I can’t help it. Every time I see the word, ‘lab’, it evokes images of smoke, arcing Tesla coils, boiling green flasks, and crazy Christopher Lloyd hairstyles.

When a pharmacist in A community setting refers to lab values, they’re usually asking a patient directly to ascertain whether all the bases have been covered. More often than not, the patient does not know what they’ve been tested for, let alone the actual LAB values. Fortunately, With our newly expanded scope of practice, coupled with the incoming drug information system, these awkward conversations with patients will soon come to an end.

As clinicians taking on broader responsibilities, performing lab requisitions is one more unknown that we need to navigate. There are numerous applications that scream for pharmacist intervention. A1C and INR are at or near the top of the list, but I suspect that many other practical uses are waiting to be discovered.

In speaking with a close RN friend of mine, she thought pharmacists having access to lab values was a wonderful idea, but brought up a number of pitfalls that we’ll need to consider when we officially begin:

– Shall we be authorized to request all tests, or be restricted in some fashion through a permit system?

– The cost of a test.

– The appropriate monitoring frequency for a given test.

– Are tests to be used to aid diagnosis or strictly to monitor existing therapies?

– Who owns the test results and the right to intervene if necessary?

– What is the lab capacity in a given jurisdiction?

There is a fear that once able, pharmacists in community settings will want to create baselines for all patients. Some of these will be absolutely reasonable and will fill gaps in patient care. Others may be open to interpretation and potentially create conflict with other care providers. I offer a couple of examples from my time in long-term care. At the time, the Nurse Practitioner and I routinely spent a couple of hours reviewing 50 patient charts at a time ahead of meeting with the nursing staff and medical director of the 200-resident facility where we worked.

1) B12 – We performed a focused medication review on patients receiving vitamin-B12 injections, noting that many did not have blood counts requested since their admission years prior. Out of a dozen patients, we were able to discontinue six of them that showed upwards to three times therapeutic levels. Although the long-term toxicity was not much of a concern, it was one more injection to track (and thereby eliminate for the time being) and in two of the cases, blood counts had not rebounded due to a relative iron-deficiency that had gone unchecked.

2) T4/TSH – As per accreditation standards at the time, we aimed to have a complete medication review performed with 6 weeks of admission. Often patients discharged from hospital were relatively stable on their current regimens, and needed time to get acclimated to their new surroundings. Usually at this time, we determined monitoring parameters for bloodwork and obtained baselines if the file was incomplete. During one session, we decided to review all patients taking thyroid hormone and discovered that some residents had not been screened in years. Many were frail and drawing blood was difficult, but we didn’t see that as a reason to stop monitoring. Almost all required a dosage adjustment and corrected some previously unexplained symptoms due to hyper or hypothyroidism.

It was not always easy. One of the stumbling blocks was the impact to workflow on Thursdays. Blood was normally collected in the mornings and shipped to the lab in the early afternoon. This of course added some extra work that wasn’t always easy to plan. Another was the attending physician’s apprehension in having us discover an issue that was missed or ignored due to a plausible reason. He would then need to possibly defend his/her action/inaction to us, nursing staff, and perhaps even the resident or their families.

I guess it will be another learning experience for all of us, but I look forward to the day when we can ask and receive a clearer picture of an individual’s health from a lab test. I’ll even bring my own Tesla coils.

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.