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How to get the best service from a referral laboratory.

Among the most telling aspects of laboratory service, in referral as in primary labs, is the ability to cope with emergencies and other unusual circumstances. Promptly addressing such difficulties is the hallmark of a fine-quality operation. To get what you need from referral labs in such situations as well as under normal conditions, cultivate a good working relationship with a responsible person on the premises. The person should be able to smooth the inevitable rough spots in lab service and have access to all areas of the lab. He or she also should be readily available to you.

Continual communication with your referral lab will go far toward correcting large and small problems as they arise. Solutions to common difficulties between primary and referral labs follow.

* Physician complaints. The person most likely to complain about referral lab service, possibly without knowing the test was sent out in the first place, is the primary physician. Doctors who order tests must be helped to understand that the referral laboratory must function through many "middlepersons." These people may make the full range of human error--drawing specimens incorrectly, forgetting to call for pickup, mislabeling request forms, using the wrong tubes, and so on.

When the primary physician complains about poor service, these "middlepersons" may become defensive and project their own guilt on the referral lab, thus compounding the problem. One way to prevent such miscommunication is to encourage the primary physician to communicate directly with the referral lab, preferably with its medical director.

Top people at the primary laboratory should not feel threatened by such communication. Their personal exchanges can be particularly helpful when there is any confusion over the interpretation of test results. One of the most important advantages to the primary lab of such a steady working relationship is in being buffered from physicians' questions and complaints.

* Turnaround time. No single faced of lab service causes more consternation to the referring physician than slow turnaround time (TAT). Awaiting the receipt of results are such events as the physician's interpretation of clinical values and determinations concerning treatment and prognosis, further testing of the patient, and the timing of the patient's return office visit.

Any delay will intensify anxiety for the patient, who may be facing major surgery or lifelong medication. The stymied patient will direct anger at the physician, who may pass it down the line through the primary laboratory to the referral lab.

In an effort to hasten turnaround time and make everybody happy, the referral lab is continually tempted t sacrifice quality and get the results out. The pressure is particularly great when assays that have failed to meet in-house quality control standards must be repeated. Incessant demands for faster TAT make it even harder for the referral lab to resist the temptation to speed things up.

* Defining TAT. Much of the difficulty could be avoided if referring labs understood what turnaround time really means. In some situations, it signifies the entire period from the time the physician writes a test order to the time results are received. This overall TAT should be distinguished from several other "times": lab time, from the specimen's arrival at the lab to the time results are sent out--both of which should be indicated on the referral laboratory's report sheet; laboratory work days, excluding weekends and holidays; and assay time, from the time an assay is begun to the time the calculated result is ready to be reported. Physicians often incorrectly consider published assay time and overall TAT to be identical.

Just as not all TAT is equal, not all assays are equal. The referral lab may perform common tests daily and less common ones less frequently. The turnaround time for an assay that is done once a week will depend in part on whether the specimen arrives in time to be included with that week's batch. TAT (not counting transportation) for a once-weekly test with an assay time of seven days, for example, is 7 to 14 days. For this reason, it is crucial for the requesting physicians to konw the referral lab's schedule. Published times should also be posted at the primary lab in all send-out areas.

Quality control findings occasionally make it necessary to repeat an assay. The published TAT may not include the time required for such repeats. When this happens, the primary laboratory should relay the new expected time of delivery to the ordering physician.

Ordering physicians should be helped to understand that the pressure for faster TAT can result in shortcuts that reduce quality. An example: Serum total estrogens, a direct immunoassay performed without chromatography and intended for monitoring ovarian responses to gonadotropin therapy for infertility, can be reported the same day the specimen is received. Yet obtaining accurate serum estradiol values requires purification by extraction and chromatography prior to radioimmunoassay, a 30-hour procedure. Only the serum estradiol assay has the sensitivity and specificity required to distinguish estrogen deficiency from normal ovarian function or to detect small increases in estradiol that may lead to gynecomastia.

