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A cost-effective emergency room laboratory.

A cost-effective emergency room laboratory

Turnaround time on emergency room specimens used to be slow in our hospital. Clinicians waited 60 to 90 minutes for many test results; sometimes it took as long as three hours.

The main problem was the 100 yards separating the ER from the emergency lab, which was situated off a cafeteria corridor. Hospital messengers negotiated the distance, but not always at the moment specimens were ready to go. The messengers had other duties as well, such as transporting patients and blood for transfusions.

Our solution: Eliminate the distance. We carved out a Stat lab right in the ER, and average turnaround time dropped to 20 minutes almost overnight. Now test results often get to an examination room before the patient does. (The lab also does some Stat work for other areas of the hospital's acute care building; the main laboratory is four blocks away.)

Fast emergency service is vital. Our 605-bed municipal hospital has 1.5 million Queens residents in its catchment area. Located between two major highways, the hospital acts as primary patient-receiving center for 911 emergency calls in the eastern half of Queens County, for the Fire Department, and for both Kennedy and LaGuardia airports.

ER volume averages 270 patients per day and exceeds 97,000 per year. Thirteen to 15 per cent--or 12,000 to 14,000 per year--are ultimately admitted for further treatment. They are the hospital's primary source of inpatients, accounting for 60 to 70 per cent of total admissions.

The transformation of emergency room lab service began in 1978 with the arrival of a new chief of clinical chemistry. As head of the largest laboratory department, he fielded a large share of the house staff's complaints about slow turnaround time on ER tests. Discussing the situation, he and the hematology chief eventually concluded that the best answer was to offer chemistry, hematology, coagulation, and urinalysis testing right in the emergency room.

Hematology already provided red cell counts and differentials in the ER, literally out of a closet. The house staff had insisted on that because the hospital, which has a large black population in its immediate area, sees many patients who have sickle cell anemia.

For its part, chemistry took over one of the examining rooms--just enough space for the centrifuges, a large analyzer, and a technologist. The new lab opened in late 1979 for round-the-clock Stat testing and immediately compressed the average turnaround time to less than a half-hour.

This quick performance encouraged interns and residents to continue sending specimens downstairs long after they rotated out of the ER to other medical services. Not surprisingly, turnaround time began to suffer. When it climbed back to almost 60 minutes, the laboratory issued a set of ground rules.

Stat specimens are still accepted from pediatrics, the intensive care units, and the labor and delivery suite. All other high-priority specimens are sent to the main laboratory via a Stat messenger service. To make sure this work is done promptly, the main lab established a Stat island for chemistry and blood gas testing.

With turnaround time back on track, crowding became the emergency lab's primary problem. When the house staff complained about the difficulty of tracking specimens sent to the separate hematology and chemistry areas, the laboratory decided to consolidate services. Several medical departments took up the cause, and the emergency lab moved into what had been the orthopedic cast room. Two technologists now covered each shift.

In the summer of 1981, a new emergency department director came on board. Impressed by the unique on-site Stat lab, he began campaigning to add blood gases to the test menu. But respiratory therapy was responsible for the procedure at that time, and the chemistry chief was inclined to leave it that way. The laboratory lacked space and staff for the extra work.

The ER director persisted, and the Stat lab finally annexed an administrative office. Into that room went side-by-side blood gas analyzers and a third technologist per shift. With this new capability, we became an official receiving hospital for the New York City Fire Department, which sent us more smoke inhalation cases. The Stat lab soon took over blood gas testing for all of the ICUs, but the third staff member still had time to share in some of the work done by the other technologists.

Currently measuring 12 20 feet, the lab contains the following instruments: Astra 9, ACA IV, IL Co-oximeter. American Optical bilirubinometer, ELT 1500, Coag-A-Mate Junior, and two Corning 178 blood gas analyzers. The menu consists of some 30 chemistry and blood gas tests, coagulation, urinalysis, and full CBC. It was jointly developed by the directors of pediatrics, obstetrics and gynecology, chemistry, hematology, and the emergency department with the aim of providing those test results that clinicians feel they must have within a half-hour.

The instruments are essentially the same as those found in the main laboratory and its Stat island. That makes it easier on personnel: Emergency lab staffing for the day and evening shifts is handled by a rotation of technologists from the main lab every six weeks.

Three technologists are on duty throughout most of the day. Workload studies showed a slack period from 2 a.m. to 6 a.m., so the late-night blood gas technologist leaves at 2 unless the lab is unusually busy. (There's no rotation on the third shift. A total of 4.5 FTEs are permanently assigned those hours.)

