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Confirmatory testing for UA

  • 1.  Confirmatory testing for UA

    Posted 02-22-2019 23:27

    Hello Everyone!
    In November 2018, Dr. Redwine, the ASCLS Chemistry/Urinalysis SA Chair, posted the following "Question of the Month":  Are tests under the umbrella of "confirmatory tests" relevant or available for urinalysis in today's clinical laboratories?
    At my hospital laboratory, we only run Ictotest to confirm a positive bilirubin.  We stopped the SSA test (use urine TP, UPE, and IFE instead) and the Clinitest (lack of supply) years ago.  We never use the Acetest, or Watson-Schwartz.
    My question is: Do you still teach the principles of these confirmatory tests that most of us don't perform anymore?   Does the ASCP certification exam still ask about them?
    I am teaching UA this semester and am unsure whether to include confirmatory testing.  Please advise.  Thanks.

    Minh


    Minh Kosfeld, PhD, MLT(ASCP)CM
    Investigative and Medical Sciences Program Director
    Assistant Professor
    Department of Clinical Health Sciences
    Doisy College of Health Sciences
    Saint Louis University

    Email: minh.kosfeld@health.slu.edu




  • 2.  RE: Confirmatory testing for UA

    Posted 02-23-2019 14:37

    Excellent questions and timing Dr. Kosfeld, and I hope the SA community will respond. This semester, I am teaching a course called Clinical Microscopy, which covers all the body fluids that require microscopy/cellular counts, and this week I have the lab called "special chemistries." I use the lab to teach the Watson- Schwartz test, SSA for proteins by gradation (1+, 2+, eg.), turbidimetry with spectrophotometry, and the Kingsbury Clark, to be comprehensive. I would love to know the answer to your questions because my students could use the time doing another urine microscopic before moving on to the next body fluid; if they are historical.

    Your last question is the most relevant to me, "Does the ASCP certification exam still ask about them?" That answer will determine what I do in the future, and this week if others respond in time.

    Thanks for the post.

     

    Gerald


  • 3.  RE: Confirmatory testing for UA

    Posted 02-24-2019 07:18
    Hi Gerald - I would like to suggest that whether something is on the cert exam should not be the top priority.  The exam is always behind the times, just because of the way it is constructed.  I say this based on my experience with the National Credentialing Agency (NCA) exam some years back.  The process for developing cert exams is never truly current.  They do a practice analysis, then revise the exam, and by the time the exam goes live, it is a year or more later.  Then the exam based on that practice analysis is live for several years.  It does not stay current during that time. Besides - how many questions could be asked on these items that are concerning you?  Even if your students missed this one question, it would not be a pass/fail issue due to the high reliability of the exam.

    I would like to recommend an article in CLS from Sue Beck and Tara Moon at University of North Carolina.  They published a really nice algorithm for thinking about these curricular decisions in general.

    In short, if the assay demonstrates an important fundamental principle, then you might want to keep it.  If your clinical facilities do the test, then keep it.  If none of the above, then drop it and use the time to hone other skills or for more contemporary content.  Trust your own judgment on what your students need to know rather than trying to teach to the cert exam.  There will be enough overlap that they will pass just fine.  This philosophy served me well for 35 years of teaching.

    Regards, Kathy

    ------------------------------
    [Kathy] [Doig]
    [Leadership Development Committee Chairperson 2018-19]

    [doig@msu.edu]
    ------------------------------



  • 4.  RE: Confirmatory testing for UA

    Posted 02-24-2019 19:17

    Hi Kathy,

    Thank you for this timely feedback. I wanted to reply after reading the article that you referenced but am not able to bring it up at this time. However, I appreciate the advice; so, rather than completing a lab with antiquated testing I think I will discuss them and move on to the more needful microscopic examinations. I think some of my problem with moving on is a certain enjoyment in extracting recipes from old Tietz books to make the required reagents and the testing. I will continue to look for the article to search for other needs for updating labs and lectures that I may have overlooked.
    Thank you for the reference and feedback.


    Gerald




  • 5.  RE: Confirmatory testing for UA

    Posted 03-02-2019 20:04
    Kathy,

    I completely agree with your opinion that teaching to pass a certifying exam shouldn't be a top priority. The purpose of the program should be to instill good, sound, theoretical knowledge in the clinical laboratory students as this will serve them and their patients better in the long run. After all, specific boards/certifications aren't forever (e.g. NCA, HEW), but the need for competent clinical laboratory personnel is here to stay.

    ------------------------------
    Chad C. McMillan, M.Sc. MT/MDxT(AAB)
    Aureus Medical Group
    Groveland FL
    352 348-3354
    ------------------------------



  • 6.  RE: Confirmatory testing for UA

    Posted 03-03-2019 08:42
    Edited by Susan Stalewski 03-03-2019 08:44
    All:
    It's good to see this robust discussion in our community!  I may have missed this in one of the threads but encourage everyone to consult the ASCLS Entry Level Curriculum- reviewed and revised in 2016 and supported by our Body of Knowledge.  UA confirmatory tests are included in the ELC (and we, the Scientific Assemblies and others in ASCLS) intend for the ELC, BOK, ASCP BOC and practice analysis to be in sync with each other (not always perfect).