The referring lab should assist the ordering physician in not asking for tests that will take longer than really needed. To take one rather extreme example, ordering the highly specific and quantitative beta-human chorionic gonadotropin ([beta]-hCG) immunoassay, which has a 10-hour assay time, would be wasteful for the physician who merely wanted a rapid screening test for pregnancy. An ordinary gonadotropin assay would do.

When dealing with issues of TAT, consider the instance where a test is so unusual, rare, or esoteric that even the referral laboratory must send it out. That lab is probably in a better position than the primary lab to judge where to send the specimen and to do so more efficiently. It's easier for primary labs to deal with one facility than with half a dozen.

It is the responsibility of the referral laboratory to indicate at the time the specimen is received that it will be forwarded to another facility for analysis. In such cases, ascertain cost and turnaround time immediately.

* Request forms. Subspecialty physicians tend to know exactly what tests they want. The technical staff of the primary laboratory must transmit this message clearly. The referral lab is responsible for educating the requesting personnel about distinctions between tests commonly ordered by practitioners of each subspecialty and about the terminology used on request forms. A good report will allow the requesting laboratory to call directly for such information rather than making arbitrary decisions on request forms or on incoherent notes attached to them.

Before sending out any test request about which there is any question, the referring laboratory should ask the ordering physician to clarify the request. The clinician who receives the result of an insensitive thyroid-stimulating hormone (TSH) radioimmunoassay will be justifiably unhappy if a sensitive TSH immunometric assay was desired.

* Test requests. The test request forms used by physicians are often created by the primary laboratory in an effort to identify requests in a way that the physician, the primary laboratory, and the referral lab will all understand. The request form created by the referral laboratory is usually kept in the primary hospital laboratory's transfer area and seldom found in either the hospital ward or the physician's office.

When physicians want a test that doesn't appear on the list, they may write in the request under "other cemistries" or check a general test heading that doesn't strictly match what the referral laboratory offers. The transferring technologist must then correlate the request given with the checkoff list on the referral laboratory's request form.

What if there are discrepancies? Perhaps the physician has written "IGF" (insulin-like growth factor) on the request form. The referral laboratory performs three versions of this assay: IGF-I unextracted, IGF-I by extraction assay, and IGF-II. The transferring technologist must deermine (or guess) which procedure the physician wants.

Or perhaps the primary physician has requested "thyroid antibodies." The technologist sending out the request must decide whether to order antithyroid microsomal antibody, antithyroglobulin antibody, antithyroid peroxidase antibody, [anti-T.sub.3] autoantibody, or [anti-T.sub.4] autoantibody.

To make each request as specific as possible, the subspecialty physician needs access to a complete list of methodologies available at the referral lab. One way to keep that information handy is to retain a copy of the referral lab's procedure manual or catalog at the primary laboratory and physician's office. Frequent telephone or, when practical, face-to-face communication between physician and referral lab is best.

The request form should include not only test names but also the volume of specimen required for each test. To offset losses during transfer and to provide enough material for performing duplicate or repeat assays when necessary, the form usually calls for a little more than the minimum needed.

In special cases, particularly in pediatrics, a smaller specimen than usual will be large enough to provide the data desired by the physician. In such cases, the referral lab should always be apprised of the situation. Otherwise, its accessionh room personnel might end the sequence prematurely by stamping the form "quantity not sufficient."

* Clinical data. The referral lab has good reasons for requesting clinical data for subspecialty specimens. Even the most rudimentary clue concerning the clinical test to be processed, such as the notation "after ACTH infusion," is valuable in at least the following four situations:

Dilution. If test results are expected to be high, the specimen can be appropriately diluted before the assay is performed. This will prevent the need for a repeat test at greater dilution, thus reducing cost and turnaround time.

