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Editor's note: In March of 2007, the University of Iowa Hospitals and Clinics (UIHC) converted its state-of-the-art core lab to NT-proBNP. UIHC had been an early adopter of BNP in 2000. Advances in clinical utility and application of natriuretic peptides spurred Ronald Feld, MD, director of Clinical Chemistry, to further investigate the increased benefits NT-proBNP might provide UIHC cardiologists, their patients and the hospital's core lab.
The following roundtable is a continued discussion that began in the June issue. Participants include Dr. Feld; Andrew Nugent, MD, specialist in Emergency Medicine at UIHC; Sue Zaleski, laboratory manager, Department of Pathology; John Kemp, MD, director of Laboratories; Patricia Riley, assistant clinical director of the Heart and Vascular Center; and Jeff Kulhavy, lead scientist, Automation Laboratory.
The reality of change always presents numerous challenges, yet there were clear benefits to be derived from the change. What did you have to overcome to actually get to implementation?
Dr. Feld: We had to do some education. We had to explain to clinicians what the new assay was and what the benefits were to them. Roche was very helpful in bringing in experts to talk to the cardiologists. And, there was a lot of literature that we could cite to support our case. You have to make it a win/win. We already knew it was a win from the laboratory point of view, but we had to demonstrate to the clinicians there would be benefits for them and the laboratory. Once we did that, it went smoothly.
Discuss how you educated clinicians and gained their consensus.
Dr. Feld: Sometimes clinicians take the lead and request the new test from the lab. But often the laboratory has to take the lead and alert clinicians that a new test is available. That's what happened with Troponin; it was the laboratory that introduced Troponin to our clinicians. It's always a partnership between the lab and our clinicians. You must keep the communication lines open to ensure clinicians and the laboratory are always talking about the latest test available.
How did you neutralize some of the challenges relating to actual clinician uptake of the test?
Kulhavy: We offered both assays so people could re-baseline. Laying the groundwork and talking to clinicians is always a long process. It took us just over nine months.
Dr. Nugent: In the ER, it was as simple as changing the order on the IPR and using the new test. If Dr. Feld tells us it's a better test, we go with it.
Can you speak to end goals in terms of improved outcomes, improved mortality rates?
Dr. Feld: If you look in the literature, the assays were somewhat comparable in terms of the clinical information they were going to provide the clinician. For the laboratory, NT-proBNP was a definite plus. As I said, we automated a manual assay, we got an assay with much better information and that was much more stable in terms of being able to add it on to samples. So for us, it was an assay that we could draw from our main tube. There were numerous benefits for us-financial, clinical, etc. Clinicians are getting better, more precise information; precision is important in being able to tell the difference between two numbers. Consider the same test, separated by time. Are those numbers different or are they the same? An assay that has a 10 percent imprecision versus a 1 or a 2 percent imprecision is better in terms of saying, "Yes, I really believe this is going up or this is going down."
Any impact on the ED department?
Dr. Nugent: We're always looking for yes/no answers in the ER. When BNP first came out, it was actually kind of comical because you would get a number like 3,000 and weren't sure what to do with it. We used to call the cardiologist and say, "The BNP is 3,000," and they'd say, "Okay, we'll admit them and try to figure out what that means." Now, we get a reference range that comes with the NT-proBNP based on aging. I think it's very useful.
What about the nursing end?
Riley: From the conversion standpoint, it was hard for us to get used to because that reference range changed. But again, it helps clinicians decide whether to admit the patient. Because our nursing team takes calls, we can monitor these numbers. We can have the patient come in, have the blood drawn, watch it and evaluate what's going on. It really helped streamline the care delivery we can provide to our patients.
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