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Transfusion Medicine Transformation

at Vancouver Coastal Health (VCH)

Heather Mah, Regional Technical Practice Lead VCH Vancouver, Canada

Immucor User Group 2016 Oakland California

Effective Use of Automated Capture® Panels and ImmuLINK™

for Cross-Site Antibody Identification

Province of British Columbia

• 357,000 sq miles

( California 163,700 sq miles)

• 4.5 million pop.

• Six Government funded Health Authorities administer health services

Vancouver Coastal Health

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Vancouver Coastal Health

PRGH

PHC

SMH

RH

VGH

LGH

UBCH

Whistler

SGH

Vancouver Coastal Health

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Service Delivery Model

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Vancouver General Hospital

VGH serves as a hub site for 10 facilities

Lions Gate Hospital

• Average travel time from LGH for urgent

antibody investigation samples is 67

minutes via the Lions Gate Bridge

Richmond Hospital

46,000 T/S annually 7,000 T/S annually

7,000 T/S annually

• More effective automation for large hub site

• Lean workflow

• Scalable automation appropriate for community hospitals

• Centralized data management

• Efficient cross-site antibody identification

VCH TM Transformation Goals 2013/14

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Better Automation at VGH

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• Expanded test menu including testing of AI panels (T/S, ABR1, XM, panels, donor

unit confirm,)

• Large through-put

• Continuous access to load and unload samples and reagents at any time

• Dynamic scheduling - run tests in any order

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LEAN Principles Application VGH

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Original State

LEAN Principles Application VGH

LEAN = Eliminating waste, cycle time reduction for STAT Group and Screen Testing

• Create a value-stream map of the original state

• Develop new workflow to reduce non-value added time

• Redesign bench configuration and analyzers’ placement

• Move NEO®s to new location /Add Echo®

• Measure various parameters to assess benefits.

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LEAN Principles Application VGH

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ECHO

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LEAN Principles Application VGH

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LEAN Principles Application VGH Parameter Original State Renewed State

Total travel distance

433 sq ft 145 sq ft

Employee travel time to check results

1.25 hrs/day 0 hrs/day

TAT for T/S from ER

1 hr 10 min (average for first 8 months)

1 hr 5 min (average since repositioning of NEOs)

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TAT increased at implementation

Scalable Automation

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ECHO® • Efficiency gains at LGH

and RH

• Improved standardization of test set up and reading

• Opportunity to shift some Antibody Identification testing closer to patient

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Centralized Data Management

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ImmuLINK™

ImmuLINK™

• ImmuLINK™ middleware allows web-based review of data from multiple instruments

Centralized Data Management

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ImmuLink

serverSunquest

VNEO1

VNEO2

LECHO1

RECHO

VIMLNK

LIMLNK

RIMLNK

NEO® and Echo®

(Immucor) Analyzers

ImmuLINK™ Implementation Process

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VCH MULTI-SITE TMS ANALYZER IMPLEMENTATION TIMELINEDates: May 1, 2013 to July 31, 2014

List of Activities Days Jul/13 Jan/14 Jul/14

Implementation Processes at VCH

NEO/ECHO Installation and Validation - VGH/LGH 98

ImmuLINK Installation and Setup 49

Sunquest Software Development 63

ImmuLINK and Sunquest Configuration/Testing 49

Document Creation - Operating Procedures 161

Document Creation - Test Scripts 56

NEO and ImmuLINK Training - VGH 56

ECHO and ImmuLINK Training - LGH 119

ImmuLINK Virtualization at KDC 49

Security and Privacy Review Process 133

KDC ImmuLINK Server Installation and Validation 66

ECHO Installation and Validation - RH 28

ECHO and ImmuLINK Training - RH 64

* VGH - Vancouver General Hospital LGH - Lions' Gate Hospital RH - Richmond HospitalRH - Richmond Hospital

VGH/LGH Analyzers & ImmuLINK LIVE

18-Nov-2013

ImmuLINK @ KDC LIVE20-Mar-2014

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3

4

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RH ECHO LIVE15-Jul-2014

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ImmuLINK™ Implementation Challenges

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• ImmuLINK Virtualization – Kamloops Data Center (KDC)

• Lack of redundancy, backup, and support on ImmuLINK server hardware – Initiate plans to virtualize the server to KDC

• Application to HSSBC privacy office for review to fulfill security and privacy concerns

• Re-validation of ImmuLINK™ at KDC

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Effective Use of Automated Capture® Panels and ImmuLINK™

for Cross-Site Antibody Identification

Reagent Panels • Pre-dispensed

• Stable for 120 days from manufacture

• 3 different solid phase panels

• Easy to use on automated platform (automated panels)

• Assay TAT = 27 minutes on Echo

• 69% of investigations can be completed using only these panels

Efficient Antibody Identification

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Automated Panels for AI

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• Antibody investigations – Can be performed using

only automated panels 69% of the time (N=489)

• ImmuLINK™ middleware allows web-based review of data from multiple instruments

ImmuLINK™

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ImmuLink

serverSunquest

VNEO1

VNEO2

LECHO1

RECHO

VIMLNK

LIMLNK

RIMLNK

NEO® and Echo®

(Immucor) Analyzers

ImmuLINK™ - Multiple Sites

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Test site LGH - panel results viewed at VGH

01:35

02:12

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ImmuLINK™ - Multiple Sites

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Report from ImmuLINK™

- Test site LGH (02:12)

- Retrieved & interpreted at

VGH (02:30)

ImmuLINK™ - Multiple Sites

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Report from ImmuLINK™

- Anti-Fya interpretation at VGH (3:20 AM phone report to LGH)

Sample arrives

at VGH 02:45

LEAN Principles Application VCH

LEAN = Eliminating waste, cycle time reduction for STAT Group and Screen Testing

• Create a value-stream map of the original state

• Develop new workflow to reduce non-value added time and incorporate technology enhancement

• Implement new workflow at LGH and VGH

• Measure TAT for urgent antibody investigations for 10 weeks to assess the benefit.

