possible jail time. The law states that healthcare workers (HCWs) must obtain the patient’s written authorization for any use or disclosure of PHI unless the use or disclosure is for treatment, payment, 12 UNIT I: THE HEALTHCARE SETTING or healthcare operations. To avoid litigation in this area, all HCWs and students must sign a conﬁdentiality and nondisclosure agreement afﬁrming that they understand HIPAA and will keep all patients’ information conﬁdential. COMMUNICATION SKILLS Phlebotomy is both a technical and a people-oriented profession. Many different types of people or customers interact with phlebotomists. Often, the customer’s perception of the healthcare facility is based on the employees they deal with on a one-to-one basis, such as a phlebotomist. Customers expect high-quality service. A phlebotomist who lacks a good bedside manner (the ability to communicate empathically with the patient) increases the chances of becoming part of a legal action should any difﬁculty arise while a specimen is being obtained. Favorable impressions result when healthcare workers respond properly to patient needs, and this occurs when there is good communication between the healthcare provider and the patient. Communication Deﬁned Communication is a skill. Deﬁned as the means by which information is exchanged or transmitted, communication is one of the most important processes that takes place in the healthcare system. This dynamic and constantly changing process involves three components: verbal skills, nonverbal skills, and the ability to listen. Test your knowledge of communication components in Labeling Exercise 1-1 in the WORKBOOK. Communication Components Verbal Communication Expression through the spoken word is the most obvious form of communication. Effective healthcare communication should be an interaction in which both participants play a role. It involves a sender (speaker), a receiver (listener), and, when complete, a process called feedback, creating what is referred to as the communication feedback loop (Fig. 1-5). Accurate verbal exchange depends upon feedback, as it is through feedback that the listener or receiver is given the chance to clarify ideas or correct miscommunication, which may be due to preformed biases. Normal human behavior sets up many communication barriers (biases or personalized ﬁlters) that become obstructions to hearing and understanding what has been said and are frequent causes of miscommunication. Examples of communication barriers are language limitations, cultural diversity, emotions, age, and physical disabilities such as hearing loss. To encourage good verbal communication, the phlebotomist should use a vocabulary that is easily understood by his or her clients. To avoid creating suspicion and distrust in FEEDBACK REACTION Emotions Emotions Physical disabilities Physical disabilities MESSAGE HEALTH CARE WORKER Language limitations Cultural diversity CLIENT Language limitations Age Cultural diversity Age REACTION FEEDBACK Figure 1-5 The verbal communication feedback loop. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING C. D. E. F. G. H. I. Answers: B. B-2 E-5 H-4 A-5 D-3 G-6 C-1 F-2 I-3 Figure 1-6 Nonverbal facial cues. Can you match the sketches with the correct affects? (1) happy, (2) sad, (3) surprise, (4) fear, (5) anger, (6) disgust. A. 13 individuals from other countries, the phlebotomist should be aware of cultural differences and avoid clichés and nonverbal cues that could be misunderstood; he or she should practice active listening to what has been said. Active Listening True communication is not just about speaking. It is more difﬁcult to communicate than just to speak, because effective communication requires that the listener participate. It is always a two-way process. The ordinary person can absorb verbal messages at about 500 to 600 words per minute, and the average speaking rate is only 125 to 150 words per minute. Therefore, to avoid distraction, the listener must use the extra time for active listening. Active listening means taking positive steps through feedback to ensure that the listener is interpreting what the speaker is saying exactly as the speaker intended. Listening is the foundation of good interpersonal communication. The phlebotomist will ﬁnd that listening carefully to what is being said is particularly valuable in building rapport with patients. Nonverbal Communication It has been stated that 80% of language is unspoken. Unlike verbal communication, formed from words that are one-dimensional, nonverbal communication is multidimensional and involves the following elements. Kinesics The study of nonverbal communication is also called kinesics; it includes characteristics of body motion and language such as facial expression, gestures, and eye contact. Figure 1-6 illustrates an exaggerated and simpliﬁed form of the six emotions that are most easily read by nonverbal facial cues. Body language, which most often is conveyed unintentionally, plays a major role in communication because it is continuous and more reliable than verbal communication. In fact, if the verbal and nonverbal messages do not match, it is called a kinesic slip. When this happens, people tend to trust what they see rather than what they hear. As health professionals, phlebotomists can learn much about patients’ feelings by observing nonverbal communication, which seldom lies. The patient’s face often tells the health professional what the patient will not reveal verbally. For instance, when a patient is anxious, nonverbal signs may include tight eyebrows, an intense frown, narrowed eyes, or a downcast mouth (Fig. 1-6). Researchers have found that certain facial appearances, such as a smile, are universal expressions of emotion. Worldwide, we all recognize the meaning of a smile; however, strong cultural customs often dictate when it is used. 14 UNIT I: THE HEALTHCARE SETTING TABLE 1-2 Territorial Zones and Corresponding Radii Territorial Zone Zone Radius Intimate 1 to 18 inches Personal 1½ to 4 feet Social 4 to 12 feet Public More than 12 feet KEY POINT To communicate effectively with someone, it is important to establish good eye contact. A patient or client may be made to feel unimportant and more like an object rather than a human being if eye contact is not established. Proxemics Proxemics is the study of an individual’s concept and use of space. This subtle but powerful part of nonverbal communication plays a major role in patient relations. Every individual is surrounded by an invisible “bubble” of personal territory in which he or she feels most comfortable. The size of the bubble or territorial “zone of comfort” depends on the individual’s needs at the time. Four categories of naturally occurring territorial zones and the radius of each are listed in Table 1-2. These zones are very obvious in human interaction. It is often necessary, in the healthcare setting, to enter personal or intimate zones; if this is not carefully handled, the patient may feel threatened, insecure, or out of control. Appearance Most healthcare facilities have dress codes because it is understood that appearance makes a statement. The impression the phlebotomist makes as he or she approaches the patient sets the stage for future interaction. The right image portrays a trustworthy professional. A phlebotomist’s physical appearance should communicate cleanliness and conﬁdence. Lab coats, when worn, should completely cover the clothing underneath and should be clean and pressed. Shoes should be conservative and polished. Close attention should be paid to personal hygiene. Bathing and deodorant use should be a daily routine. Strong perfumes or colognes should be avoided. Hair and nails should be clean and natural-looking. Long hair must be pulled back and ﬁngernails kept short for safety’s sake. In addition, according to current CDC hand hygiene guidelines, healthcare workers with direct patient contact cannot wear artiﬁcial nails or extenders. KEY POINT Phlebotomists will ﬁnd that when dealing with patients who are ill or irritable, a conﬁdent and professional appearance will be most helpful to them in doing their job. Touch Touching can take a variety of forms and convey many different meanings. For example, accidental touching may happen in a crowded elevator. Social touching takes place when a person grabs the arm of another while giving advice. Today, therapeutic touch that is designed to aid in healing has found a new place in medical practice. This special type of nonverbal communication is very important to the well-being of human beings and even more so to those suffering from dis-ease. Because medicine is a contact profession, touching privileges are granted to and expected of healthcare workers under certain circumstances. Whether a patient or healthcare provider is comfortable with touching is based on his or her cultural background. Because touch is a necessary part of the phlebotomy procedure, it is important for the phlebotomist to realize that, patients are often much more aware of your touch than you are of theirs; there may even be a risk of the patient questioning the appropriateness of touching. Generally speaking, patients respond favorably when touch conveys a thoughtful expression of caring. