Monitoring of critical laboratory results to improve quality of patient care in a large urban clinic In Uganda

Objectives
Follow-up of critical laboratory results can present a challenge in resource limited settings due to high patient volumes, overstretched human resources and no systematic communication from the laboratory. An audit conducted in 2013 in a large outpatient HIV-center revealed that <50% of critical results were acted upon within 24 hours. Our objective is to describe the impact of the new developed guidelines on reducing mortality of patients with critical results.
Methods
Results must be immediately communicated by the laboratory to a physician via an “on-call phone”; patients should be contacted and asked to return to the clinic. In addition all critical laboratory results were reviewed and tagged by Quality Management staff. Design: retrospective survey of all files of patients who had in 2014 at least one of the following: Hb <5.5g/dl, creatinine >3.4mg/dl, positive serum Cryptococcus-Antigen (Crag). Clinician’s actions were categorized and described. Turnaround time was determined and incidence of mortality between 2013 and 2014 compared.
Results
During 2014, 5,907 patients had any laboratory test done. Hb <5.5g/dl: 36(0.6%) patients. Action taken: blood transfusion 17/36 (47%), heamatinics14/36(39%) and 2/36(6%) dewormed. Creatinine >3.4mg/dl: 64/3291(1.9%) patients. Action taken: antiretroviral treatment regimen switched 43/64(67%), 2/64(3%) stopped, 12/64(19%) referral to the renal unit. Positive serum-Crag 17/464(3.7%). Action taken: 12/17(71%) started on fluconazole, 5/17(29%) were already on treatment. Turnaround time for Hb and serum crag was <1 day, creatinine 13.3 days. From 2013 and 2014 the mortality decreased in patients with Hb<5.5g/dl from 27.9 to 2.8%, with creatinine>3.4mg/dl from 32.9 to 3.1% and with positive serum-Crag from 36.4 to 23.5%.
Conclusions
Critical results monitoring system greatly improves patient turnaround time, and reduces mortality through timely communication and patients follow up. We believe our system could serve as a role model for similar programs in Sub-Saharan Africa to improve quality of care.