    ------------------------------
    Susan Stalewski
    Coordinator ASCLS Scientific Assemblies
    Vice Chair ASCLS Body of Knowledge committee

    Director Academic Initiatives and Planning
    University of Wisconsin Milwaukee
    West Milwaukee WI
    (414) 671-1259
    ------------------------------



  • 7.  RE: Confirmatory testing for UA

    Posted 02-25-2019 08:58
    Although retired, I still teach UA/Body Fluids..  I do include the ictotest as confirmatory to a positive bilirubin but I tell the students they can look up the other tests you listed in the event they work in a lab that still performs those tests.  There is too much to include in the MLS curriculum to cover outdated or rarely performed procedures.  If they are still on the BOC exam, so-be-it, eventually they will be removed.

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    Carol McCoy
    Edmond OK
    (405) 340-6765
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  • 8.  RE: Confirmatory testing for UA

    Posted 03-03-2019 01:16
    Not to mention, not all students plan on working in a clinical lab. Some will go into industry, R and D, or advanced degrees (PhD, MD, Pharm D, DCLS,..,.) you name it. I have never taught to the board exam only!

    Pat

    ------------------------------
    Pat Tille Ph.D. MLS(ASCP) FACSc

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  • 9.  RE: Confirmatory testing for UA

    Posted 02-25-2019 08:42
    I still teach about the Ictotest, Acetest, Clinitest and SSA test because I am not certain that these have been removed from the certification exam and they are still included in the 6th edition of Strasinger's Urinalysis textbook which we use.

    ------------------------------
    Adele Marone
    MLS Program Director
    University of New Hampshire
    DURHAM NH
    603-862-1376
    ------------------------------



  • 10.  RE: Confirmatory testing for UA

    STATE PRESIDENT
    Posted 02-26-2019 08:53
    I have attached the newest (in effect 1/1/2019) content guidelines for the MLT and MLS exams. Confirmatory tests are still on the outline and therefore "fair game" for those writing the questions for the certification exams. They are available on the website.

    We do our practice analysis every 5 years and the updates to the content outline are based on that.

    Stacey

    ------------------------------
    Stacey Lyn Robinson
    Chair, Hematology Exam Committee
    staceylynrobinson@gmail.com
    ------------------------------



  • 11.  RE: Confirmatory testing for UA

    Posted 02-26-2019 09:00

    ​As a chemistry tech most of the urinalysis isn't my purview since Heme handles that in our labs, but I would definitely still do the SSA or at least emphasize it when discussing semi-quantitative urine protein because turbidimetric urine total protein assays are still what we use for many quantitative urine total protein methodologies. Be it SSA or benzethonium chloride it is a similar mechanism and it never hurts to reinforce methods they will learn elsewhere.

    In the case of our labs it also serves to demonstrate the interconnectedness of all the disciplines.



    ------------------------------
    Ryan Collison
    Lab Education Specialist
    Cleveland Clinic
    Cleveland OH
    (216) 444-5476
    ------------------------------



  • 12.  RE: Confirmatory testing for UA

    Posted 02-26-2019 10:14

    Thank you, Stacey,

     

    Although I work with the guidelines you sent to me, your response helps me in two ways. ALL of the conversations, in fact, has helped bring me to these conclusions.

    1.       I better see what is causing me concern. The industry indicates one thing, and the exam (understandably) reflects another. So when I came on board replacing Mr. K, one of my Professors, over ten years ago, antiquated tests were and are still on the board exam. I felt obligated to teach them in both lecture and labs. Since hearing all of the responses, I will scale back to mentioning them with the possibility of a level I (recall) question on an exam.

    2.       Your response also offers a more systematic approach to the problem. To date, updates to my curriculum have been ad hoc, but the five-year interval, which coincides with the lifespan of hospital instruments, is a much better idea.

     

    Thank you.

    Gee, just as I am posting, I see Ryan's response, but the better judgment, with mixed feelings, tells me it is time to focus on the more pressing needs in the profession.

    Thanks all.

    Gerald




  • 13.  RE: Confirmatory testing for UA

    Posted 02-27-2019 16:48
    ​Aloha,

    Although the topic is confirmatory testing I believe the larger picture is one of academia versus technical philosophies.

    As a student long ago it was reqd to take calculus, physics, inorg chem, org chem, quant chem, general biochem, cell bio, general bio, micro, A&P, immunology, foreign language, all in add'n to MT courses....  now our University no longer reqs calc, physics, quant chem, cell bio nor foreign language, all the heavy stuff.  Our program has conformed to the economics of our time where technical aspects outweigh academia and the processes behind 'pushing the button.'  Students are less trained to be critical thinkers to understand processes & medicine associated with their work.  It is understandable that this is occurring for why would a student take heavy duty courses to enter a program that pays half that of an RN?  No wonder we have surplus nurses and short on techs.  We made it easier and less academic to lighten the path in an attempt to encourage enrollment.  But alas our MT program still has only 6, 7, 8 students annually.

