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Elevating patient care at University of Michigan Hospital.

At a busy tertiary-care academic center where the clinical lab churns out 8 million test results a year--7 million just in chemistry and immunodiagnostics--effective deployment of automation and information technology to maximize productivity and cost efficiency is a given. Such is the case at the University of Michigan Hospital (UMH). At the chemical pathology department, productivity gains are only part of the story. Indeed, the lab has been able almost to double its volume over a period of almost four years, without adding staff or instrumentation. Just as important are quality improvements that have made a positive impact on patient care. From 2004 to 2009, the number of errors was reduced by half while volume almost doubled. Turnaround time also kept dropping. Today, 97.3% of in-patient STAT samples are delivered within the targeted TAT of 45 minutes, while 99.8% of routine samples are on time for the 120-minute goal. Last but not least, the lab was able to reduce the number of SST tubes per patient, by as much as 60% in the outpatient area--a welcome change that benefits patients and their caregivers.

Powering productivity through workflow design

Chemical pathology at UMH provides chemistry, special chemistry, immunology, and toxicology testing services for all three hospitals on campus, with a total of 865 beds and 1,600 physicians, as well as 30 health centers and 120 outpatient clinics within a 60-mile radius. To accommodate the consistent annual growth rate of 3% to 5%, a mix of inpatient and outpatient, STAT, and routine testing needs, the lab designed and implemented a new automation line in 2006, including three immunoassay systems, three chemistry systems, two centrifuges, and two sample managers that handles 100 different chemistry and immunoassays, all managed by networking solution. Six instruments took over the workload of eight analyzers used prior to the redesign and have supported the volume growth over the last four years. Today, the automation line runs 24/7.


Automating previously manual tasks: The networking solution can be programmed to execute tasks that are often performed manually. At UMH's chemical pathology lab, it handles automatic repeat testing for some tests. The lab also takes advantage of specialized algorithms for infectious-disease testing; for example, when duplicates of hepatitis or HIV tests are required, the system will run the duplicates automatically. This saves technologists time since, by the time they review the results, the necessary dilutions and/or repeats have been performed already. Similarly, when there is an add-on, the system will locate the patient sample on the automation line with no manual intervention, run the test, and report the result (or flag it for technologist review as appropriate). Turnaround is faster since there is no delay waiting for the technologist to locate the specimen.

Autoverification streamlines results reporting: With autoverification, each result is classified based on criteria programmed into the system, flagging only those results that require technologist review. This means there are fewer results to review--at UMH, 80% of test results are reported directly without technologist review. It also means that the same rules are applied, consistently, to review the results.

A backup for the LIS: When the LIS is down, the networking solution provides a computerized backup, alleviating delays.


Measurable gains in quality care Even more important than the improvement in productivity is the impact of automation and information technology on patient care.

Improved TAT expedites clinical decisions: Auto-verification and the automation of typically manual processes have reduced manual steps and decreased TAT. Routine samples classified as "on time" based on the 120-minute goal increased from 98.4% in August 2007 to 99.8% in August 2009. Using a 60-minute benchmark for all STAT samples, on-time STAT-sample TAT increased in the same time period from 89.9% to 99.8%. Furthermore, inpatient STAT samples meeting a 45-minute goal advanced from 66.7% to 97.3% in the same period, while 95.6% of outpatient STAT samples were reported within the 45-minute goal, compared to 77.6% two years ago. TATs such as these support timely clinical decisions and specific clinical guidelines in some cases.

Reduced error rates enhance patient safety. Error rate is an important benchmark of quality and safety. At UMH, standardization of the results-review process, automation of error-prone manual tasks (e.g., locating specimens for add-ons), and the reduction of the number of results requiring staff review have contributed to a reduction of the number of reported errors.
Reduction in error rates]

      Average monthly errors  Average monthly test volume

2004             26                      356 K
2006             13                      600 K
2007             10                      651 K
2008             12                      655 K

Note: Table is made from bar-graph.

Fewer blood draws. The consolidation of more than 100 different tests on the automation line has significantly reduced the number of SST tubes required. In the past, for example, a basic profile, lipids, and thyroids might require three different blood tubes. Now, only one tube is needed. In the outpatient group, this means a 60% reduction in number of SST tube draws.


Pointers for middleware evaluation For labs looking into lab-informatics solutions, the starting point is a list of what the lab wants to accomplish. In the case of UMH, considerations such as reducing staff stress and handling the ever-increasing volume were the primary concerns. And middleware needs should be reviewed in the context of the current LIS, with the goal of complementing LIS capabilities. With autoverification, one important feature to look at is the ease of rules writing and the flexibility to build rules, as needed, for special circumstances. Delta checking by both absolute value and percentage is important, as is quality control (QC) and the ability to stop results if QC is out. Technical support is a factor, as is the vendor's commitment to product enhancements on an ongoing basis.

Sue Stern, MS, MT(ASCP), is administrative healthcare manager in the Chemical Pathology Department at the University of Michigan Hospital in Ann Arbor, Ml. From Siemens' ADVIA line, Stern used its LabCell Automation Solution, three Centaur Immunoassay Systems, three 2400 Chemistry Systems, and the CentraLink Networking Solution.
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Title Annotation:LAB MANAGEMENT
Author:Stern, Sue
Publication:Medical Laboratory Observer
Geographic Code:1U3MI
Date:Jan 1, 2010
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