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING 15 Effective Communication in Healthcare It is not easy for the patient or the health professional to face disease and suffering every day. For many patients, being ill is a fearful and even terrifying experience; having blood drawn only contributes to their anxiety. Patients reach out for comfort and reassurance through conversation. Consequently, the phlebotomist must understand the unusual aspects of healthcare communication and its importance in comforting the patient. Communication between the health professional and patient is more complicated than normal interaction. Not only is it often emotionally charged, but it also involves, in many instances, other people who are close to the patient and who may tend to be critical of the way the patient is handled. Recognizing the elements in healthcare communication—such as empathy, control, trust, and conﬁrmation—will help the phlebotomist to interact with the patient successfully. Elements in Healthcare Communication Empathy Deﬁned as identifying with the feelings or thoughts of another person, empathy is an essential factor in interpersonal relations. It involves putting yourself in the place of another and attempting to feel like that person. Thoughtful and sensitive people generally have a high degree of empathy. Empathic health professionals help patients handle the stress of being in a healthcare institution. A health professional who recognizes the needs of the patient and allows the patient to express his or her emotions helps to validate the patient’s feelings and gives the patient a very necessary sense of control. Control Feeling in control is essential to an individual’s sense of well-being. People like to think that they can inﬂuence the way things happen in their lives. An important element relating to communication in the healthcare setting is recognizing fear in patients, which stems from a perceived lack of control. A hospital is one of the few places where individuals give up control over most of the personal tasks they normally perform. Many patients perceive themselves as unable to cope physically or mentally with events in a hospital because they feel fearful and powerless owing to this loss of control. Consequently, the typical response of the patient is to act angry, which characterizes him or her as a “bad patient,” or to act extremely dependent and agreeable, which characterizes him or her as a “good patient.” If a patient refuses to have blood drawn, the phlebotomist should allow that statement of control to be expressed and even agree with the patient. Patients who are allowed to assert that right will often change their minds and agree to the procedure because then it is their decision. Sharing control with the patient may be difﬁcult and often time-consuming, but awareness of the patient’s need is important. Respect and Conﬁrmation Respect is shown in both a positive feeling for a person and in speciﬁc action demonstrating that positive feeling. It is an attitude that conveys an understanding of the importance of that person as an individual. Believing that all people are worthy of respect at some level is extremely important in healthcare communication. The effect of honoring and respecting the person as a unique individual is conﬁrmation of the patient’s presence and needs. If a healthcare worker shows disrespect for a patient, it cannot help but be noticed by the patient and may affect the patient’s condition in a negative way. Too often, busy healthcare workers resort to labeling patients when communicating with coworkers and even with patients themselves. They may say, for example, “Oh, you’re the one with no veins” or “You’re the bleeder, right?” Such communication is dehumanizing and is a subtle way of “disconﬁrming” patients. A conﬁrming exchange with the patient in the ﬁrst example could be, “Mrs. Jones, I seem to remember that we had a hard time ﬁnding a suitable vein last time we drew your blood.” Or, in the second case, “Mr. Smith, wasn’t there a problem getting the site to stop bleeding after the draw last time?” 16 UNIT I: THE HEALTHCARE SETTING Trust Another variable in the process of communication is trust. Trust, as deﬁned in the healthcare setting, is the unquestioning belief by the patient that health professionals are performing their job responsibilities as well as they possibly can. As is true with most professionals, healthcare providers tend to emphasize their technical expertise while sometimes completely ignoring the elements of interpersonal communication that are essential in a trusting relationship with the patient. Having blood drawn is just one of the situations in which the consumer must trust the health professional. Developing trust takes time, and phlebotomists spend very little time with each patient. Consequently, during this limited interaction, the phlebotomist must do everything possible to win the patient’s conﬁdence by consistently appearing knowledgeable, honest, and sincere. In summary, by recognizing the elements of empathy, control, trust, respect, and conﬁrmation, the phlebotomist can enhance communication with patients and assist in their recovery. Understanding these communication elements will help when they are used with other means of communication, such as using the telephone. Telephone Communication At present, the telephone is a fundamental part of communication. It is used 24 hours a day in the laboratory. To phlebotomists or laboratory clerks, it becomes just another source of stress, bringing additional work and uninvited demands on their time. The constant ringing and interruption of the workﬂow often cause laboratory personnel to overlook the effect their style of telephone communication has on the caller. To maintain a professional image, every person given the responsibility of answering the phone should review proper protocol. Each one should be taught how to answer, put someone on hold, and transfer calls properly. To promote good communication, proper telephone etiquette (see Table 1-3) should be followed. The Healthcare Setting Virtually everyone in the United States becomes a healthcare consumer at some time. For many, working through the bureaucracy involved in receiving healthcare can be confusing. Healthcare personnel who understand how healthcare is organized and ﬁnanced and their role in the system can help consumers negotiate the system successfully, with minimal repetition of services and consequently at lower cost. HEALTHCARE DELIVERY Two general categories of facilities, inpatient (nonambulatory) and outpatient (ambulatory), support all three (primary, secondary, and tertiary) levels of healthcare currently offered in the United States. See Box 1-3 for a listing of services and practitioners associated with the two categories. Ambulatory Care and Homebound Services Changes in healthcare practices that have signiﬁcantly decreased the amount of time a patient spends in the hospital have led to innovative ways to provide healthcare, including a wide range of ambulatory services deﬁned as medical care delivered on an outpatient basis. These services meet the needs of patients who may still require nursing care, lab tests, or other follow-up procedures after discharge from the hospital. Ambulatory care is generally classiﬁed into two types: (a) freestanding medical care settings and hospital-owned clinics and (b) outpatient departments and urgent care facilities. In recent times, outpatient demands have fallen heavily on hospital emergency departments, which is a very costly way of delivering care and distracts the staff from true emergencies. New ambulatory health services are being developed for the fastest-growing segment of the population—the elderly. Many homebound elderly require nursing care and physical therapy to be given and specimens for laboratory tests to be collected where they reside, either in their homes or in long-term care facilities. A number of agencies employ nurses, respiratory therapists, phlebotomists, and other healthcare workers to provide these services. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING TABLE 1-3 17 Proper Telephone Etiquette Proper Etiquette Communication Tips Rationale Answer promptly. If the phone is allowed to ring too many times, the caller may assume that the people working in the laboratory are inefﬁcient or insensitive. State your name and department. The caller has a right to know to whom he or she is speaking. Be helpful. Ask how you can be of help When a phone rings, it is because someone needs to the caller and facilitate the something. Because of the nature of the healthcare conversation. business, the caller may be emotional and may beneﬁt Keep your statements and answers from hearing calm, pleasant voice at the other end. simple and to the point so as to avoid confusion. Prioritize calls. Inform a caller whose call is interrupting It takes an organized person to coordinate several calls. one from someone else. The caller should be informed if he or she is interrupting Always ask permission before putting another call. a caller on hold in case it is an emergency that must be handled immediately. Transfer and put Tell a caller when you are going to on hold properly. transfer the call or put it on hold and learn how to do this properly. Note: Do not leave the line open, and do not keep the caller waiting too long. Disconnecting callers while transferring or putting them on hold irritates them. Leaving the line open so that other conversations can be heard by the person on hold is discourteous and can compromise conﬁdentiality. Check back with the caller when on hold for longer than expected; this keeps him or her informed of the circumstance. If a caller is waiting on hold too long, ask if he or she would like to leave a message. Be prepared to record information. Have a pencil and paper close to the phone. Listen carefully, which means clarifying, restating, and summarizing the information received. Documentation is necessary when answering the phone at work to ensure that accurate information is transmitted to the necessary person. Reading back the information when complete is one of the best ways to ensure it is correct. Know the laboratory’s policies. Make answers consistent by learning the laboratory’s policies. People who answer the telephone must know the laboratory policies to avoid giving the wrong information. Consistent answers help establish the laboratory’s credibility, because a caller’s perception of the lab involves more than just accurate test results. Defuse hostile situations. When a caller is hostile, you might say “I can see why you are upset. Let me see what I can do.” Some callers become angry because of lost results or errors in billing. Validating a hostile caller’s feelings will often defuse the situation. After the caller has calmed down, the issue can be addressed. Try to assist everyone. If you are uncertain, refer the caller to someone who can address the caller’s issue. Remind yourself to keep your attention on one person at a time. It is possible to assist callers and show concern even if you are not actually answering their questions. Validate callers’ requests by giving a response that tells them something can be done. Sincere interest in the caller will enhance communication and contribute to the good reputation of the laboratory. 18 UNIT I: THE HEALTHCARE SETTING BOX 1-3 TWO CATEGORIES OF HEALTHCARE FACILITIES Outpatient Inpatient Principal source of healthcare services for most people. Offer routine care in physician’s ofﬁce to specialized care in a freestanding ambulatory setting. Serve primary care physicians who assume ongoing responsibility for maintaining patients’ health. Serve secondary care physicians (specialists) who perform routine surgery, emergency treatments, therapeutic radiology, and so on in same-day service centers. The key resource and center of the American healthcare system. Offer specialized instrumentation and technology to assist in unusual diagnoses and treatments. Serve tertiary care (highly complex services and therapy) practitioners. Usually requires that patients stay overnight or longer. Examples are acute care hospitals, nursing homes, extended care facilities, hospices, and rehabilitation centers. Public Health Service One of the principal units under the Department of Health and Human Services (HHS) is the Public Health Service (PHS). Its mission is to promote the protection and advancement of the nation’s physical and mental health. It does so by sponsoring and administering programs for the development of health resources, prevention and control of diseases, and dealing with drug abuse. PHS agencies at the local or state level offer defense against infectious diseases that might spread among the populace. These agencies are constantly monitoring, screening, protecting, and educating the public (see Table 1-4 for examples of services provided by local health departments). Public health departments provide their services for little or no charge to the entire population of a region, with no distinction between rich or poor, simple or sophisticated, interested or disinterested. Public health facilities offer ambulatory care services through clinics, much like those in hospital outpatient areas, military bases, and Veterans Administration and Indian Health Service facilities. As the country moves into managed care, integration between primary prevention and primary/ambulatory care is necessary. Because containment of healthcare costs is the driving force behind managed care and major changes to healthcare coverage, proactive public health programs are increasing as a way to signiﬁcantly reduce overall healthcare costs. HEALTHCARE FINANCING Healthcare is expensive, and the cost continues to escalate. Paying for healthcare services involves multiple payers and numerous mechanisms of payment. The consumer must make choices based on ﬁnancial considerations as well as medical need and can no longer afford to be passive in the process. The healthcare provider, such as the phlebotomist, in addition to being a consumer, is also an employee of an institution that relies on third-party payers (health insurers) for a major portion of its income. Third-Party Payers Payment methods used may be either direct or indirect. Payments to the provider by the patient are referred to as direct pay, self-pay, or out-of-pocket pay. Indirect pay involves a TABLE 1-4 Examples of Services Provided by Local Health Departments Vital statistics collection Tuberculosis screening Health education Immunization and vaccination Cancer, hypertension, and diabetes screening Operation of health centers Public health nursing services Venereal disease clinics CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING TABLE 1-5 19 Methods of Payment and Diagnosis Coding Method of Payment Abbreviation Description Prospective payment system PPS Begun in 1983 to limit and standardize the Medicare/Medicaid payments made to hospitals Diagnosis-related groups DRGs Originally designed by the American Hospital Association, hospitals are reimbursed a set amount for each patient procedure using established disease categories Ambulatory patient classiﬁcation APC A classiﬁcation system implemented in 2000 for determining payment to hospitals for outpatient service Diagnosis Codes Abbreviation Description International Classiﬁcation of Diseases, 9th rev., Clinical Modiﬁcation ICD-9-CM For coding of diagnoses. In the past, all major payers used this coding system, which groups together similar diseases and operations for reimbursement. International Classiﬁcation of Diseases, 10th rev., Clinical Modiﬁcation ICD-10-CM For coding of diagnoses; contains more codes and covers more content than ICD-9 International Classiﬁcation of Diseases, 10th rev., Procedural Coding System ICD-10-PSC For coding of diagnoses; more adequately represents services provided in an inpatient hospital setting. It is a much broader range of codes with room for expansion and greater speciﬁcity. third party. A third-party payer can be an insurance company, the federal government, a managed care program, or a self-insured company that pays for healthcare services on behalf of its employees. Some healthcare providers are even beginning to contract directly with the employers to provide healthcare, thus eliminating insurance carriers. Third-party payers have greatly influenced the direction of medicine. In the past decade, major changes have come about in healthcare payments and third-party reimbursements. Table 1-5 shows methods of payment and coding that have been used to standardize healthcare expenses. Diagnosis and Billing Codes Managed care systems face major challenges in remaining ﬁscally strong in the coming years. For that reason, it is imperative that all services be billed correctly and as quickly as possible. But with the advent of new technologies and electronic transfer of data, billing has become even more challenging. The lack of standardization and confusion in the diagnostic and procedural coding led to the passage in 1996 of HIPAA. This bill was designed to improve the efﬁciency of the healthcare system by establishing standards for electronic data exchange, including coding systems. The goal of HIPAA regulations is to move to one universal procedural coding system as the future standard. The Center for Medicare and Medicaid Services (CMS) contracted with 3M Health Information Systems to develop the Procedural Coding System (PCS) to replace the list of procedure codes found in ICD-9-CM. It is called International Classiﬁcation of Diseases–Tenth Revision, Procedural Coding System, or ICD-10-PCS. It contains nearly 198,000 procedure codes. The current procedural terminology (CPT) codes were originally developed in the 1960s by the American Medical Association to provide a terminology and coding system for physician billing. Physicians’ ofﬁces have continued to use it to report their services. Now all types of healthcare providers use CPT to classify, report, and bill for a variety of healthcare services. In 2013, ICD-10-PCS procedure codes will be available for use in inpatient settings and CPT procedure codes will continue to be used for patients seen in ambulatory settings and for professional services in inpatient settings. Reimbursement The history of institutional reimbursement is tied to entitlement programs such as Medicare and public welfare in the form of Medicaid. Before 1983, hospitals were paid retrospectively and reimbursed for all services performed on Medicare and Medicaid patients. A comparison of Medicare and Medicaid Programs is listed in Box 1-4. 