Mr Q is a 50-year-old electronics designer with metastatic esophageal cancer treated with third-line palliative chemotherapy. Recently, he has spent more than half of his time in bed due to a general lack of energy, although he walks without assistance or dyspnea. He was admitted to a university hospital in May 2006 for intractable nausea and vomiting.His medical history was remarkable for migraine headaches, depression, and ulcerative colitis during childhood. He was diagnosed with esophageal cancer by endoscopic biopsy in October 2005. Thoracic computed tomography (CT) scans at the time showed circumferential thickening of the distal esophagus and an enlarged gastrohepatic lymph node. In December 2005, he began presurgical chemotherapy with docetaxel and capecitabine. In February 2006, he underwent an exploratory laparotomy but the tumor was found to be unresectable. A 20 ϫ 20-mm stent was inserted in the gastroesophageal junction for impending obstruction and a jejunostomy feeding tube ( J-tube) was placed. In March 2006, CT scans showed evidence of liver metastases.Mr Q had experienced intermittent nausea and vomiting throughout his course of chemotherapy and reported a painful burning sensation in the chest and epigastrium since the esophageal stenting. Ten days before admission he had begun palliative chemotherapy with capecitabine. Afterwards, his nausea and vomiting worsened considerably, with vomiting episodes occurring up to 10 times a day, consisting of both dry heaves and emesis of bilious fluid. There was no apparent temporal relation of these symptoms to oral in-CME available online at www.jama.com Author Affiliations are listed at the end of this article.

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LynchOur Infusion patients need to have their CBC/manual diff and CMP results prior to receiving their treatments. Our patients start in Phlebotomy, and then go to wait in the Infusion waiting room, waiting for their lab results prior to receiving any treatments. We switched tube type from serum gel to plasma gel for our chemistry samples. This eliminated waiting for clotting of sample. Adopted the use of STAT spin centrifuges to reduce the specimen centrifugation time. New lab order status (ASAP) created for our Infusion patients. Blue specimen transport bag introduced to assist with triaging the patient samples from phlebotomy. Created a draw station in the Infusion department. We added a second Chemistry analyzer and a second Hematology analyzer with an automatic stainer in the main lab. Introduced specimen triaging at the analyzers to expedite the testing of Infusion specimens. Hematology analyzer for "Blast" classification was adjusted. Increased staff resources, moving staff and training staff to areas needed. We worked with our Bone Marrow lab staff to increase expertise for abnormal differentials. Creating a satellite lab in the Infusion department to run Hematology and Chemistry samples for our Infusion patients helped to expedite the results. We revised reporting algorithms to expedite the release of results where additional manual differential review would not change the results. We worked with Infusion clinic to reduce calls to the lab for results. We worked as a team, including input from all areas involved: Phlebotomy, Nursing, Infusion clinic, Central Processing, Core lab staff, Information Technology, and Laboratory Management to decrease our TAT.

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