WISCONSIN STATE LABORATORY OF HYGIENE - UNIVERSITY OF WISCONSIN

Interactive Training Webinar for Newborn Screening

Specimen Collection

Patrice Held, PhDCo-Director, Wisconsin Newborn Screening and Biochemical Genetics Laboratory

Assistant Professor, Dept of Pediatrics, University of Wisconsin-Madison

August 2014 Survey was sent to all NBS submitters to highlight concerns with specimen collection process

September 2014 Workgroup of DHS, NBS laboratory, Hospital representatives (5) met to review survey responses and

identify/prioritize issues related to specimen collection

October 2014 The same workgroup of DHS, NBS laboratory, and Hospital representatives (5) met to

brainstorm/identify/prioritize way to improve specimen collection

Frequent issues identified by submitters Lack of a consistent site-specific process Lack of instructional materials Lack of training No visual inspection before shipping specimens Using capillary tubes Blood Clotting within circles on the specimen card

QI Project:Reducing unsatisfactory specimen submission

2.77%

2.19%2.32%

2.13%

1.79%

1.62% 1.62%

1.94%1.80%

2.04%

2.53%

1.89%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Perc

enta

ge o

f Uns

atis

fact

ory

Spec

imen

s

Unsatisfactory Specimen Collection

2014Average:

2013 = 2.6%2014 = 2.0%

Reasons for Unsatisfactory Specimens2014

BLOOD CLOTS 38.4%

INCOMPLETE SATURATION (HIGH

HEMATOCRIT)16.6%

FILTER PAPER DAMAGED

(CAPILLARY)13.0%

INCOMPLETE SATURATION

11.8%

LAYERED SPECIMEN6.7%

SMEARED OR DISCOLORED BLOOD

3.4%

BLOOD ON TAN COVER

3.2%

PLASMA SEPARATED FROM RBCs

2.8%RECEIVED >7 DAYS AFTER COLLECTION

0.8%

Action Items

We were awarded federal funding through the Centers for Disease Control and Prevention to

design a web-based training module for specimen collection

This project was 100% funded with federal funds from a federal program of $16,500. This project was supported by Cooperative Agreement #U60HM000803 funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not

necessarily represent the official views of CDC or the Department of Health and Human Services.National Center for Immunization and Respiratory Diseases (IP)

Office of Surveillance, Epidemiology and Laboratory Services (OSELS)National Center for HIV, Viral Hepatitis, STDs and TB Prevention (PS)National Center for Zoonotic, Vector-borne, and Enteric Diseases (CK)

National Center for Environmental Health (NCEH)Coordinating Office for Terrorism Preparedness and Emergency Response (CTPER)

Wisconsin Newborn Screening Program

Basics on newborn screening specimen collection and submission

Helping babies get started on the right foot

www.slh.wisc.edu/moodle

Released in April 2015

Learning Objectives

Illustrate proper blood specimen collection

Outline the precise steps to take after blood collection

In the event of an unsatisfactory specimen, explain the necessary steps for specimen recollection

Describe quality assurance activities a submitter must utilize to ensure the collection process is performed correctly and consistently on all babies

Webinar Format

The training covered in this webinar is specific to the process for blood collection and submission

This webinar is approximately 60 minutes long and includes:Pre- and Post-tests

Family StoryTraining module

Webinar EvaluationAvailable for PACE credit

Demographic Information

N=676, 9 months after release

180

321

5

132

0

38

0

50

100

150

200

250

300

350

Phlebotomist Nurse Midwife Laboratorian Physician Other

Which of the following best describes your job/title?

Demographic Information

N=676, 9 months after release

465

117

31 32

105

38

0

50

100

150

200

250

300

350

400

450

500

Collect Specimenand Complete Card

Information

Only CollectionSpecimen

Only CompleteCard Information

Supervisor Package Specimens Other

What is your role in the NBS specimen collection process?

Overall Quiz Results

Mean=6.2 Mean=8.2

P value <0.0001

The whiskers represent the min and max value scored by any one learner. The box represents the 25th and 75th

percentile.

Pre-Te

st

Post-T

est

0

5

10

15S

core

s(1

0 po

ssib

le p

oint

s)

N=676, 9 months after release

2.5%

2.2%

2.0%

2.1%

1.4%

1.0%

1.2%

1.4%

1.3%1.3% 1.4% 1.4%

2.8%

2.2%2.3%

2.1%

1.8%

1.6% 1.6%

1.9%1.8%

2.0%

2.5%

1.9%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Un

sats

fact

ory

Sp

ecim

en R

ate

2015

2014

Unsatisfactory Specimen Collection

April 20, 2015 distribution of webinarAugust 15, 2015 distribution of postersAverage:

2013 = 2.6%2014 = 2.0%2015 = 1.6%

PACE Creditcontinuing education

During the 9 month period from release of the webinar, 409 out of 676 total learners (60.5%) obtained PACE credit after viewing the webinar.

Evaluationrelevance of material

396 total respondents to survey

EvaluationDelivery of Content

396 total respondents to survey

EvaluationDo you intend to use this webinar for training?

8 (8%)

11 (10%)

82 (81%)

No

NA

Yes

“This is the second facility I have worked in within the state of Wisconsin in 22 years. This is the first time I have actually been trained. Most information I learned by fellow workers training me but some information I was taught was incorrect. Thank you.”

• 58% are already using webinar for staff training• 8% indicated that they will use it for yearly

competency assessments

“This link has been forwarded to all laboratorystaff involved with the collection process andwill be the subject of discussion at the nextlaboratory staff meeting.”

YES

NO

NA

EvaluationDo you have any suggestions for future versions of this webinar?