20 UNIT I: THE HEALTHCARE SETTING BOX 1-4 MEDICARE AND MEDICAID PROGRAM COMPARISON Medicare First enacted in 1965. Federally funded program for providing healthcare to persons over the age of 65, regardless of their ﬁnancial status, and to the disabled. An entitlement program because it is a right earned by individuals through employment. Financed through Social Security payroll deductions and copayments. Beneﬁts divided into two categories; Part A, called hospital services, and Part B, called supplementary medical insurance (SMI), which is optional. Medicaid First enacted in 1965. Federal and state program that provides medical assistance for low-income Americans. No entitlement feature; recipients must prove their eligibility. Funds come from federal grants and state and local governments and are administered by the state. Beneﬁts cover inpatient care, outpatient and diagnostic services, skilled nursing facilities, and home health and physician services. Arizona is the only state that has devised its own system outside of Medicaid, called the Arizona Health Care Cost Containment System (AHCCCS). It differs in that the providers (private physician groups) must bid annually for contracts to serve this population and patients are able to choose their healthcare provider through annual open enrollment. THE CHANGING HEALTHCARE SYSTEM Healthcare systems are currently undergoing major revisions. The driving force behind these changes is the perceived need to control costs. Government social programs and other managed healthcare plans continually negotiate discounts on the amount they will reimburse healthcare facilities, forcing the facilities to cut costs and downsize operations. It has become the goal of all healthcare organizations to deliver high-quality, cost-effective care in the most appropriate setting or, in other words, strictly through the management of care. Managed Care Managed care is a generic term for a payment system that attempts to manage cost, quality, and access to healthcare by: Detecting illnesses or risk factors early in the disease process Putting into practice various ﬁnancial incentives for providers Offering patient education Encouraging healthy lifestyles Most managed care systems do not provide healthcare to enrollees; instead, they enter into contracts with healthcare facilities, physicians, and other healthcare providers who supply medical services to the enrollees/clients in the plan. Beneﬁts or payments paid to the provider are made according to a set fee schedule, and enrollees must comply with managed care policies such as preauthorization for certain medical procedures and approved referral to specialists for claims to be paid. Because the association of provider, payer, and consumer is the foundation of managed care systems, several concepts have been developed to control this relationship, including gatekeepers and large services networks. Case Management One of the most important concepts in managed care is that of the designated case manager (primary care physician , gatekeeper), whose responsibility it is to coordinate all of a patient’s CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING 21 healthcare. The case manager is an experienced healthcare professional, not necessarily a physician, who knows the patient’s condition and needs and where available resources for support and treatment can be found. As the patient’s advocate, this person has the responsibility to advise the patient on healthcare needs and coordinate responses to those needs. The case manager’s responsibilities also include providing early detection and treatment for disease, which can reduce the total cost of care. Network Service Systems Today’s large managed care organizations (MCOs) evolved from prepaid healthcare plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). HMOs are group practices reimbursed on a prepaid, negotiated, and discounted basis of admission. PPOs are independent groups of physicians or hospitals that offer services to employers at discounted rates in exchange for a steady supply of patients. MCOs contract with local providers to establish a complete network of services. Providers are reimbursed on the basis of the number of enrollees served—not on the number of services delivered. The goal of the MCO is to reduce the total cost of care while maintaining patient satisfaction, and this can best be done if the patient can get the right care from the right provider at the right time. To accomplish this, integrated healthcare delivery systems (IDSs) have been developed. An IDS is a healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services from prebirth to death. Some of the institutions through which the services are offered along this continuum of care are acute care hospitals, subacute care facilities, ambulatory surgery centers, physician ofﬁce practices, outpatient clinics, and skilled nursing facilities (SNFs). This approach provides more cost-effective care than that of an array of separate healthcare organizations. The focus of an IDS arrangement is holistic, coordinated care rather than fragmented care performed by many medical specialists. Medical Specialties In managed care, the primary physician is most often a family practitioner, pediatrician, or internist. As a manager of a person’s care, he or she is expected to refer to the appropriate specialist as needed. Some of the many healthcare areas in which a doctor of medicine (MD) or doctor of osteopathy (DO) can specialize are listed in Table 1-6. ORGANIZATION OF HOSPITAL SERVICES Hospitals are often large organizations with a complex internal structure required to provide acute care to patients who need it. Actually the term hospital can be applied to any healthcare facility that has these four main characteristics: Permanent inpatient beds 24-hour nursing service Therapeutic and diagnostic services Organized medical staff The healthcare delivery system in hospitals has traditionally been arranged by departments or medical specialties. People who do similar tasks are grouped into departments, the goal being to perform each task as efﬁciently and accurately as possible. The following ﬂowsheet of organizational structure (Fig. 1-7) illustrates the formal roles and relationships within a hospital. The ranks in the lines of authority are structured so that functions and services are clustered under similar areas with an executive, such as a vice president, administering each area. This grouping allows for efﬁcient management of the departments and a clear understanding of the chain of command. The physicians practicing at the hospital have been granted clinical privileges (i.e., permission to provide patient care at that facility) by a hospital governing board. Many other members of the medical team are not actual employees of the facility. However, many hospitals do directly employ radiologists, critical care specialists, and hospitalists (a relatively new position). The hospitalist is a general physician who assumes the care (admission and ongoing treatment) of inpatients in the place of a primary care physician. 