Chemistry. Clinical clues give the referral lab insight into what the physician is looking for and enable workers there to choose the right chemistry from the start. For example, a serum testosterone is ordered. Because the specimen was obtained from a male with androgen deficiency, a greater volume of serum will be required to quantify low levels of testoster-one. Being informed in advance of relevant clinical information about the patient will thus assist the lab in providing better service.

Preparation. The care with which a patientis prepared foruncture may determine the ultimate usefulness of the test results derived from the blood specimen taken. Single serum sampling in a specialized field such as endocrinology is seldom of much value without due regard for fluctuations caused by the physical status of the patient at the time of sampling: age, weight, sex, diet, posture, emotional state, time of day, and prior medications.

Series. Running all specimens in a clinical series in the same assay improves statistical precision. In radioimmunoassays, for example, the intra-assay coefficient of variation for precision may be 5% to 7%, whereas interassay reproducibility may be as high as 10% to 15%. Therefore, if all five human growth hormone specimens from an insulin infusion test are run in the same assay, a better statistical analysis will result than could be obtained by spreading them out over several assays. It would be best to indicate on the laboratory slip, "Tube #2 in a series of 5."

* Specimen preparation. Sending appropriate specimens, essential to obtaining good service, begins with an appreciation of which specimens require special handling. If the temperature of a specimen for plasma renin activity is allowed to rise above 4[degrees]C at any time during preparation for shipping, for example, renin substrate will be converted to angiotensin I and the value found will be incorrect.

The presence in serum of cortisol-binding globulin causes the equilibrium of cortisol between serum and intracellular fluid in blood cells to be unequal. Allowing such a specimen to hemolyze will make it impossible to interpret the results.

Referral laboratories provide written instructions, usually in the form of manuals, on the proper handling and shipment of specimens. Any additional questions can be answered on the telephone.

Materials and equipment for special handling should be available to the primary lab's send-out staff. A few tests, such as plasma renin, require refrigerated centrifugation or a tested substitute for separating serum from clots. All requiements should be identified before the specimen is drawn.

Some specimens must be sent in special tubes to assure uniform handling and reduce the variability of results. Certain polypeptides are best sent in plastic vials provided by the referral lab. Ordinary test tubes are poor for shipping because these polypeptides adsorb to glass surfaces and, to a lesser extent, to some plastics.

* Specimen transfer. Once the decision has been made to send a specimen to a referral laboratory, the actual number of miles it must travel within the continental United States makes little difference. Properly handled, such a transfer can be done efficiently. Handled improperly, however, the results can be disastrous.

Packaging. Serum must be placed in a vial that not only fits the chemical requirements of the specimen but also will withstand the physical trauma of shipping. The cap must be absolutely leakproof. Simple failure to screw the cap tightly has ruined many a specimen. Patient identification should be clearly written on the label with an appropriate marker even if the package contains only one tube and a request slip. Once the tube arrives at the referral lab. it will not be alone.

Frozen specimens. Dry ice extends the usefulness of specimens for up to four days. The shipping container should be made of polyfam or a similar insulation material and large enough to accommodate dry ice that won't dissipate before the specimen has reached the lab. As the ice dries and shrinks, tightly packed tubes will become loose. Shipments packed with dry ice should therefore include thawproof packing. Frozen specimens should never be transported in glass containers.

Weekends. Does the referral laboratory provide weekend pickup? Storage of a serum specimen for even two or three days can alter its chemical components.

Shipping address. Use only the mailing label supplied by the referral lab. There may be one address for shipping and another for correspondence and billing. Alert the lab before shipping anything by private courier.

Requests for pickup. Become acquainted with the referral lab's courier routes and time schedules. Ordinarily, pickup is initiated by a phone call. Place such calls as early as possible after venipuncture. If a specimen is drawn in the late afternoon, phone right away to order a pickup early the next morning. Waiting overnight to call and reaching the lab after couries have left the next morning may delay pickup until afternoon.

