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My useful niche as send-out technologist; the author's research and enterprise in ordering tests from referral labs have delighted doctors and expanded test volume.

The author's research and enterprise in ordering tests from referral labs have delighted doctors and expanded test volume.

Seven years ago, when my children were entering school, I decided to resign from my job for a while. Because I wanted to be at home for them before and after school, it seemed a good time for a hiatus in my career.

I was working full time in histology in the laboratory of a 530-bed hospital. The lab director expressed dismay at my decision and asked me to stay. The assistant lab director (now our lab director) proposed a solution: to create a part-time position directing send-out tests. This step would accommodate my preferred hours while resolving our continuing problem of uncoordinated referral testing. Funds were found in the budget and a job was born.

* Muddle. In the past, no single person had been assigned to handle send-out tests. Specimens had been left in a designated area in the lab until one technologist or another took the initiative to prepare them for shipment. Occasionally a technologist would be assigned to oversee the area for a week at a time while performing the regular routine.

Similarly, no individual was designated to receive and follow up on reports. Results were entered in the log book in which the test had been signed out, but no one consistently checked to make sure they had arrived at all, much less on schedule.

Our physicians had started to wonder if ordering esoteric tests was worth the effort. Our hospital endocrinologist, for example, was frustrated because we were not keeping results straight for his orders of multiple tests to be performed on the same patient on three succeeding days. Partial results and slow turnaround time were delaying diagnosis.

* News travels fast. I settled into a small area within the main lab. As physicians called the lab looking for results or with send-out orders, they were given my name and told that I was now in charge. Our medical staff was delighted to have a contact person available to provide information and follow through to the final report. Internists began to ask for tests they had recently read about in clinical journals. Their phone calls and my workload quickly increased.

With the help of the endocrinologist, who was happy about our new arrangement, I devised a worksheet for tracking send-outs and recording test results.

* Choosing a referral lab. To reduce turnaround time, and because some referral labs batched tests and couldn't always do the one we wanted on the day we wanted it, I quickly branched out and began to use more labs. For basic reference material, I began to accumulate directories published by referral labs--catalogs of what they offer. I now have several dozen.

We use three major referral labs routinely and send occasional tests to about 25 more. Our selection is often influenced by the discount prices we receive from several referral labs as the result of a purchasing contract that we hold in conjunction with a group of other small local hospitals.

At first, when I was off duty, one technologist or other would prepare specimens and send them out, aided only by my directories. I trained a couple of techs to do this work; then they left. One or two people from the phlebotomy section knew enough to help out, but they weren't always available when questions arose.

To keep the situation in hand, I started a rotary card file, arranged alphabetically by test name. On each card I write the common name and any alternate names of the test; the best referral lab for that test; the test code number given in the catalog; the charge code assigned by the hospital (for common tests) or the price of the test (for others); any special instructions--whether the specimen should be frozen or placed in a tube with oxalate or heparin, for example, or the serum separated immediately or protected from light; and the Current Procedural Terminology (CPT) code. On the back of the card, I write any phone number or extension or special mailing address that will help a call to reach the right person or a specimen to arrive at the right destination without delay.

When a new test comes along, I add a card to my rotary file. If a test is no longer offered by a given lab, I note on the card that the test has been discontinued or will now be done in-house. That decision, based largely on test volume, is made by the appropriate section supervisor in consultation with the pathologist and lab manager. After a test has been outdated for some years, I remove the card.

* Daily routine. The specimens we receive are accompanied by hospital requisition slips containing the name of the test or tests requested. Specimens may consist of serum, plasma, whole blood, urine, feces, calculi, amniotic fluid, cultures, sputum, surgical specimens, or cerebrospinal fluid. (Pap tests are done in-house.) Each specimen is given an accession number and entered into the send-out lab log book (Figure I). Some referral labs provide similar books. Our flow of work is summarized in Figure II.

Every referral lab supplies its own test request forms, usually in triplicate. Although multiple tests for the same patient may be entered on one request slip, I have found it more convenient to separate specimens that will travel at room temperature from those that must be frozen.

* Preparing for transport. Each referral lab supplies its own plastic tubes. (Some labs used to print their names on the tubes, but developments in hazardous waste disposal have made them less eager for the tubes to be identified so readily.) We label each tube with the patient's name and any other information required by the referral lab.

Many specimens must be specially prepared for shipping. Instructions appear in the directories. Blood is spun down and separated, then frozen, if necessary. Urine is measured for total volume, adjusted for pH as instructed, and placed in the proper mailing container. Other preparatory activities include placing calculi in mailing containers, preparing chromosome studies, and freezing cerebrospinal fluid.

Specimens are placed in plastic bags and left for pickup by couriers from three major labs twice a day (formerly once a day). In some cases we use the U.S. Postal Service or an overnight carrier.

Once specimens drawn during the night and during morning rounds are prepared, I place the hospital requisitions in a file box. I retain each form until the test report has come back.

Once a day I receive a copy of the hospital discharge summary, listing patients who left the day before. I check to see whether any patients whose test requisitions remain in our work-in-progress file have been discharged. I mark the corresponding hospital request slip with the date of discharge or death and refile the slip.

* Receiving reports. We receive some result reports by mail, but most by computer printout. One referral lab gave us a computer and printer connected with its internal computer system. We enjoyed this until the Federal Government, finding such "donations" an unreasonable inducement to use a company's services, made us give it back. The replacement was another computer and printer, which provides only hard copies of reports--satisfactory, but not so helpful. Another lab gave us a screen and printer. This setup provides us with not only printed reports but also on-screen information including test and CPT codes, prices, test requirements, and turnaround time. Historical data are also available.