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Cross-Site AI: Original State

Complete Forms

Notify VGH

Package & and

Send out Sample

First Antibody ID Panel by Manual GEL

Secondary Panels

Pheno- typing

Report to LGH

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Start

1 hour

2 hours

3 hours

4 hours

5 hours

Travel time = Waste

Mean TAT for urgent cross-

site antibody investigations

was 4.6 hours. Target TAT is

4 hours.

LGH Activities VGH Activities

New Positive

Antibody Screen

Cross-Site AI: Improved TAT

First Antibody ID

Panel

Notify VGH

Package & and

Send out Sample

First Panel Secondary

Panels - typing

Report to LGH

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Start

1 hour

2 hours

3 hours

4 hours

5 hours

LGH Activities

VGH Activities

New Positive

Antibody Screen

First Panel

Print Immu-LINK

report

First Panel

Exclu-sions

Secondary Panels

Pheno- typing

Report to LGH ImmuLINK™ Report

Change in mean TAT to 3.3 hours from 4.6

hours for original state

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• 34 urgent antibody investigations with cross-site collaboration

• Specificity assigned in 59% of cases as indicated in table

Measure cont’d

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SPSA = pan-reactive, negative DAT, negative PEG

Unidentified = exclusions complete, unexplained

reactions in solid phase and/or PEG

• 38% of the cases had nonspecific reactions (mean TAT for this group 3.1 hours)

• Immucor acknowledged higher rates of equivocal and unexpected results with Capture™ reagents

• Potential impact on patient care and additional resources

• Negates some of the benefits of panels and ImmuLINK™ for cross-site AI.

Measure cont’d

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SPSA = pan-reactive, negative DAT, negative PEG

Unidentified = exclusions complete, unexplained

reactions in solid phase and/or PEG

Conclusions

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Benefit of new workflow and technology was a change in mean TAT to 3.3 hours from 4.6 hours for original state

1st panel results available to VGH via ImmuLINK™ shortly after referral by LGH and before arrival of sample

Opportunities to further decrease TAT by testing with additional Ready-ID® panels at referring sites

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Conclusions

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LGH staff is pleased to have more

involvement in the AI process and

have ability to perform preliminary

analysis of the first panel

VGH staff noted a reduction in

hands-on time and TAT to complete

the investigations

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NEW Positive Antibody

Screen requiring STAT

AI Process

Run Ready-ID on ECHO STAT

Order VAI* Test in

Sunquest

Complete Referral AI

Request Form

Ensure timing of Panel

Completion is recorded

Fax & Phone request for STAT AI to

VGH

Order Additional Samples if

needed

Package Samples for

Sendout

Send out samples via

CAB or COURIER

Print Panel & Screen Report

from ImmuLINK

Perform Exclusions and

Initial Conclusion

If Additional Solid Phase Panels are...

Arrived

NOT Arrived

Contact RH / LGH

to perform panel testing

Receive Call and run

requested panel onto ECHO STAT

Phone VGH when testing

complete

Samples arrive at VGH

PhoneRH / LGH with Final

Results

RH / LGH to order

Phenotyped Units if

required

Crossmatch Units,

Phenotyping as required

Fax & Phone received from

RH / LGH, note time of

Panel Completion

RH

/ L

GH

Pro

cess

VG

H P

roce

ss

Complete AI Process

Not RequiredWait for

Samples to arrive

Required and if Samples

have...

SAMPLES

If Patient still at RH / LGH...

* RH use STAT priority LGH use Urgent priority

Referral Antibody Investigation Flow

• More effective automation for VGH √

• LEAN workflow √

• Scalable automation appropriate for LGH & RH √

• Centralized data management - ImmuLINK™ √

• Efficient cross-site antibody identification √

Transformation Goals Accomplished

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Issue: • Files with multiple Master

Lists (ML) • Each of the 3 sites may

have different Capture-R® Ready-ID® panels in use

• Potential for error when selecting (ML) on which to transcribe results from ImmuLINK™ report

• Time consuming to transcribe results

Working Collaboratively with Immucor

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Proposed ImmuLINK™ enhancements:

1. Panel Identification

• System selects lot number of panel

• ImmuLINK report results print on Master List

2. Algorithm for rule outs

3. Manual panels

• Save and store in data base

• Useful for select cells

Working Collaboratively with Immucor

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Acknowledgements

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Executive Sponsor Richard Walker

Medical Leads Dr. Kate Chipperfield, Dr. Kristine Roland

Technical Supervisor (VGH) Pam Danesin

Project Managers Ellie Sheng (LIS) Heather Mah (Lab)

LIS Steve Arai

Technical Support/Trainer Luca Rizzetto

Technical Support/ImmuLINK Lawrence Sham

LEAN Project Margaret Walsh

K/O – Trainers, Site Champion Pam Danesin, Kate Chan, Shelley Tapp (LGH) Teresa Sharp (RH)

Learning and Ideas All staff!

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Thank you

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Questions?