Timing. Test reports should be delivered in time to be of most use. If results from the main hospital lab go to the wards at 5:00 p.m., results should arrive from the referral lab by 4:30. Otherwise they may not reach the wards until late the next day, possibly delaying treatment or incurring an extra night's stay in the hospital.

* Result reporting. The identification data on the test result report sent by the referral laboratory is only as complete as what was sent out in the first place. Information provided by the referring laboratory should include patient name, ID number or other secondary form of identification, primary lab, ordering physician, and date and time the specimen was obtained. For many tests, it is also important to indicate the patient's age andsex so that the referral lab will be able to supply and age- or sex-related reference values on the report.

The referral lab should notify the primary lab concerning the date on which the specimen was received and the date on which it sent the report. Having this information makes it possible to assess different aspects of turnaround time for quality control and quality assurance purposes.

The numercial result of the tests performed should be expressed in appropriate units. To avoid gross errors of transcription--indicating micrograms for microunits, for example--the laboratorian at the primary lab who will transfer that information to the institution's reporting sheet must be knowledgeable in the relevant areas.

Any anticipated age- or sex-related values should be indicated on the reporting sheets at the primary lab. Providing a single computer-stored value for all results is not sufficient.

* Units of response. The report communicates more than numbers, but includes units--which imply standardization. Generally accepted standards may, however, still be lacking forassays in some new fields. Perhaps no properly purified material is yet available. Many hormones still cannot be produced synthetically and must be purified from biological sources, a procedure that may be done differently in various laboratories.

When a bioassay is used as a reference, therefore, results are often reported in units of response. Certain hormones that raise blood pressure are measured in units of BP rather than by weight.

For other hormones occurring in several slightly different forms, there may be no consensus about values. Absolute values may differ among laboratories, depending on the standard used; if so, the referral laboratory should state what values have been used. A wide variety of current reference standards is available from the World Health Organization (WHO), among other groups.

Different analytical methods employ different absolute values. The same standard for plasma renin activity, for example, will yield a different absolute answer at every level when run at variable pH ranges.

* Reusing specimens. It's common for the primary lab to ask that a specimen be reused for a repeat determination or for an assay that was not requested originally. If parathyroid hormone (PTH) measures low in a hypercalcemia specimen, for example, a PTH-related peptide determination may be requested to explore the possibility of tumor hypercalcemia. To prepare for such requests, the referral lab should freeze and retain previously run specimens.

* Materials and records. Referral laboratories are often asked to provide an early report of an assay in progress. The most the primary laboratory should expect to learn, however, is that the specimen was received, is being assayed, and will yield results at a certain time. Tests cannot conveniently be tracked in mid-assay. Although it is acceptable to demand a great deal from the referral lab, expecting something that cannot be provided will inevitably result in disappointment.

Records at the referral laboratory can be useful to the primary lab after the fact as well. The referral lab becomes an archive for answers on previously assayed specimens when report forms or patient charts are lost at the primary lab. You'll have the most success in requesting an old report if you provide the patient's name and identification number, not just the date on which the specimen was obtained.

* Collaboration. Sending a specialized test to a referral laboratory and following up on the result report entails a series of interactions on the phone and in writing, often via computer, and sometimes in person. From the moment of obtaining a specimen, and in some cases even before, awareness of what the referral lab needs so that is can provide the best possible service will help you obtain that service. Rest assured that the referral lab wishes to provide such service.

If service ever lags, take your concerns to the referral lab. Work with people you previously identified there, developing a collaborative relationship in which each partner adjusts procedures to make things better for the other. Primary and referral laboratories are staffed by professionals for whom providing the best in health care is the ultimate goal.
COPYRIGHT 1991 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1991 Gale, Cengage Learning. All rights reserved.

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Title Annotation:Using Referral Labs Efficiently, part 3
Author:Nelson, Jerald C.
Publication:Medical Laboratory Observer
Date:Aug 1, 1991
Words:3195
Previous Article:Laboratorians: on the front lines of exposure; lab-related findings from the 7th International Conference on AIDS.
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