Our lab's new computer system will be fully operational in about a year. I'm looking forward to computerizing my files.

I'll soon have more room, too, when our little are is enlarged. Safety concerns as well as the need for more space compelled us to expand beyond one counter. We will have one for paperwork and another for specimens. A thin metal headset makes my considerable telephone time more comfortable and enhances mobility.

* Recording results. The copy of the result report that I retain is filed alphabetically by patient surname and placed in an envelope with the other reports received that day. Writing the date on the envelope makes it easy to look up old reports by comparing that date with the one which the test was returned, as recorded in the sendout log book. The copies in envelopes, which I keep unceremoniously in boxes in a storage closet, are saved for six months to a year, depending on available space.

When time permits, I immediately supply the billing information to the data processing people in our hospital's billing department. Sometimes other responsibilities force me to put off that task for a while.

* Experts. When ordering physicians tell me what they would like done, I'm glad I have a strong technical background. To do my research, I call on experts: the physician in charge of infection control at our institution, pathologists, Ph.D. scientists, medical technologists, nurses, and other health professionals with expertise in the subject at hand. These experts provide details about the test to be performed.

All my work would be pointless if I didn't understand their explanations well enough to relay to the attending physician. I have often called physicians at the Centers for Disease Control in Atlanta. They appreciate my ability to grasp the topic and usually invite me to call again, if necessary.

My rotary file contains cross-references under numerous categories: test name, expert's name, place where the expert works, and general area of test, for example. Some of this priceless information resides in my brain. Although I plan to transfer most of the data to our computer, there's no substitute for human memory.

* Research. I start my hunt for an unusual test by going through my stack of directories. Some searches are easier than others. Finding a lab to do whole blood viscosities, for example, took a while. Many referral labs said they had formerly done this test but had discontinued it. After calling all our local hospitals and our bigger accounts, I pored over small directories from more distant places and found a lab in Michigan that still did the test.

Physicians have recently submitted queries on tests for Fifth disease, Clostridium botulinum, dioxin, simian B herpesvirus, and Lyme polymerase chain reaction (PCR). None were in our directories, yet I found them all.

If I can't locate a lab to do a desired test after trying for two days, I call the doctor and ask whether the test was requested for research or patient care. If the physician still wants to have the test done, he or she may be able to suggest where to have the test performed, or if not, to cite a reference, such as a recent journal article.

Finding a lab that performs the desired test is not the end of the process. I always ask for specimen requirements. Referral labs can be very specific about their requirements: using overnight mail; a plastic foam container inside a corrugated box; or sealed, puncture-proof plastic bags. I might have to mark the package "avoid excess heat or cold" or send it at room temperature or frozen.

I ask the cost of each test, the complete address, the name and telephone extension of a contact person for future reference, and billing instructions. Finally, I ask for estimated turnaround time.

Like health care practitioners everywhere, our physicians have become more and more cost conscious. If a test will be too expensive for its probable benefit, they may decide not to have it done. Most of the time, however, we do all tests requested.

After about five years under this system, requests for send-outs had increased so much that I ended up working full time after all. This suited my career plans, since my children were older by then. I have now done send-outs full time for two years.

* Right person for the job. I find my detective work very interesting. I enjoy speaking with people from all over the country who willingly share the wealth of information they have accumulated.

I feel strongly that send-outs should be managed as a lab section, with one person providing continuity and a constant and consistent improvement in service. It is essential to have a dedicated person so that confidentiality in HIV testing, pre-employment drug screening, and other sensitive areas can be maintained.

Anyone who contemplates undertaking such a position should be attuned to doing research. A persistent nature is helpful, since it's often necessary to persevere when faced with a difficult request. Doing the job well requires more than rotating fill-ins--although that's the way we used to do it, and the way it is often done in hospitals. The assistant lab director who originally designed the position for me believed that the diversity of tests sent out required a technical person with a background in routine lab work. This has certainly proved to be true.

I have become known as a local resource for other laboratorians at my facility and beyond. Technologists at local hospitals have called me to ask how to send out special tests and where to send the specimens. Many say that physicians at their institutions have left them messages to call me and ask about my protocol. I may become a "send-out" myself if tentative plans to share my experiences with other labs are fulfilled. I would enjoy presenting in-service programs at another facility or a professional meeting.

The achievements of my mini-department have paid off for our hospital as well as our lab. Physicians who are considering joining the hospital staff are brought to me on their grand tour of the facility. We feel that what we offer has attracted some new doctors and pleased current ones.

* Greater efficiency. Having a corner for send-outs has helped make our lab more organized. Technologists are let alone to do their work; those with no interest in doing send-outs needn't worry about having to squeeze them into their schedules.

The result of all these benefits is that patient care has improved. Expediting diagnosis and treatment helps reduce the length of hospital stay. Fast treatment is particularly important during these days of DRGs, when patients seems to be sicker and when our formerly typical patient is often treated on an outpatient basis.

Billable tests from our send-out section have mushroomed. Statistically, the numbers show a gradual rise in tests sent out. On a monthly basis, however, the numbers increase and decrease as we bring some tests in-house and start sending out new ones. If our send-outs continue to multiply as we expect them to, we'll be ready.

Katharine M. Tully Barnes, a medical technologist, runs the laboratory send-out section at Baptist Hospital, Pensacola, Fla.
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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Author:Barnes, Katharine M. Tully
Publication:Medical Laboratory Observer
Date:Jun 1, 1991
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