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Creating a bar code chemistry system.

New chemistry analyzers at the author's laboratory required bar codes, but there was no money for them in the capital budget.

PRESSURE within the laboratory profession to improve quality and productivity while reducing operational costs has made bar coding an everyday necessity.

There are several ways to use bar coding in the lab. None is more efficient, in my experience, than an integrated approach that uses the bar code collection list.|1~ In this article I will discuss how we implemented such a system while upgrading the instrumentation in the chemistry section of the laboratory at Washington Hospital Center, a 911-bed not-for-profit hospital in Washington, D.C.

* Generating lines. At the core of the collection list system is the application of the bar code label to the specimen container as early as possible. That means generating the label immediately after the order reaches the laboratory--in many cases before the phlebotomist leaves to collect the specimen.

Figure 1 is an example of a collection list "line" generated in our laboratory. Bar code labels and patient information are generated side by side in a continuous stream of lines, each measuring 1.33 x 8.5 inches. (A detailed explanation of a similar line appeared in last month's MLO.|2~)

Each line includes basic patient information, test orders, the number and types of tubes needed, and any special instructions. Accession and/or specimen identification numbers, assigned by the hospital information system (HIS) or laboratory information system (LIS), are shown in human-readable and bar code form. Placing the test order prompts an "intelligent" printer to generate a line. The phlebotomist carries the collection list to the patient's bedside, where the specimens are drawn and the appropriate labels peeled from the line and applied. Specimens can then be accurately identified throughout testing.

* Saving effort. When specimens arrive in a lab that has host-query bidirectional interfaces between the LIS and bar code-capable analyzers, the rest is automatic. Thanks to the interface, the original test order that prompts the generation of the collection list and labels also tells the appropriate analyzers that the specimen is coming. There is no need to read work lists or relabel specimens when they reach the analyzer.

Since there also is no need to relabel specimens manually or to place them in a specific order on the analyzer, the chance for specimen identification errors is minimized. The analyzer identifies each specimen by its bar-coded accession number and performs the requested tests. The results are automatically uploaded to the LIS and made available on monitors throughout the hospital. Time is saved, errors are reduced, and an increased volume can be handled by the same number of lab employees.

* Installing analyzers. Those were the benefits we sought when we decided to implement our collection list system. In January 1991 the decision was made to install new chemistry analyzers that would have a host-query bidirectional interface with our LIS. Advising me on the decision was a committee that included the chemistry and phlebotomy supervisors and representatives of the LIS and central receiving staffs.

The chosen analyzers required bar codes to access specimens. Taking that route would mean that all our specimen tubes would have to be relabeled with bar code labels before being loaded onto the analyzers. Yet secondary relabeling is an unconscionable waste of time.|2~

* LIS price. A further complication arose regarding our LIS. The software we were using would not support bar coding at the collection list level. At $25,000, the software we needed was prohibitively expensive at a time when our hospital was in financial stress. We had not allocated any budget dollars toward bar coding and had not included bar coding in the project to implement new chemistry analyzers. An additional disincentive was that even if we could have afforded it, the upgrade would take six months.

The project was at a standstill for lack of funds and because our chemistry supervisor did not want to relabel specimens. We had obtained these instruments mainly to read bar codes. Now we were being asked to incur the extra expense of secondary relabeling. This would not fulfill our desire to improve efficiency in the chemistry section.

The new instruments--two Beckman CX7s (Beckman Instruments Inc., Brea, Calif.)--would maximize our efficiency to some extent, but we wanted to make them work so we did not have to add staff. One new FTE, at an annual cost of $26,000, would have had to be added to relabel specimens at the work site. Quite the contrary, we wanted to reallocate some of our staff to do specialized testing, such as for HIV.

* No capital outlay. To avoid incurring any capital cost, we bypassed making a purchase acquisition for the analyzers. They were obtained through a reagent rental contract, a route we also decided to take in acquiring bar code printers.

In April 1991, Beckman suggested that we could solve our printer problem by acquiring the MedPlus 2400F (MedPlus Inc., Cincinnati). This "intelligent" direct thermal printer|3~ could be programmed to interact with our newly acquired bidirectional analyzers. The manufacturer offered an acquisition method that would bypass the LIS software dilemma while providing us with bar coding at the collection site.

Again there was no capital outlay. We concluded a label agreement plan with MedPlus that included labels, service, and any necessary reprogramming of the printer microprocessor, such as adding symbologies or analyzers. Our agreement is similar to the reagent rental agreement that got us the CX7s. We buy the label paper--our annual label volume is about one million--and, in exchange, MedPlus lends us the printers. Our LIS vendor was upset with us for having taken that route, but it works. Figure 2 offers details of the three options we faced when deciding to implement bar coding.