22 UNIT I: THE HEALTHCARE SETTING TABLE 1-6 Medical Specialties Specialty Area of Interest Specialist Title Anesthesiology Partial or complete loss of sensation, usually by injection or inhalation Anesthesiologist Cardiology Diseases of the heart and blood vessels and cardiovascular surgery, a subspecialty of internal medicine Cardiologist Dermatology Diseases and injuries of the skin; more recently, concerned with skin cancer prevention Dermatologist Endocrinology Disorders of the endocrine glands, such as, sterility, diabetes, and thyroid problems Endocrinologist Family medicine Individual and family care by integrating biological, behavioral, and clinical sciences for treatment General or family practitioner Gastroenterology Digestive tract and related structural diseases, a subspecialty of internal medicine Gastroenterologist Gerontology Effects of aging and age-related disorders Gerontologist Hematology Disorders of the blood and blood-forming organs Hematologist Infectious Diseases Contagious and noncontagious infections caused by pathogenic microorganisms ID Specialist Internal medicine Diseases of internal organs and general medical conditions; uses nonsurgical therapy Internist Nephrology Diseases related to the structure and function of the kidney Nephrologist Neurology Disorders of the brain, spinal cord, and nerves Neurologist Obstetrics and gynecology Sees women through pregnancy, childbirth, disorders of the reproductive system, and menopause Gynecologist Oncology Tumors, including benign and malignant conditions Oncologist Ophthalmology Eye examinations, eye diseases, and surgery Ophthalmologist Orthopedics Disorders of the musculoskeletal system, including preventing disorders and restoring function Orthopedist Otorhinolaryngology Disorders of the eye, ear, nose, and throat Otorhinolaryngologist Pediatrics Diseases of children from birth to adolescence, including wellness checks and vaccinations Pediatrician Psychiatry Mental illness, clinical depression, and other behavioral and emotional disorders Psychiatrist Pulmonary medicine Function of the lungs; treatment of disorders of the respiratory system Pulmonologist Rheumatology Rheumatic diseases (acute and chronic conditions characterized by inﬂammation and joint disease) Rheumatologist Urology Urinary tract disease and disorders of the male reproductive system Urologist Managed care has led to a reduction in the number of healthcare personnel, whereas the number of services remains the same. This has resulted in the formation of teams of crosstrained personnel and the consolidation of services. Such reengineering, as it is called, is designed to make the healthcare delivery system more process-oriented by combining related groups of tasks into a system that is customer-focused. This management of process is reﬂected in a new type of hospital organization that blends former distinct departments into service or process areas. The intent is to create a “gentle handoff” for patients between service areas instead of the abrupt “toss and catch” approach, which can occur in traditional settings with distinct and separate departments. Although the lines between former departments are becoming blurred, Table 1-7 shows the services areas that are identiﬁed as essential. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING 23 BOARD OF DIRECTORS CHIEF OF MEDICAL STAFF PRESIDENT AND CEO Sr. Director Performance Excellence Case Management Patient Representative Infection Control Performance Improvement VP Clinical & Support Services Director Laboratory Director Medical Imaging Director Pulmonary/ Respiratory & Endoscopy Services Director Cardiovascular Services VP/Chief Nursing Officer VP Community Development Director Women’s & Children’s Services Director Volunteers Director Pediatrics & NICU Interim Director Foundation Interim Director ICU/Tele Retail Services Gift Shop, ATM, Coffee Shop, Sandwich Shop, Florist Director Perioperative Services VP & Chief Medical Officer Director Planning Administrator Physician Services Medical Director Trauma Manager Medical Staff Services Director Emergency & Trauma Services Director Pharmacy Director Guest Services Director Physical Medicine & Rehab Director Education & Workforce Development Director Medical Surgical Services/ Dialysis Services Interim Manager Patient Access Services Hospital Supervisors Figure 1-7 An example of a hospital organizational chart. CLINICAL LABORATORY SERVICES Clinical laboratory (lab) services perform tests on patient specimens. Results of testing are primarily used by physicians to conﬁrm health or aid in the diagnosis, evaluation, and monitoring of patient medical conditions. Clinical labs are typically located in hospitals, outpatient clinics, physicians’ ofﬁces, and large reference laboratories. Traditional Laboratories There are two major divisions in the clinical laboratory, the clinical analysis area and the anatomical and surgical pathology area. All laboratory testing is associated with one of these two areas (see Box 1-5). Laboratories in large hospitals have organizational structures similar to the facility organizational chart based on management structure or hierarchy. People who do similar tasks are grouped into departments, the goal being to perform each task as efﬁciently and accurately as possible. Match laboratory departments with laboratory tests in the Matching 1-4 Activity in the WORKBOOK. Clinical Analysis Areas Hematology The hematology department performs laboratory tests that identify diseases associated with blood and the blood-forming tissues. The most commonly ordered hematology test is the complete blood count (CBC). The CBC is performed using automated instruments, such as the Coulter counter (Fig. 1-8), that electronically count the cells and calculate results. A CBC is actually a multipart assay reported on a form called a hemogram (Tables 1-8 and 1-9). Coagulation Coagulation is the study of the ability of blood to form and dissolve clots. Coagulation tests are closely related to hematology tests and are used to discover, identify, and monitor defects in the 24 UNIT I: THE HEALTHCARE SETTING TABLE 1-7 Essential Service Areas of a Hospital Service Area Departments Within Area Services Performed Patient care services Nursing care Direct patient care. Includes careful observation to assess conditions, administering medications and treatments prescribed by a physician, evaluation of patient care, and documentation in the health record that reﬂects this. Staffed by many types of nursing personnel including registered nurses (RNs), licensed practical nurses (LPNs), and certiﬁed nursing assistants (CNAs). Around-the-clock service designed to handle medical emergencies that call for immediate assessment and management of injured or acutely ill patients. Staffed by specialists such as emergency medical technicians (EMTs) and MDs who specialize in emergency medicine. Designed for increased bedside care of patients in fragile condition. Found in many areas of the hospital and named for the type of patient care they provide (e.g., trauma ICU, pediatric ICU, medical ICU). Concerned with operative procedures to correct deformities and defects, repair injuries, and cure certain diseases. All work is performed by licensed medical practitioners who specialize in surgery. Emergency services Intensive care units (ICUs) Surgery Support services Central supply Dietary services Environmental services Health information technology Professional services Cardiodiagnostics (EKG or ECG) Pathology and clinical laboratory Electroneurodiagnostic technology (ENT) or electroencephalography (EEG) Professional services Occupational therapy (OT) Pharmacy Physical therapy (PT) Respiratory therapy (RT) Diagnostic radiology services Prepares and dispenses all the necessary supplies required for patient care, including surgical packs for the operating room, intravenous pumps, bandages, syringes, and other inventory controlled by computer for close accounting. Selects foods and supervises food services to coordinate diet with medical treatment. Includes housekeeping and groundskeepers whose services maintain a clean, healthy, and attractive facility. Maintains accurate and orderly records for inpatient medical history, test results and reports, and treatment plans and notes from doctors and nurses to be used for insurance claims, legal actions, and utilization reviews. Performs electrocardiograms (EKGs/ECGs, or actual recordings of the electrical currents detectable from the heart), Holter monitoring, and stress testing for diagnosis and monitoring of therapy in cardiovascular patients. Performs highly automated and often complicated testing on blood and other body ﬂuids to detect and diagnose disease, monitor treatments, and, more recently, assess health. There are several specialized areas of the laboratory called departments or clinical laboratory areas (see Box 1-5). Performs electroencephalograms (EEGs), tracings that measure electrical activity of the brain. Uses techniques such as ambulatory EEG monitoring, evoked potentials, polysomnography (sleep studies), and brain-wave mapping to diagnose and monitor neurophysiological disorders. Uses techniques designed to develop or assist mentally, physically, or emotionally disabled patients to maintain daily living skills. Prepares and dispenses drugs ordered by physicians; advises the medical staff on selection and harmful side effects of drugs, therapeutic drug monitoring, and drug use evaluation. Diagnoses physical impairment to determine the extent of disability and provides therapy to restore mobility through individually designed treatment plans. Diagnoses, treats, and manages patients’ lung deﬁciencies (e.g., analyzes arterial blood gases [ABGs], tests lung capacity, administers oxygen therapy). Diagnoses medical conditions by taking x-ray ﬁlms of various parts of the body. Uses latest procedures, including powerful forms of imaging, that do not involve radiation hazards, such as ultrasound machines, magnetic resonance (MR) scanners, and positron emission tomography (PET) scanners. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING BOX 1-5 25 TWO MAJOR DIVISIONS IN THE CLINICAL LABORATORY Clinical Analysis Areas Specimen processing, hematology, chemistry, microbiology, blood bank/ immunohematology, immunology/ serology, and urinalysis Anatomical and Surgical Pathology Tissue analysis, cytologic examination, surgical biopsy, frozen sections, and performance of autopsies Figure 1-8 A medical technologist checks CBC results on the Coulter LH780 automated hematology analyzer. TABLE 1-8 Hemogram for Complete Blood Count (CBC) Assay Name of Test Abbreviation Examples of Clinical Signiﬁcance Hematocrit Hct Values correspond to the red cell count and hemoglobin level; when decreased, indicate anemic conditions. Hemoglobin Hgb Decreased values indicate anemic conditions; values normally differ with age, sex, altitude, and hydration. Red blood cell count RBC count Measure of erythropoietic activity; decreases in numbers are related to anemic conditions. White blood cell count WBC count Abnormal leukocyte response indicative of various conditions, such as infections and malignancies; when accompanied by low WBCs, differential test becomes more speciﬁc. Platelet count Plt Ct Decreased numbers are indicative of hemorrhagic diseases; values may be used to monitor chemotherapy or radiation treatments. Differential white count Diff Changes in the appearance or number of speciﬁc cell types signify speciﬁc disease conditions; values are also used to monitor chemotherapy or radiation treatments. Indices Changes in RBC size, weight, and Hgb content indicate certain types of anemias. Mean corpuscular hemoglobin MCH Reveals the weight of the hemoglobin in the cell, regardless of size. Decreased hemoglobin content is indicative of iron-deﬁciency anemia, increased hemoglobin content is found in macrocytic anemia. Mean corpuscular volume MCV Reveals the size of the cell. Decreased MCV is associated with thalassemia and iron-deﬁciency anemia; increased MCV suggests folic acid or vitamin B12 deﬁciency and chronic emphysema. Mean corpuscular hemoglobin concentration MCHC Reveals the hemoglobin concentration per unit volume of RBCs. Below-normal range means that RBCs are deﬁcient in hemoglobin, as in thalassemia, overhydration, or iron-deﬁciency anemia; above-normal range is seen in severe burns, prolonged dehydration, and hereditary spherocytosis. Red blood cell distribution width RDW Reveals the size differences of the RBCs. An early predictor of anemia before other signs and symptoms appear. 26 UNIT I: THE HEALTHCARE SETTING TABLE 1-9 Other Common Hematology Tests Test Examples of Clinical Signiﬁcance Bone marrow Detects abnormal blood cells and evaluates blood cell formation and function. Cerebrospinal (CSF) and other body ﬂuids Presence or absence, number and type of cells. Hematocrit on ﬂuid indirectly measures ﬂuid volume. Eosinophil count Increased numbers in direct count indicate parasitic infections and allergies. Erythrocyte sedimentation rate (ESR) Increased rate at which red blood cells settle out is indicative of inﬂammatory conditions or necrosis of tissue. Lupus erythematosus (LE cells) Presence of typical LE cells is diagnostic of systemic LE. Osmotic fragility Increased red cell fragility is indicative of hemolytic and autoimmune anemias; decreased fragility is indicative of sickle cell disease and thalassemia. Reticulocyte (retic) count Increased number of retics in circulating blood attest to bone marrow hyperactivity. Sickle cell screen Sickling of red cells indicates presence of Hgb S, an abnormal hemoglobin variant. blood-clotting mechanism. They are also used to monitor patients who are taking medications called anticoagulants (chemicals that inhibit blood clotting) or “blood thinners.” The two most common coagulation tests are the prothrombin time, used to monitor warfarin therapy, and the activated partial thromboplastin time, for evaluating heparin therapy (Table 1-10). Chemistry The chemistry department performs most laboratory tests. This department often has subsections such as toxicology and radioimmunoassay. Computerized instruments (Fig. 1-9) used in this area are capable of performing discrete (individualized) tests or metabolic panels (multiple tests) from a single sample. Examples of panels frequently ordered to evaluate a single organ or speciﬁc body system are given in Table 1-11. The most common chemistry specimen is serum; however, other types of specimens tested include plasma, whole blood, urine, and various other body ﬂuids. Examples of tests normally performed in the automated clinical laboratory section are provided in Table 1-12. Serology or Immunology The term serology means the study of serum. Serology tests deal with the body’s response to the presence of bacterial, viral, fungal, or parasitic diseases stimulating antigen–antibody reactions that can easily be demonstrated in the laboratory (Table 1-13). Autoimmune reactions, in which autoantibodies produced by B lymphocytes attack normal cells, are becoming more prevalent and can be detected by serologic tests. Testing is done by enzyme immunoassay (EIA), agglutination, complement ﬁxation, or precipitation to determine the antibody or antigen present and to assess its concentration or titer. TABLE 1-10 Common Coagulation Tests Test Examples of Clinical Signiﬁcance Activated partial thromboplastin time (APPT) Prolonged times may indicate stage 1 defects; values reﬂect adequacy of heparin therapy. D-dimer Evaluates thrombin and plasmin activity and is very useful in testing for disseminated intravascular coagulation (DIC); also used in monitoring thrombolytic therapy. Fibrin split products (FSP) High levels result in FDP fragments that interfere with platelet function and clotting. Fibrinogen Fibrinogen deﬁciency suggests hemorrhagic disorders and is used most frequently in obstetrics. Prothrombin time (PT) or International normalized ratio (INR) Prolonged times may indicate stage 2 and 3 defects; values are used to monitor warfarin therapy and to evaluate liver disease and vitamin K deﬁciency. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING 27 Figure 1-9 A clinical chemist reviews stat chemistry results from Dade Behring’s Dimension® Xpand Plus Basic automated chemistry analyzer. Urinalysis The urinalysis (UA) department may be housed in the hematology or chemistry area or may be a completely separate section. Urine specimens may be analyzed manually or using automated instruments (Fig. 1-10). UA is a routine urine test that includes physical, chemical, and microscopic evaluations (Table 1-14). The physical examination assesses the color, clarity, and speciﬁc gravity of the specimen. The chemical evaluation, performed using chemical reagent strips, screens for substances such as sugar and protein and can be read by hand, visually, or with a urine analyzer. A microscopic examination establishes the presence or absence of blood cells, bacteria, crystals, and other substances. Microbiology The microbiology department analyzes body ﬂuids and tissues for the presence of microorganisms, primarily by means of culture and sensitivity (C&S) testing (Fig. 1-11). Results of a C&S tell the physician the type of organisms present and the particular antibiotics that would be most effective for treatment. It is very important to collect, transport, and handle microbiology specimens properly in order to determine the presence of microorganisms and identify them appropriately. An instrument used only for blood cultures makes it easy to identify and review the specimens for microbial growth, as shown in Figure 1-12. Subsections of microbiology are bacteriology (the study of bacteria), parasitology (the study of parasites), mycology (the study of fungi), and virology (the study of viruses) (Table 1-15). Blood Bank or Immunohematology The blood bank or immunohematology department of the laboratory prepares blood products to be used for patient transfusions. Blood components dispensed include whole blood, platelets, packed cells, fresh frozen plasma, and cryoprecipitates. Blood samples from all donors and the TABLE 1-11 Disease- and Organ-Speciﬁc Chemistry Panels (CMS-Approved) Panel Grouping Battery of Selected Diagnostic Tests Basic metabolic panel (BMP) Glucose, BUN, creatinine, sodium, potassium, chloride, CO2, calcium Comprehensive metabolic panel (CMP) Glucose, BUN, creatinine, sodium, potassium, chloride, CO2, AST, ALT, alkaline phosphatase total protein, albumin, total bilirubin, calcium Hepatic function panel A AST, ALT, alkaline phosphatase, total protein, albumin, total bilirubin, direct bilirubin Renal function panel Glucose, BUN, creatinine, sodium, potassium, chloride, CO2, calcium, albumin, phosphorus ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CO2, carbon dioxide. 