What to do with a sample if further tests, unasked, are needed?

A few years ago, a patient’s sample sent to my laboratory was flagged by the automated CBC counter as possibly having blast cells. Now the clinician had only asked for a CBC, not for CBC with microscopy, even though laboratory’s form offered both options. What should the lab do in such a case? Should it provide the CBC values, as requested? Or should it also mention the flagged finding of possible blasts (with appropriate interpretation)?

In another example too, the clinician had requested a CBC. The CBC analyzer also generates a graph that provides the red cell distribution. In this case, the graph showed two peaks, indicating the presence of very small cells as well as very large cells: a picture consistent with dimorphic anemia. Since this clinician, too, did not ask for an examination of the blood film, the lab was not expected to comment on the discrepancy in cell volumes. What should the lab do? Should it simply provide the CBC values, or should it conduct a microscopy and provide a complete report?

In a third example, a clinician asked for a CBC with microscopy. On microscopy, the lab found Faggot cells, raising the possibility of promyelocytic anemia. Such a finding would be an indication for molecular studies to confirm the diagnosis, but of course the clinician had not asked for these. The situation is often dire: delay in diagnosis and treatment by a day or two may result in complications and even death. What should the lab do?

In my opinion it should be obligatory for the lab to ensure that if follow up action is required, it should be taken by the lab. The patient’s interests come first. If a delay in diagnosis can materially harm the patient, the delay should be avoided if possible. This obviously raises issues regarding payment, but those are administrative processes that can easily be addressed.

Accreditation bodies should make such follow up action a requirement, and check if systems are in place to see that the patient gets the best possible care.

SK Sood

31 Dec 2017