A number of advantages flow from turnaround time of 20 minutes for most tests. These advantages assumed greater importance recently when our state came under the DRG system. Rapid availability of results speeds up diagnosis and can reduce length of stay if the emergency room physician decides to admit a patient.

Unnecessary admissions, particularly in the "overnight-for-observation' category, have dropped at our hospital. For example, with rapid and sophisticated pregnancy testing, we no longer routinely admit suspected cases of ectopic pregnancy for possible surgical evaluation. This is a significant benefit, since the rate of ectopic pregnancy in our patient population is three times the national average.

Fast turnaround on electrolytes means more rapid disposition of patients presenting with such diagnoses as syncope versus seizure disorders. Similarly, with cases of possible drug overdose, the emergency laboratory can rule out certain agents and enable physicians to send patients home after several hours' observation in the ER.

Duplicate test orders have also fallen sharply. In the past, the house officer routinely ordered a complete laboratory workup as soon as an ER referral arrived on his or her floor. Many of these same tests were already under way--the results just hadn't been posted on the chart. So the laboratory was saddled with extra, unnecessary work; turnaround time lengthened; the patient received a larger lab bill; and the physician got two identical sets of test results.

Testing in the emergency room changed all that. Results are charted immediately--the comprehensive chart sometimes even precedes the patient to the floor-- and the house officer can follow up with appropriate therapy almost as soon as the patient arrives.

Of course, we have occasional problems. Orders from other departments periodically flood the ER laboratory. Special requests are accommodated wherever possible, but when turnaround starts creeping up to 30 or 40 minutes, laboratory management tallies the orders from a particular medical service and places a phone call to the chief resident. The doctors are very cooperative about preserving the lab's low turnaround time.

Some technologists dislike the pressure of the ER laboratory and the confinement of working in a small space. Others thrive on the duty. The lab places technologists on the medical front line--it's not unlike serving with a MASH unit. They can walk a few steps and see the patients they have just run tests on. They share a physician's concern about a difficult case and, on occasion, they don't mind doctors standing next to them, waiting for a test result. At the same time, a physician may gain new respect for laboratorians after witnessing a two-minute turnaround on an automated blood count or arterial blood gas.

An air conditioning overhaul late last year forced the laboratory to move out of the emergency room temporarily, 50 yards down the hall. Turnaround time tripled during the four-month relocation, primarily because of transport delays. At this time, we learned how much the house staff appreciated the ER lab. They lamented the loss of rapid service and the inability to make appropriate patient dispositions quickly.

In the past, hospitals like ours with an annual emergency room volume of nearly 100,000 patients saw no need to market this department. That attitude is changing, partly because of DRGs but also in response to competition from freestanding clinics.

Patients are no longer willing to spend several hours lost in a hospital ER shuffle, certainly not for a minor injury. They are also balking at the high walk-in fee-- charged regardless of the level of care required--not understanding the tremendous overhead costs required to staff and maintain an emergency department. Freestanding clinics recognized these shortcomings. They drastically cut the initial fee, offered better turnaround, and began siphoning off the non-acute market, which was the emergency room's major source of revenue.

Many hospitals are responding with a strategy that establishes two tracks in the ER. Patients with minor problems are automatically transferred to the second track, which features a lower walk-in fee, minimal delay, and the assurance that full-range medical care is close at hand if needed.

Waiting time is the key to success. Patients go to the freestanding clinics largely because of convenience. The Stat lab plays a pivotal role in shortening the wait.

A big selling point for setting up an ER laboratory is its cost-effectiveness, especially in a DRG environment. Such a lab can be made sophisticated and versatile enough to handle all after-hours testing for the hospital. It would cost about $300,000 to buy the instruments used in our lab, but we opted for reagent-rental contracts.

As for expansion, when a doctor says he needs a specific test in the ER lab instead of the main lab. we counter with three questions: Will it enable you to treat patients faster? Are you going to admit some of them faster? Will they go home earlier? If the answers are yes, we will strongly consider adding the test.

The bottom line is whether the patient and the hospital will benefit.

Photo: Lab medicine on the front lines in an emergency department

At far left, co-authors Thomas Kwiatkowski, M.D., and Alan Portnoy, Ph.D., pause outside the emergency room at Queens Hospital Center. The ER lab, measuring 12 20 feet, is designed for optimum efficiency. At near left, a technologist runs a hematology analyzer Above, the blood gas tech processes specimens.
COPYRIGHT 1986 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1986 Gale, Cengage Learning. All rights reserved.

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Author:Portnoy, Alan L.; Kwiatkowski, Thomas
Publication:Medical Laboratory Observer
Date:Jul 1, 1986
Words:1797
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