28 UNIT I: THE HEALTHCARE SETTING TABLE 1-12 Common Chemistry Tests Test Associated Body System Examples of Clinical Signiﬁcance Alanine aminotransferase (ALT) Liver Marked elevations point to liver disease; used for monitoring liver treatment. Alpha-fetoprotein (AFP) Liver Increased values in hepatic carcinoma; elevation of AFP in prenatal screening indicates neural tube disorder. Alkaline phosphatase (ALP) Liver or bone Elevated ALP levels because of biliary obstruction and bone disease. Ammonia Liver Increased blood levels indicate cirrhosis and hepatitis. Amylase Pancreas and liver Increased levels of this enzyme diagnostic of acute pancreatitis; decreased values associated with liver disease, cholecystitis, and advanced cystic ﬁbrosis. Aspartate aminotransferase (AST) Liver or heart Increase in enzyme indicative of liver dysfunction; signiﬁcant increase following myocardial infarction. Bilirubin Liver Increased levels in the bloodstream point to red cell destruction and liver dysfunction. Blood gases (ABG) Kidneys, lungs Measures pH, partial pressure of carbon dioxide (PCO2), and partial pressure of oxygen (PO2) to evaluate the acid–base balance. Blood urea nitrogen (BUN) Kidney Elevated values because of impaired renal function from toxins, inﬂammation, or obstruction B-type natriuretic peptide (BNP) Heart A cardiac marker. Brain natriuretic peptide increases in response to ventricular systolic and diastolic dysfunction and is diagnostic of congestive heart failure. C-reactive protein High sensitivity (hs-CRP) Heart A cardiac marker. Detects low level of CRP for assessment of risk for developing myocardial infarction when acute coronary symptoms are present. Carcinoembryonic antigen (CEA) Nonspeciﬁc Increased in the cases of malignancy, effective for the early detection of colorectal cancer. Calcium Bone Increased levels associated with diseases of the bone; used in monitoring effects of renal failure. Cholesterol (total) Heart Indicative of high risk for cardiovascular disease. Cortisol Adrenals Elevated levels signify adrenal hyperfunction (Cushing syndrome); decreased levels indicate adrenal hypofunction (Addison’s disease). Creatine kinase (CK) Heart or muscle Elevated values point to muscle damage (i.e., myocardial infarction, muscular dystrophy, or strenuous exercise). Creatinine Kidney Increased levels indicate renal impairment; decreased levels associated with muscular dystrophy. Drug analysis Values monitored to maintain therapeutic range and avoid toxic levels for drugs such as barbiturates, digoxin, gentamicin, lithium, primidone, phenytoin, salicylates, theophylline, or tobramycin. Electrolytes (sodium, potassium, chloride, CO2) Kidney, adrenals, heart Sodium values, increased in disorders of the kidney and adrenals; decreased values of potassium seen in irregular heartbeat; chloride values are increased in kidney and adrenal disorders and decreased in diarrhea. Glucose Pancreas Elevated levels signify diabetic problems; decreased values support liver disease and malnutrition. Gamma-glutamyl transferase (GGT) Liver Elevated values assist in the diagnosis of liver problems speciﬁc for hepatobiliary problems. Hemoglobin A1C Pancreas Glycohemoglobin level shows what type of diabetic control has occurred over the past several months. (continued) CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING TABLE 1-12 29 Common Chemistry Tests (Continued) Associated Body System Test Lactate dehydrogenase (LD) Examples of Clinical Signiﬁcance Increased lung, kidney, and liver dysfunction. Lipase Pancreas Increased levels in acute pancreatitis, pancreatic carcinoma, and obstruction. Prostate speciﬁc antigen (PSA) Prostate Performed to screen patients for the presence of prostate cancer, monitor progression of disease and the response of the patient to treatment. Total protein Liver or kidney Low levels point to liver and kidney disorders; elevated levels may occur with multiple myeloma and dehydration. Triglycerides Heart Increased values indicate lipid metabolism disorders and serve as an index for evaluating the possibility of atherosclerosis. Troponin-I Heart Serves a cardiac marker. Used in early diagnosis of small myocardial infarcts that are not detectable by conventional diagnostic methods. Uric acid Kidney Elevated values found in renal disorders and gout. Vitamin B12 and folate Liver Decreased levels indicate anemias and disease of the small intestine. recipient must be carefully tested before transfusions can be administered so that incompatibility and transfusion reactions can be avoided (Table 1-16). Transfusion services offered by the blood bank department collect, prepare, and store units of blood from donors or patients who wish to donate their own units for autologous transfusion should that be needed. Anatomical and Surgical Pathology Histology Histology is deﬁned as the study of the microscopic structure of tissues. In this department, pathologists evaluate samples of tissue from surgeries and autopsies under a microscope to determine if they are normal or pathological (diseased). Histological techniques include two TABLE 1-13 Common Serology and Immunology Tests Test Examples of Clinical Signiﬁcance Bacterial Studies Antinuclear antibody (ANA) Antistreptolysin O (ASO) titer Cold agglutinins Febrile agglutinins FTA-ABS Rapid plasma reagin (RPR) Rheumatoid factor (RF) Positive results indicate autoimmune disorders, speciﬁcally systemic lupus erythematosus Can demonstrate streptococcal infection Present in cases of atypical pneumonia Presence of antibodies to speciﬁc organisms indicates disease condition (i.e., tularemia) Fluorescent treponemal antibody absorption test, conﬁrmatory test for syphilis Positive screen indicates syphilis; positives must be conﬁrmed Presence of antibody indicates rheumatoid arthritis Viral Studies Anti-HIV Cytomegalovirus antibody (CMV) Epstein–Barr virus (EBV) Hepatitis B surface antigen (HBsAg) Human immunodeﬁciency virus is screened Conﬁrmation test Presence of this heterophil antibody indicates infectious mononucleosis Demonstrates the presence of hepatitis antigen on the surface of the red cells General Studies C-reactive protein (CRP) Human chorionic gonadotropin (HCG) Increased levels in inﬂammatory conditions Present in pregnancy (serum and urine) 30 UNIT I: THE HEALTHCARE SETTING Figure 1-10 A Siemens Clinitek Advantus Analyzer urine strip reader. of the most common diagnostic techniques found in the laboratory: (1) biopsy, obtaining samples by removal of a plug (small piece) of tissue from an organ and examining it microscopically, and (2) frozen section, obtaining tissue from surgery and freezing it, then examining it immediately to determine whether more extensive surgery is needed. Before tissues can be evaluated, they must be processed and stained. This is the role of a person called a histologist. Cytology Cytology and histology are often confused. Whereas histology tests are concerned with the structure of tissue, cytology tests are concerned with the structure of cells. In this department, TABLE 1-14 Common Urinalysis Tests Test Examples of Clinical Signiﬁcance Physical Evaluation Color Clarity Speciﬁc gravity Abnormal colors that are clinically signiﬁcant result from blood melanin, bilirubin, or urobilin in the sample Turbidity may be the result of chyle, fat, bacteria, RBCs, WBCs, or precipitated crystals Variation in this indicator of dissolved solids in the urine is normal; inconsistencies suggest renal tubular involvement or ADH deﬁciency Chemical Evaluation Blood Bilirubin Glucose Ketones Leukocyte esterase pH Protein Nitrite Urobilinogen Microscopic Evaluation Hematuria may be the result of hemorrhage, infection, or trauma Aids in differentiating obstructive jaundice from hemolytic jaundice, which will not cause increased bilirubin in the urine Glucosuria could be the result of diabetes mellitus, renal impairment, or ingestion of a large amount of carbohydrates Elevated ketones occur in uncontrolled diabetes mellitus and starvation Certain white cells (neutrophils) in abundance indicate urinary tract infection Variations in pH indicate changes in acid–base balance, which is normal; loss of ability to vary pH is indicative of tissue