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Meeting new challenges in an office lab; the need to keep pace with higher test volume transformed this clinic's laboratory into a well-automated operation.

More test work is coming to physicians' office laboratories because of new Government methods of health care payment. To meet the challenge, many of these labs are changing from cubbyhole operations performing only urinalyses and CBCs to highly automated facilities capable of sophisticated on-site testing.

Our clinic's laboratory underwent the metamorphosis from manual to automated operation during the last five years. To our surprise, our growth closely paralleled steps taken by hospital labs to raise their productivity as reported in a March 1984 MLO article, "Improving Lab Productivity: The Search for Strategies."

Here's the path we followed to technological maturity:

* Instrumentation. The productivity measure cited by the highest number of hospital laboratories in the MLO article was the acquisition of automated instruments. This has also been our single most effective measure. Before automating, our group laboratory performed an average of 25 manual CBCs a day, some routine chemistries with a spectrophotometer, urinalyses, routine throat and urine cultures, and prothrombin times and PTTs. Testing then as now was for our patients only.

When an oncologist and an internist joined the seven physicians already in the group, we knew the number of CBCs would increase. The doctors approved the purchase of a seven-parameter semiautomated counter for nearly $15,000. Turnaround time shortened, red cell indices were routinely provided, and we all became spoiled on automation.

Then one day our coagulation timer gave out. There was talk that this make would soon be discontinued, which meant that supplies might no longer be available. Rather than repair it and risk not having supplies, we replaced it with one that has a disposable chamber holding six tests. This $3,500 timer does three in-duplicate tests at a time versus the old instrument's one at a time. The disposable supplies are also cheaper.

When our old-fashioned differential counter broke and we could not get replacement parts, we bought an electric model that cost only a little more than a new manual counter. Technologists in our lab love it because the electric keypad reduces arm and hand fatigue. The instrument's nontotal button allows the operator to bypass an automatic count at 100 cells and go on to higher numbers, which is necessary for platelet counts. Throughput for differentials improved with this purchase.

Another time-saver is a 30-hole centrifuge that replaced a six-hole model whose motor burned out after 20 years of service. The new centrifuge--a $500 investment--enables us to process blood for send-outs much faster. And we can spin all the tubes for a rheumatoid latex titer at once instead of in batches.

About a year ago, we decided to go for it and do our own 20-test chemistry panels and thyroid function tests with a $32,000 chemistry analyzer. One of our goals was to cut back our monthly reference lab bill, which was $6,000 after volume discounts.

It was the right time to buy. Prices had dropped and manufacturers were offering compact, no-frill instruments to meet the needs of the office laboratory market. Cost projections showed us that we would spend about $6 per patient profile with our own automated instrument, compared with $6.25 to send out the tests. We would be doing the tests with available staff, so they represented no increase in technologist salary time. To complete the system, we purchased a rebuilt microflame photometer from a distributor who had used it for demonstrations, and an Apple IIe microcomputer with printer, monitor, and two disk drives. The complete setup allows us to present collated panel results on our own customized report form, with flagged abnormals.

A short program written for the microcomputer produces consecutively numbered labels for the lab and the radiology department. We also adapted a program to produce Levey-Jennings charts for quality control. Recently added word processing software enables us to write reports, memos, and letters, and produce forms on the microcomputer. We had been purchasing laboratory request forms at a cost of 6 cents each. Now we buy stock two-part blank computer paper and produce our own forms for 2 cents.

The word processor is helping us put together a comprehensive laboratory manual. We plan eventually to have a spreadsheet and data management program to help with administrative reporting.

Within the last year, the laboratory leased a $48,000 fully automated blood cell and platelet counter. This analyzer replaced the seven-parameter semiautomated counter mentioned earlier. It has reduced platelet counting time from 20 minutes to one minute and increased accuracy. We anticipated that additional hematology testing will be generated to justify this acquisition.

At the same time, we replaced our sodium and potassium electrolyte analyzer with a leased $17,000 four-parameter ion-selective electrode analyzer. Technologist involvement in producing batches of electrolytes for chemistry panels has been reduced from an hour to five minutes. Stat electrolytes are available in two minutes.

Needless to say, the addition of automated instrumentation to an office lab is a major endeavor that causes concern--to the lab staff, who wonder if they can do the extra work, and to administrators, who wonder if the laboratory can make the venture cost-effective.

* Staff training. Hospital laboratories in the MLO article mentioned staff training as an important productivity measure. We are handling a far higher volume with a small increase in staff, thanks in large measure to training.

In the last year alone, the average number of tests our lab performs each month has increased by almost 500 tests (see Figure I). During this period, 20-test chemistry panels increased by 30 each month. (Panels are counted as one test in total tests performed.)

Five years ago, our laboratory staff consisted of two medical technologists, a nurse-phlebotomist, and a college student working as a part-time aide. Today we have two MTs, one full-time phlebotomist, one part-time phlebotomist who stays until 6 p.m. to process late specimens and do the lab shutdown, and one full-time medical assistant who can stock supplies as well as set up blood cell counts and urinalyses.

To keep hiring at a minimum, our staff has learned to do more. We have taken advantage of the medical group's continuing education policy, which provides for fully paid attendance at professional workshops. Among the particularly helpful events were a clinical chemistry review held by the ASCP in Kansas City, covering renal tests, electrolyte balance, thyroid function tests, and quality control, and recently held seminars on microcomputers in the clinical lab sponsored by Duke University and the Texas Medical Center in Houston. Through such sessions, the lab staff has kept up to date on such techniques as the ELISA method for thyroid function tests, ion-selective electrodes, and monoclonal antibody assays for pregnancy.

