Reducing turnaround time for ABGs in the ICCU.
THE ACUITY OF OUR PATIENTS has increased while the health care dollar has shrunk. Timely test results are more critical than ever for those labs that want to achieve the best possible patient care. While point-of-care testing is the road to speedy results for many institutions, our hospital lab used the total quality management (TQM) process to significantly improve arterial blood gas turnaround time to the intensive coronary care units (ICCU), thereby keeping the work in the central lab.
Swedish American Hospital is a 400-bed, full-service, acute-care center in Rockford, Ill. Part of the Swedish American Health System, we are recognized as a regional leader in cardiovascular medicine, cancer treatment, psychiatry and mental health, surgery, gastroenterology, and emergency and trauma care.
Turnaround time (TAT) for arterial blood gases in the ICCU has been a recurring concern at our facility and among caregivers generally for many years. Extensive discussions, many analyses, and such remedies as filing incident reports and talking over especially long TATs with individual technologists produced no lasting improvement.
Finally, an interdepartmental TQM project team that included personnel from nursing, the clinical lab, and respiratory therapy was charged with the mission of achieving an acceptable TAT for arterial blood gases drawn in the ICCU. Author Schiller was team leader for the project, which began in April of 1991 and concluded successfully in September of 1992.
* Gathering and charting data. Because the TQM process is data-driven, the team needed published data on acceptable standards for blood gas TAT. Little usable data were available, however. We studied hospital quality assurance reports in an attempt to identify a pattern or to locate causes creating prolonged TATs. The reasons for the lengthy turnaround times in these reports varied greatly; problems occurred on all shifts. We needed data to determine the "ideal" and "minimal" acceptable TATs according to clients--the physicians, nurses, and respiratory therapists (RTs) most affected.
We developed a questionnaire and gave it to 23 registered nurses (RNs), 15 RTs, and 11 physicians. The return rate was an amazing 100%. Histograms were developed from the collected data to demonstrate the ideal and minimal acceptable TATs for arterial blood gases.
* Establishing current TAT. We developed a flow chart that clarified the processes that contributed to prolonged turnaround time: ordering, collecting, analyzing, and reporting. We knew we needed to establish the current TAT in order to monitor any improvements. After collecting data for 3 weeks, the turnaround time for all types of blood gases proved to be 51.3 minutes. When displayed in a flow chart, these data demonstrated that the largest portion of time was preanalytical.
Arterial blood gas requests at Swedish American are categorized as routine, Stat, or timed, with the latter constituting the majority. We decided to focus our attention on timed gases, postulating that the less frequent Stat and routine specimens would be affected by our proposed solutions aimed at improving TAT on timed ABGs. After reviewing the data for the timed gases, we discovered that the average TAT was acceptable to only 4% of our clients.
* Improving the process. We used the brainstorming technique to identify possible solutions. Twenty-five possibilities emerged; each was reviewed, discussed, and evaluated on the basis of feasibility, cost, and ease of implementation. The proposed solutions with the greatest impact on TAT were:
Point-of-care testing. The inauguration of such a service would have the greatest single impact but would also be very costly. (We estimated about $95,000 in first-year expenses, not counting the additional cost of laboratory staff to train and supervise ICCU personnel.) A cost-benefit analysis validated the assumption that additional lab personnel costs would be incurred. There were two other practical considerations. Nurses expressed concern about assuming the QC and maintenance responsibilities that point-of-care testing equipment would require. They felt that their primary focus should be patient care. The second concern involved computer interfacing. Because of the nature of the hospital's billing and charting procedures, point-of-care equipment would require computer interface to the hospital information system (HIS). That would render the units immobile, decreasing their effectiveness.
Pneumatic tube system. The transport of specimens through a pneumatic tube system--under consideration before our team was established--was assumed to be faster than our current method. Data collection was necessary to validate this assumption, however.
We simulated delivery via pneumatic tube by using clinical lab science students to transport specimens for 2 weeks. This data collection showed a savings of 9 minutes. The experiment contributed to the decision by the hospital's board of directors to approve installation of a tube system throughout the institution and its satellite facilities.
Early morning phlebotomy team. Most of the morning blood collection at our hospital was performed by clinical laboratory scientists (medical technologists). This left only a skeleton crew in the central lab to respond to timed and Stat testing. That shortfall contributed to delays in analysis, especially when large batches of specimens arrived.
It was not unusual to have 8 to 15 sets of blood gases come from the ICCU at one time, competing with emergency department and surgery Star requests. To counter this logjam, we created an early morning phlebotomy team made up entirely of phlebotomists. That team allows laboratorians to stay in the lab to perform blood gas testing as soon as those specimens arrive. The use of the phlebotomy team has also improved the TAT for other tests collected on the morning round. No batching of ABGs. Many blood gases were ordered in the ICCU at the same time, primarily because of physician preference. This practice caused batching that contributed to the aforementioned logjam.
Many ABGs were also collected by respiratory therapists at regularly scheduled ventilator changes. We requested input from our specialists in pulmonary medicine, who decided that RTs could make early morning ventilator changes at staggered times, as long as certain criteria were met. We worked with the RTs to change their schedules. Creating the pneumatic tube system also helped ease the batching problem.
RNs or RTs draw specimens. Arterial line draws demonstrated shorter TATs than direct arterial puncture specimens. While it is not always clinically acceptable to have an arterial line, the possibility of RNs or RTs obtaining the majority of arterial specimens was an option discussed by the team.
RTs are trained in doing arterials, including the administration of Novocaine to control the inherent pain. Members of the respiratory therapy department conducted extensive training and skill verification to pass along their drawing knowledge to the ICCU nursing staff. The ability to draw arterial blood gases has given the RNs more control over their patients' care.
* Monitoring the process. To maintain the gains we have achieved in TAT, continuous monitoring is necessary. Author Tiffany, the supervisor of the clinical chemistry section, uses the HIS to generate a daily TAT report. She reviews it for TATs that exceed the allowable maximum.
There is an excellent working rapport between the laboratory and the ICCU staff nurses. Many problems are averted with a single telephone call or visit. * Dramatic reduction. Figure 3 is a before-and-after comparison that shows how we improved the TAT by targeting particular segments of the testing process. Arterial blood gas TAT has been more than halved--from 51 to 20 minutes, with most of the improvement coming in the pre- and postanalytical phases. Not surprisingly, client satisfaction has jumped from 4% to 80%, based on original data collected from physicians, RTs, and RNs.
Part of our quality improvement was the installation of a new HIS. This system, which provides much more rapid transmission of data between the laboratory and the ICCU, saved nearly 13 minutes in TAT. (Under the old system, ABG results were queued en route to the ICCU, wasting time.)
The new computer system also provides an on-line turnaround time report that enables the lab to monitor its progress toward customer service goals. Fewer complaints are received about TAT. Following the successful handling of a turnaround time dilemma, our clinical laboratory scientists are much more aware of their impact on patient care.
By reducing the amount of time laboratorians spend on specimen collection, we have allowed them to focus more on putting the rest of their laboratory science education and skills to work, and have increased their job satisfaction. Schiller is MT program director and Tiffany is chemistry supervisor at Swedish American Hospital, Rockford, Ill.
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|Title Annotation:||arterial blood gas; intensive coronary care units|
|Author:||Schiller, Lorinda; Tiffany, Debbi|
|Publication:||Medical Laboratory Observer|
|Date:||Feb 1, 1994|
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