breakdown Proteinuria is an indicator of renal disorder, such as injury and renal tube dysfunction Positive result suggests bacterial infection but is signiﬁcant only on ﬁrst-morning specimen or urine incubated in bladder for at least 4 hours Occurs in increased amounts when patient has hepatic problems or hemolytic disorders Analysis of urinary sediment reveals status of the urinary tract, hematuria, or pyuria; the presence of casts and tissue cells is a pathologic indicator CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING Figure 1-11 A microbiologist prepares to review antibiotic sensitivities from the Siemens Micro Scan Walk Away 96 Plus. Figure 1-12 A microbiologist reviews blood cultures processed by the BactALERT 3D microbiology system. TABLE 1-15 Common Microbiology Tests Test Examples of Clinical Signiﬁcance Acid-fast bacilli (AFB) Positive stain means pulmonary tuberculosis; used to monitor the treatment of TB Blood culture Positive culture results (bacterial growth in media) indicate bacteremia or septicemia CLOtest Presence of Helicobacter pylori Culture and sensitivity (C&S) Growth of a pathogenic microorganism indicates infection (culture); in vitro inhibition by an antibiotic (sensitivity) allows the physician to select the correct treatment Fungus culture and identiﬁcation Positive culture detects the presence of fungi and determines the type. Gram stain Positive stain for speciﬁc types of pathogenic microorganisms permits antimicrobial therapy to begin before culture results are known Occult blood Positive test indicates blood in the stool, which is associated with gastrointestinal bleeding from carcinoma. Ova and parasites Microscopic examination of stool sample showing ova and parasites solves many “etiology unknown” intestinal disorders. 31 32 UNIT I: THE HEALTHCARE SETTING TABLE 1-16 Common Blood Bank and Immunohematology Tests Test Examples of Clinical Signiﬁcance Antibody (Ab) screen Agglutination indicates abnormal antibodies present in patient’s blood Direct antihuman globulin test (DAT) Positive results point to autoimmune hemolytic anemia, hemolytic disease of the newborn (HDN), and transfusion incompability Type and Rh Determines blood group (ABO) and type (Rh) by identifying agglutinins present or absent Type and crossmatch Determines blood group and serves as a general screen for antibodies of recipent’s blood; then recipient and donor blood are checked against each other for compatibility Compatibility testing Detection of unsuspected antibodies and antigens in recipient’s and donor’s blood, which could cause a severe reaction if transfused cells in body tissues and ﬂuids are identiﬁed, counted, and studied to diagnose malignant and premalignant conditions. Histologists often process and prepare the specimens for evaluation by a pathologist or cytotechnologist. The Pap smear, a test for early detection of cancer cells, primarily of the cervix and vagina, is one of the most common examinations performed by this department. The Pap test is named after Dr. George N. Papanicolaou, who developed a staining technique used to detect malignant cells. Cytogenetics An area found in larger labs is cytogenetics. In this section, samples are examined for chromosomal deﬁciencies that relate to genetic disease. Specimens used for chromosomal studies include tissue, blood, and amniotic ﬂuid. The DNA histogram is the latest such test for genetic and malignant disorders. DNA ﬁngerprinting and molecular genotyping have become the prevalent form of scientiﬁc testing in forensic medicine. Stat Labs In today’s healthcare environment, laboratory services in some tertiary care facilities have had to set up STAT labs in the emergency department (ED), also known as the emergency room (ER). STAT means “immediately.” Ideally, procedures and tests performed in the ED are those needed to respond to medical emergencies, such as the urinalysis as shown in Figure 1-13. Because the American Hospital Association (AHA) along with the medical profession have committed to saving lives by saving time in the ED, diagnostic laboratory tests must be available on site. For example, both the American College of Cardiology (ACC) and the AHA are working to reduce the time between a heart attack patient’s arrival and his or her treatment with percutaneous coronary intervention (PCI). The campaign is called “door-to-balloon time” (D2B) and is designed to get the patient from the ED to the cardiac catheterization (cath) lab within 90 minutes. Reference Laboratories Reference laboratories are large independent laboratories that receive specimens from many different facilities located in the same city, other cities in the same state, or even cities that are out of state. They provide routine and more specialized analysis of blood, urine, tissue, and other patient specimens. These laboratories offer fast turnaround times (TATs) and reduced costs because of the high volume of tests they perform. Specimens sent to off-site laboratories must be carefully packaged in special containers designed to protect the specimens and meet federal safety regulations for the transportation of human specimens. CHAPTER 1: PAST AND PRESENT AND THE HEALTHCARE SETTING 33 Figure 1-13 A medical technologist performs a complete urinalysis in the ER. CLINICAL LABORATORY PERSONNEL Laboratory Director/Pathologist The pathologist is a physician who specializes in diagnosing disease, through the use of laboratory tests results, in tissues removed at operations and from postmortem examinations. It is his or her duty to direct laboratory services so they that beneﬁt both the physician and patient. The laboratory director may be a pathologist or a clinical laboratory scientist with a doctorate. The laboratory director and the laboratory administrator share responsibilities for managing the laboratory. Laboratory Administrator/Laboratory Manager The lab administrator is usually a technologist with an advanced degree and several years of experience. Duties of the administrator include overseeing all operations involving physician and patient services. Today, the laboratory administrator may supervise several ancillary services, such as radiology and respiratory therapy, or all the laboratory functions in a healthcare system consisting of separate lab facilities across a large geographic area. Technical Supervisor For each laboratory section or subsection, there is a technical supervisor who is responsible for the administration of the area and who reports to the laboratory administrator. This person usually has additional education and experience in one or more of the clinical laboratory areas. Medical Technologist/Medical Laboratory Scientist The medical technologist (MT) or medical laboratory scientist (MLS) generally has a bachelor’s (BS) degree plus additional studies and experience in the clinical laboratory setting. Some states require licensing for this level of personnel. The responsibilities of the MT/MLS include performing all levels of testing in any area of the laboratory, reporting results, performing quality control, evaluating new procedures, and conducting preventive maintenance and troubleshooting on instruments. Effective October 23, 2009, the ASCP Board of Registry and the National Certiﬁcation Agency for Clinical Laboratory Personnel (NCA) was uniﬁed into a single certifying agency. All individuals with an active NCA credential were transitioned over to the ASCP Board of Certiﬁcation (BOC) without further requirements until recertiﬁcation is due. All CLS (NCA) certiﬁcants who had an active credential with NCA were transferred to the BOC as MLS (ASCP). 34 UNIT I: THE HEALTHCARE SETTING Medical Laboratory Technician The medical laboratory technician (MLT) is most often an individual with an associate degree from a 2-year program or certiﬁcation from a military or proprietary (private) school. As with the MT/MLS, some states may require licensing for medical laboratory technicians. The technician is responsible for performing routine testing, operating all equipment, performing basic instrument maintenance, recognizing instrument problems, and assisting in problem solving. All CLT (NCA) certiﬁcants who had an active credential with NCA on October 23, 2009, were transferred to the BOC as MLT (ASCP). Clinical Laboratory Assistant Before the arrival of computerized instrumentation in the laboratory, the clinical laboratory assistant (CLA) was a recognized position. Today, because of reductions in laboratory staff, this category of personnel has been revived. A clinical laboratory assistant is a person with phlebotomy experience who has skills in specimen processing and basic laboratory testing. Clinical laboratory assistants are generalists, responsible for assisting the MLS or MLT with workloads in any area. Phlebotomist The phlebotomist is t

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