As chief technologist, I had to learn new managerial skills, such as cost accounting, writing proposals and, not the least, motivational techniques. Much of my new expertise comes from the personal contact I have developed with local hospital laboratory directors and with professionals who serve our clinic--the accountant, business manager, and sales representatives.

Some people just don't warm up to maintenance and repair, so a manager has to encourage everyone to do his or her share. We have not purchased maintenance and service contracts because lab personnel can usually take care of today's instruments. It's less costly to pay for service calls that are genuinely needed. Manufacturers will consult with you about a malfunction on their hot lines and send out any required parts.

* Reduced send-outs. Almost a third of MLO's hospital lab respondents said they increased their test volume by reducing send-outs. By performing our own chemistry panels, we have cut as much as $2,500 off our monthly reference laboratory bill.

With our ISE analyzer, we do more electrolytes in-house than we used to send out. The cost per patient for an electrolyte panel is 33 cents, a substantial savings from the previous send-out cost of $4.50. In addition, the group's physicians have pertinent lab results in hand sooner, and none of our patients is sent to the hospital unnecessarily. CPK and liver function assays are among the other tests now done in-house rather than sent out.

* Improved ordering patterns. Test ordering efficiency--vital to productivity for hospital labs--improved in our chemistry section with creation of a six-test chemistry panel consisting of BUN, creatinine, sodium, potassium, chloride, and CO.sub.2.. Often the group's physicians order this cost-effective combination of tests rather than the 20-test panel, which includes such often unnecessary determinations as liver enzymes. The latter panel, however, is also up in volume due to the group practice's growth.

* Elimination of low-volume tests. Several low-volume tests, including iron determinations, were dropped. They wasted reagents. In addition, we ended the thyroid function testing that had been added to our menu when we first automated. Although a year's trial gave picture-perfect standard curves, patient results did not correlate with reference laboratory findings. Rather than turn out unreliable data and spend money on backup tests, we decided to resume sending out T.sub.3 and T.sub.4..

* Batched specimens. It became imperative to improve overall working patterns in the lab before we all burned out from the heavier workload. Most of a clinic's laboratory work is considered Stat. That is, the patient comes in, has blood drawn, and the physician expects results by the time the patient reaches the examination room. This worked while our workload remained light. As it grew, we needed to reorganize.

Hematology is difficult to organize differently because chemotherapy patients must have a count before they can receive medication, anemia patients must be checked out, urinary tract infections must be confirmed before treatment, and so on. Our solution was to semi-batch tests. For example, if a Stat order comes in and there are non-Stat tests waiting on the bench, we can also include them. If there are four patients needing prothrombin times in the waiting room--in an office lab you know exactly who is in the waiting room and who is being drawn--we wait to centrifuge all the blood at once.

To schedule lab work as much as possible, we sent a memo to nurses and appointment clerks to tell patients how much time to allow for lab work before their scheduled doctors' appointments. We instruct regular patients ourselves, such as those having glucose checks, on how to schedule their meals before appointments so they do not have to wait a long time for lab results.

Chemistry was ripe for batching. We had long provided uric acids, cholesterols, triglycerides, and other non-Stat tests on demand. But with increased volume, these random single tests disrupted the technologist who handled the chemistry panels and all other chemistry tests, resulting in overtime and extra reagent usage, not to mention stress and frustration.

A cost analysis of single tests versus batch tests convinced the group's physicians of the wisdom of batching. The following policies--drawn up in the laboratory and approved by the medical group's executive committee--support batching procedures.

1. Twenty-test chemistry panels drawn one day will be processed the next day unless a nurse advises the laboratory that the patient will arrive early enough in the day to include the specimen with that day's batch.

2. Six-test chemistry panels and electrolytes will routinely be held until the next day and batched.

3. Any six-test chemistry panels marked "do today" will be run in the morning with the 20-test panels if received early enough; otherwise they will be run on an afternoon batch. Electrolytes will be run the same day as the patient's appointment with the physician. Results will be ready by 5 p.m.

4. Glucoses will be done when received, on a Stat basis. All other single chemistry tests will be batched with the panels.

Frustration levels in the lab are lower because of better organization. Nurses and physicians know exactly what to expect, and the lab receives fewer phone calls asking "When will that test be done?" Technologists can do their work without interruptions.

Thanks to higher test volume and improved productivity, the laboratory's average monthly profit margin did not decrease appreciably during the period of the largest outlay for the automated chemistry system and startup costs. The margin has reached a new peak since then. Nevertheless, lab charges have not increased except for the CBC, which now contains an automated platelet count.

A less tangible but important return is the increased awareness of ourselves as professionals. We find that with a little bit of extra work we can keep abreast of the latest technology just as well as hospital medical technologists. It seems that once the outside world is aware that an office lab is interested in keeping current with technology, notices of meetings and workshops and mailings of technical literature materialize like magic. We are genuinely proud of what we have accomplished, and it shows in our work.

No amount of reorganization in an office laboratory can be effective without strong physician support. Our forward-thinking medical group has given full backing to the laboratory's efforts to provide better service.

For their part, office laboratorians must be willing to work hard and long and seek out anyone who can help. There is no accrediting agency requiring office lab personnel to keep up with new methodology. When they do so, the rewards are greater. They can say, "We did it because we wanted to very much."
COPYRIGHT 1985 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1985 Gale, Cengage Learning. All rights reserved.

Article Details
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Author:Zachry, Katherine M.
Publication:Medical Laboratory Observer
Date:Jul 1, 1985
Previous Article:Are we outdating reagents too soon? Here are ways to extend the shelf life of many lab products without jeopardizing test results.
Next Article:Designing a more productive laboratory.

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