The use of an intelligent printer to create a collection list saves us $10,100 per year over the secondary relabeling method and $1,400 per year over upgrading the LIS to permit the creation of collection lists. While the latter saving may appear marginal, it's worthwhile to note that we completely avoided capital outlay and saved as much as a year on the time required to bring our bar code system on line. (To make a capital purchase, we would have had to wait for a new budget cycle.)

* Printer features. The printer's 8.5-inch-wide carriage rolls out patient information and bar code labels side by side in a continuous stream. The instrument can also print more than one bar code symbology, or language, on the same line. That is important because while most analyzers accept several bar code symbologies, each instrument works best with only one.|4~

Wide carriages allow more labels to be printed than narrower carriages and produce wider sheets that are easier to handle. Printers with narrower carriages, such as the Intermec 8625 (Intermec Corp., Everett, Wash.), the MedPlus 1400F, and the Zebra Stripe (Zebra Technologies Corp., Vernon Hills, Ill.), are better for point-of-application labeling and for generating labels for aliquots and derivative specimens.

Wide-carriage printers are also a wiser choice for those who want to custom-design a label. That capability is especially important as a laboratory grows and adds equipment TABULAR DATA OMITTED that requires different label formats.

* Adaptability. If we acquire a new analyzer that changes our collection list, adding it to the printer instructions is no problem. For example, if we brought on line a coagulation instrument that read bar codes, we would notify our vendor of the symbology we wanted to use and the tests that would be added. The vendor would modify our label program to produce a bar code for the new instrument.

In July 1991 we went up with one CX7. At the moment we have four chemistry analyzers on line with bar codes: three Beckman CX7s and an Abbott Commander (Abbott Diagnostics, Abbott Park, Ill.). Two hematology analyzers are also part of our collection list system.

* Responsiveness. For fast response, we have nine printers: two in our lab's phlebotomy collection area, one in an outpatient collection area apart from the lab, one in a remote hospital (another facility that contracts with us for lab work), one in a Stat lab, and another in our central receiving area. We keep three as spares. When a breakdown occurs, we replace the faulty printer with one from the shelf. The malfunctioning one is sent to the manufacturer, which repairs and returns it.

* Ways to adapt. One primary factor in choosing a product is the vendor's ability to modify hardware and software to accommodate one's needs. Here are additional tips for smooth bar code printing:

Easy maintenance. Choose a printer that is easy to maintain, especially if your contract with the printer manufacturer doesn't include repair. The fewer moving parts the instrument has, the fewer pieces can malfunction. Replacing labels should be simple; cleaning should be quick. The printer should operate quietly and occupy little space.

Good label stock. Follow the recommendations of the printer manufacturer when selecting label stock, the paper on which the bar codes will be printed. Taking that advice usually helps preserve optimal performance and maintain high read rates. However similar label stocks look, not all labels are created equal. Important features to look for include infrared readability, barrier coating to prevent smudging, and extreme temperature tolerance (from - 20|degrees~F to +104|degrees~F). Barrier coating is especially important to assure that slide labels aren't contaminated by stains.

* Striving for perfection. Although no laboratory will ever achieve perfection in specimen processing, that should be the goal. The implementation of bar-coded collection lists is a step in the right direction. With a little research, laboratorians can find innovative ways to integrate bar-coded collection lists without incurring large expenses. Printer vendors can provide users with numerous payment plans from which to choose.

Flexibility is key. The bar coding of collection lists does not have to be limited to modifying a LIS vendor's software. Although this solution might work for some laboratories, we have found that the integrated collection list system, based around an intelligent printer or printers, is the most practical and cost-efficient route.

Charlotte Taylor, MT(ASCP) is director of laboratory operations at Washington Hospital Center, Washington, D.C.


1. Kasten BL. Bar code barriers gone. CAP Today. January 1991; 5(8): 6-8.

2. Kasten BL. Strategic planning for an integrated bar code system. MLO. January 1993; 25(1): 42-46.

3. Kasten BL, Schrand P, Disney M. Joining the bar code revolution. MLO. December 1992; 24(12): 22-25.

4. Kasten BL. What are all those lines and spaces? Understanding bar code technology. MLO. December 1992; 24(12): 25-27.
COPYRIGHT 1993 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1993 Gale, Cengage Learning. All rights reserved.

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Author:Taylor, Charlotte
Publication:Medical Laboratory Observer
Date:Feb 1, 1993
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