46 (46%)

9 (8%)

46 (46%)

No

NA

Yes

52% pace was too slow 21% would prefer video (not slides) of collection14% would like to see other webinars

• Specimen collection in premature infants• Hearing Screening• Heart Screening

7% requested more personal stories

Yes No

NA

Next Steps Consider creation of additional training

webinars Webinar on collection requirements for pre-

mature, low birth weight, sick newborns• Release on March 1, 2016

Webinar on hearing screening Webinar on heart screening

Develop learning management system to house training webinars

• Release on March 1st, 2016

www.slh.wisc.edu/moodle

Things I have come to learn…

There’s no such thing as perfect or complete…only continuous improvement.

Acknowledgements

Lisa Burley, Burley Consulting Brain Ploeckelman, DoIT, UW-Madison

Jan Klawitter, WSLH Dr. Mei Baker, WSLH

Dr. Charles Brokopp, WSLH

WISCONSIN STATE LABORATORY OF HYGIENE - UNIVERSITY OF WISCONSIN

Helping babies get started on the right foot

Nov 2013

Jan 2014

Mar 2014

Jul 2014

Sep 2014

Mar 2015

Apr 2015

Timeline of Wisconsin’s Quality Improvement Projects

Aug 2014

• Specimens missing key information

• Unsatisfactory Specimens

• Timing of Specimen Collection

• Timing between specimen collection and receipt at the laboratory

Wisconsin Quality Assurance:Monthly Submitter Report

Transit Time: Collection to Receipt

2014

Average:2013 (<=3d) = 87.1%2013 (<=4d) =96.9%

2014 (<=3d) =97.0%2014 (<=4d) =99.5%

94.1%

97.3%97.6%

97.3%

96.4%

98.2%

97.3%97.7%

95.8%

97.8%

97.4%

96.7%

99.0%99.3%

99.8%99.6%

99.4%99.8%

99.5% 99.6% 99.4%99.8% 99.6% 99.5%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

% o

f Spe

cim

ens

Rec

eive

d

<=3d

<=4d

Specimen Collection (24-48 hours)

84.5%

85.5%

84.1%

88.7%

89.2% 89.3% 89.6% 89.8%90.8%

92.1% 91.6%

92.5%

89.9% 90.1%

91.3%

92.8%92.2%

93.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

% In

itial

Spe

cim

ens

Col

lect

ed 2

4-48

h

24-48h

plus <24h w/ repeat

2014Average:2013 (24-48h) = 83.2%2014 (24-48h) = 89.0%

Newborn Screening Program in Wisconsin

Screening for Hearing

loss

Screening for Critical

Congenital Heart Disease

Screening for 44 different

conditions through a dried

blood spot

Importance of Timing: The Thompson Family

Testing Baseline Knowledge

Quiz Question #1

Order the following list of events within the specimen collection process.

a. Elevated the baby’s heart above the legs and warm the foot with a heating device

b. Clean the selected puncture site with an alcohol wipe

c. Puncture the skind. Wipe away the first drop of bloode. Gently allow droplet of blood to saturate the filter

paper specimen

Quiz Question #2

Indicate the ideal location for puncture site on the baby’s foot:

Quiz Question #3

How large of an incision should the lancet make in on the heel of a full term infant?

a. 1.0 mm deep by 2.5 mm longb. 0.85 mm deep by 1.75 mm longc. 1.5 mm deep by 2.0 mm longd. 2.5 mm deep by 2.5 mm longe. None of the above

Which of the following pieces of information is NOT critical for reporting of the newborn screening results:

a. Birth weightb. Birth date and timec. Collection date and timed. NICU statuse. Mother’s namef. Physicians name and contact informationg. Gestational age

Quiz Question #4

Quiz Question #5

Which of the pictures below represent the most common reason for unsatisfactory specimens?

6.8%7.0%

5.4%

4.9% 4.9%4.6%

4.9%

4.1% 4.1%

4.7%

4.2%4.4%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

% S

peci

men

s R

ecei

ved

Mis

sing

Key

Info

Missing Key Information*

2014Average:2014 = 5.0%

*birth weight, birth date and time, collection date and time, gestational age

6.8%7.0%

5.4%

4.9% 4.9%4.6%

4.9%

4.1% 4.1%

4.7%

4.2%4.4%

5.3% 5.4%5.2%

4.5%4.2% 4.0%

4.2% 4.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

% S

peci

men

s R

ecei

ved

Mis

sing

Key

Info

2014

2015

Missing Key Information*

*birth weight, birth date and time, collection date and time, gestational age

Average:2014 = 5.0%2015 = 4.6%

Specimen Collection (24-48 hours)

2015

93.9%

94.6%

94.9%94.6%

95.7%

95.3%

96.2%

95.8%

94.4%

95.2%

95.5%95.2%

96.2%

95.8%

96.7%

96.4%

92.0%

92.5%

93.0%

93.5%

94.0%

94.5%

95.0%

95.5%

96.0%

96.5%

97.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

% In

itial

Spe

cim

ens

Col

lect

ed 2

4-48

h

24-48h

plus <24h in compliance

Average:2013 (24-48h) = 83.2%2014 (24-48h) = 89.0%2105 (24-48h) = 95.1%

Transit Time: Collection to ReceiptWithin 3 days

96.4%

97.7% 97.7%98.6%

96.5%

98.6%

97.0%97.8%

94.1%

97.3% 97.6% 97.3%96.4%

98.2%97.3% 97.7%

95.8%

97.8%97.4%

96.7%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

% o

f Spe

cim

ens

Rec

eive

d

<=3d (2015)

<=3d (2014)

Average:2013 2014 2015

<=3d 87.1% 97.0% 97.5%<=4d 96.9% 99.5% 99.6%