Updating a neglected laboratory.

Some shortage of instrumentation, personnel, and money is almost part of the definition of many clinical laboratories. One reason is that the times are lean. Another is a failure of communication between the laboratories and administrative and financial departments.

By way of illustrating the latter point, let me describe the situation that exists in the New York State system of psychiatric hospitals, where I work. Granted, the state system may have some unique features; however, the principles I am about to discuss apply in any hospital laboratory setting.

To begin with, a proposed laboratory budget increase must be submitted to our hospital administration. Each administration controls its own hospital, but at the same time reports to a regional office. That office, in turn, must clear all requests with state authorities in Albany.

By the time a request arrives in Albany, it's just one small item in a sea of similar requests. Those responsible for approval or denial of the request have no idea of the medical need that prompted it. In all likelihood, they have never even seen the hospital laboratory in question.

Largely because of this factor, funding agencies appear to be unresponsive to the needs of the laboratory. As often as not, we wind up uncertain about how much we can spend.

I first became director of laboratories at this 1,000-bed hospital a little over two years ago. At that time, the budget pattern I have described was well established, and the lab was in sorry shape. Some of my academic colleagues suggested that I was in need of psychiatric counseling for taking the job with all its attendant problems.

When I moved in, I found lots of outdated equipment--and a desk full of expenditure requests that had been submitted by my predecessor but never fulfilled. The director for inpatient services told me to disregard what had gone before and draw up plans for a more efficient and modern laboratory. I started by trying to learn why the laboratory historically received low-priority treatment.

Ever-present budget restrictions explained some of the neglect. For this reason, administrative decision-makers habitually moved laboratory requests to the bottom of the list, assuming that they had low priority. Priorities assigned to other areas were mandated by the JCAH and legislation to expand psychiatric resources.

This overlooked a high incidence of physical illness among any psychiatric patient population. I researched the subject and found several studies to support my position. For example, there was evidence of frequent hormonal, metabolic, and hereditary disorders, as well as infectious, collagen vascular, and neoplastic diseases. In addition, the drugs given to psychiatric patients (either alone or in combination) produce significant side effects. The functions of many of the body's organs may be affected by these therapeutic modalities, indicating the need for a program to monitor therapeutic drugs.

I proceeded to amplify these research findings through laboratory results on our own patient population. In a study of 3,000 consecutive CBCs, we found 434 abnormalities, either in red cells, white cells, or platelets.

Ironically, we could not conduct follow-up investigations because of a shortage of instrumentation and personnel, and a lack of computer capability. Our preliminary investigation nevertheless yielded abundant evidence of all the disorders mentioned in the literature.

Because our hospital has a large geriatric population, we also discovered the presence of such diseases as diabetes, hypertension, and prostatic hypertrophy. And we documented the fact that aging adversely affects the immune system, making the elderly more susceptible to infection.

All these findings were transmitted verbally to the administration, justifying the laboratory's role in a psychiatric institution and making a strong case for updated instrumentation. The payoff proved the value of effective communication: The administration responded favorably, agreeing to consider an overall plan for modernizing the laboratory.

We also saw signs of a new medical-administrative dialogue. First, the New York City Regional Office for Mental Health arranged a medical conference so that medical representatives of all the New York regional psychiatric hospitals could meet with administrative authorities of the regional office. I took an active part in discussing the need for more communication and clearer understanding on both sides of the needs of the other.

Shortly after this meeting, and as a result of my report on the importance of the laboratory to the psychiatric hospital, I was asked by the regional office to evaluate the status of all the state's psychiatric hospital laboratories in terms of staffing, instruments, and expenses. I submitted the evaluation, and then a newly formed committee made on-site visits to all the hospitals, confirming recurrent shortages of resources.

The committee was able to suggest some areas where the state could economize. For example, in the New York City region, four institutions use an independent laboratory for testing, resulting in a large expense. Additional instruments and renovation were recommended for the laboratories at surrounding state institutions. These labs could absorb the work being sent out, saving the state a great deal of money.

Shared services make a great deal of sense, especially when hospitals are already allied as in our state system. For example, it isn't necessary for every institution to have a gamma counter for the determination of serum folate or B.sub.12 levels. If one institution in the area has a counter, other regional hospitals can send their tests there, rather than to an outside reference laboratory, and enjoy large savings.

We encountered another example of waste in the outpatient departments. Many patients are referred to private physicians for physical exams; again, their laboratory work is performed by an independent lab and billed to Medicare or Medicaid. If the system were changed to bring the work in-house, we could bill the various agencies ourselves and use the revenues to purchase reagents and improve maintenance.

The regional office received our report enthusiastically--to the point of even asking why we did not recommend computerizing our laboratories! We hadn't included computers in our requests because we felt that after so many years of neglect, basic instrumentation should get first priority. We were delighted to add on a computer proposal, budget permitting, as a significant step toward better patient care.

Thanks to improved communication, the central office in Albany has become very interested in our plight and is currently engaged in a full-scale reevaluation of the system's laboratories. It has agreed to adopt most of our recommendations. Both the medical staff and various administrative bodies have come to believe they must listen to each other in order to better employ public money and upgrade patient care.

I know that the next time I seek authorization to buy something like a CO.sub.2 incubator, the request will receive the attention that it deserves based on medical need. Barring a budget crisis, I will probably get the equipment if I have done a proper job of documenting the need.