Coagulation studies: achieving the right mix in a large laboratory network

Coagulation testing is a routine part of hospital diagnostics, with APTT, PT, and INR being among the most frequently ordered tests. These tests help assess a patient’s clotting ability and are essential for managing anticoagulant therapy. However, unexpected abnormal results can complicate clinical interpretation and require follow-up actions. Prior research has shown that manual handling of such cases can lead to inefficiencies in laboratory workflows. While it is known that most abnormal coagulation results are expected by clinicians, the frequency of clinically significant unexpected findings remains unclear. This gap motivated the design of a system to automate second-line testing and streamline follow-up procedures. No prior work had resolved how to balance automation with clinical oversight in coagulation testing. The need for a system that reduces manual intervention while ensuring patient safety remains a challenge in hospital laboratory settings.

This study aimed to evaluate the impact of an automated system for handling unexpected abnormal coagulation results in a large hospital laboratory network. The primary goal was to improve workflow efficiency while maintaining patient safety. The system was designed to trigger second-line coagulation tests automatically when specific conditions were met. These included abnormal PT or APTT results without reported anticoagulant use. The researchers sought to determine whether this system could reduce the number of cases requiring manual review without compromising clinical outcomes. The study also aimed to assess how often unexpected abnormal results led to changes in medical management. By implementing electronic rules and automated testing, the team hoped to reduce delays in reporting and improve overall laboratory performance. The study focused on whether this system could be safely applied across a large laboratory network without increasing the risk of missed diagnoses.

The study implemented a new electronic system in a hospital laboratory network that mandated clinicians to report anticoagulant use when ordering coagulation tests. When PT or APTT results were abnormal and no anticoagulant was reported, the system automatically triggered second-line tests. These included mixing studies, fibrinogen levels, and thrombin time. Any sample with abnormal second-line results was flagged for review by a haematology registrar. The system was evaluated over a 17-month period. Data were collected on the number of coagulation tests performed, the frequency of abnormal results, and the number of cases referred for clinical review. The electronic system was integrated into the hospital’s existing laboratory information system. The researchers tracked how many cases required manual intervention and how often medical management was altered as a result of the haematology registrar’s review. The system was designed to minimize unnecessary follow-up while ensuring clinically significant cases were not overlooked.

Over 17 months, 362,692 coagulation tests were performed, including APTT, PT/INR, and fibrinogen. Of these, 14,160 (3.9%) were abnormal and either had no reported anticoagulant or an unknown anticoagulant status. A total of 934 (0.3%) of these cases were referred for review by the haematology registrar. Only three (<0.001%) of the referred cases resulted in changes to medical management. The majority of abnormal results were not clinically significant and did not require further action. The automated system successfully identified cases that required follow-up without increasing the number of unnecessary reviews. The system reduced the need for manual intervention in the laboratory workflow. The electronic rules ensured that only cases with abnormal second-line test results were flagged for review. The study demonstrated that the system could handle a large volume of tests efficiently while maintaining patient safety.

The study found that most unexpected abnormal coagulation results do not require clinical intervention. The automated system successfully streamlined laboratory workflow without compromising patient safety. The electronic rules ensured that only clinically significant cases were flagged for review. The system reduced the number of unnecessary follow-up actions in the laboratory. The haematology registrar’s review was rarely needed and had minimal impact on medical management. The study supports the use of automated second-line testing in large hospital laboratory networks. The findings suggest that such systems can improve efficiency without increasing the risk of missed diagnoses. The authors propose that implementing similar systems in other hospital settings could lead to improved workflow and better use of clinical resources.