    As adjunct faculty with students rotating through my lab I see huge gaps in their understanding of processes and linking technical knowledge to the patients they serve.  They've been trained to run tests and pass the boards, not necessarily to understand.

    Sorry to sidetrack but to tie it all in -> I believe we should teach confirmatory testing (appropriate # of time) even if it becomes non-relevant in the workplace simply to teach the concepts and lab history.

    We need to fill the gaps in today's education and become the scientists we should be.

    Dean


    ------------------------------
    Dean Yoshimura
    Laboratory Director
    Waianae Coast Comprehensive Health Center
    Waianae HI
    (808) 697-3648
    ------------------------------



  • 14.  RE: Confirmatory testing for UA

    Posted 02-28-2019 01:27
    With regard to clinical setting versus academia:

    I have 2 core science degrees and understand many of the processes behind the testing. Since working in the lab, I have been told numerous times to not think and just turn out terrible numbers with notes, etc. This rubs me the wrong way on so many levels, but it seems to be the overall mindset in chemistry labs. I understand allowing the doctors to do their jobs, but being asked not to protect patient safely from my perspective seems ludicrous.

    I don't feel it is because I wad not taught or don't understand, I think the current work environment asks us not to think because those driving the decisions don't know and/or trust our expertise.

    ------------------------------
    Jessica Lawless
    MLS
    Ochsner/LSU Health
    Shreveport LA
    9795740947
    ------------------------------



  • 15.  RE: Confirmatory testing for UA

    Posted 03-01-2019 06:40
    ​Jessica:  I am not going to deny that the environment and culture you describe doesn't exist in "some" workplaces, but I also like to believe that the majority of laboratories do not operate that way.  I am seeing that with an increased focus on a culture of patient safety and high reliability that we try to elevate and reinforce the role that our laboratory professionals play in providing high quality patient care.    It is the role of laboratory management to set the tone and the environment for the culture and for empowering our staff to use judgment and to question.
    I find this true with MLS, MLT, cytotechs, histotechs and phlebotomists in our hospital laboratories as well as the MLS, MLTs and laboratory assistants that work in our ambulatory clinics.

    If the environment you describe exists, it greatly diminishes our status as a profession and goes against the grain on the emphasis on the value that laboratory professionals bring to patient care.  As I see more and more of a focus on value and Lab 2.0, the environment you describe truly saddens me.

    ------------------------------
    Rick Panning
    Senior Administrative Director
    HealthPartners
    Bloomington MN
    6512805909
    ------------------------------



  • 16.  RE: Confirmatory testing for UA

    Posted 03-01-2019 09:03
    I totally agree with Rick.  What Jessica describes is somewhat surprising.  QA and QC dictate reliable results ​and our patients should always come first. Quite frankly, the manager(s) that have told you numerous times to "not think and just turn out terrible numbers" should be disciplined or simply let go.  Turning out questionable / poor quality results is unacceptable.

    ------------------------------
    Edwin Beitz
    MLS Prog Director
    WellSpan Health
    York PA
    (717 851-2473
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  • 17.  RE: Confirmatory testing for UA

    Posted 02-28-2019 07:46
    ​Well said, Dean!! So agree.
    And yes, in our internship program we do still over confirmatory testing because it is what is done in practice even if it is not covered in a BOC exam.

    ------------------------------
    Alice Hawley
    Laboratory Manager
    Sanford Medical Center Fargo
    West Fargo ND
    (701) 282-2617
    ------------------------------



  • 18.  RE: Confirmatory testing for UA

    Posted 02-28-2019 15:06
    Very thoughtful responses. I agree with Kathy Doig and  Dean Yoshimura . First we should not use the ASCP test as the sole determinant of what to teach. Certification tests still tend to veer to the academic and take years to catch up to current practice.

    I am not in academia but I would recommend teaching those concepts because they contribute to understanding fundamental principles.  I have had to reach several were grads about spectrophotometry  and the concept of %T and absorbance. A light bulb goes on (so to speak) when  they get the concept of an instrument measuring absorbance at a certain wavelength and correlating that reading with the concentration of a substance of interest in a patient sample.  I am not talking about 1 grad: I  can think of 4 or 5 I have had those conversation with in recent years. That is a fundamental principle that doesn't go away despite the fact we no longer use colorimeters but  have sophisticated instruments with light sources, filters etc not exposed.

    My approach would be to teach 1. what the screening test measures 2. interfering substances (false pos and false neg) and why they interfere 3. confirmatory tests and why that test actually is more specific than the screening test 4. discuss that confirmatory tests are no longer performed in some labs AND what the rationale is for that decision.

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    Glen McDaniel
    Atlanta GA
    (404) 629-1164
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  • 19.  RE: Confirmatory testing for UA

    Posted 02-28-2019 16:58
    I agree with you Glen.  We need to teach the "Why" and not just the "How" so they understand principles to connect the dots.  BTW providers at my facilities love it when I can explain the 'science' behind laboratory testing.
    Dean

    ------------------------------
    Dean Yoshimura
    Laboratory Director
    Waianae Coast Comprehensive Health Center
    Waianae HI
    (808) 697-3648
    ------------------------------