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Reequipping the lab: a brisk pace of renewal.

Most laboratories have acquired their major analyzers since 1986, and many are planning new acquisitions in the next few years, a nationwide MLO survey discloses.

Instrumentation has grown current in most of the nation's clinical laboratories over the last three and a half years, and the process of renewal through purchase, reagent rental, or leasing will continue at a brisk pace into the 1990s, an MLO survey of more than 700 labs has found.

The survey covered major routine analyzers in chemistry as well as therapeutic drug monitoring and Stat electrolyte analyzers, cell counters and coagulation analyzers in hematology, and automated identification and susceptibility systems in microbiology. Payment methods for past and planned acquisitions were explored along with the value of the instruments.

Part I of our special report will deal with these matters plus instrument advantages and problems, reagent issues, and laboratory computerization. Part II, which follows, will focus on how laboratories win administration approval of proposed major acquisitions.

Of the 1,300 survey questionnaires sent to lab management members of MLD's Professional Advisory Panel, 702 were returned for a 54 per cent response rate.

Figure 1 takes stock of current instrumentation. Among the large proportion of laboratories with a major routine chemistry analyzer, for example, 68 per cent acquired the unit since 1986. More than a third of the labs with such an analyzer indicate plans to replace it by 1992, while more than 40 per cent of the labs without such an analyzer plan to acquire one.

All of the instruments in the survey are in fairly wide use. Chemistry analyzers, at 86 per cent of the labs, head the list. They are followed by cell counters (without automated differentials, at 54 per cent of the labs; with automated diffs, at 50 per cent) and coagulation analyzers (72 per cent).

Only the relatively new automated microbiology ID/susceptibitity analyzers are in fewer than half of the laboratories surveyed (43 per cent, which is still a substantial proportion).

Most of the microbiology instruments (77 per cent) were acquired since 1986. In the same period, seven out of 10 laboratories also obtained their cell counters with automated differentials. On the other hand, cell counters without automated differentials date backearlier than 1986 in most laboratories.

The proportion of labs scheduling instrument replacements by 1992 ranges from 23 per cent for TDM analyzers to 37 per cent for cell counters with automated diffs.

Figure II shows how laboratories acquired their instruments and the average value of the instruments at the time of acquisition. Seventy to 80 per cent of the labs made outright purchases of their cell counters, chemistry analyzers, Stat chemistry analyzers, and coagulation analyzers. Twothirds of the labs also bought their microbiology ID/susceptibility analyzers.

The highest use of reagent rentals occurred with therapeutic drug monitoring (50 per cent of the laboratories took the rental option) and microbiology ID/susceptibility (23 per cent). Leasing came up most frequently on cell counters with automated diffs (19 per cent); other counters (14 per cent); and chemistry analyzers (16 per cent).

Major routine chemistry analyzers and cell counters with automated diffs commanded the highest average values at acquisition-$96,600 and $91,600, respectively.

Figure III details whatever firm, budgeted plans laboratories have for replacement or first-time acquisition of instruments. Outright purchase will continue to be the predominant means of obtaining instruments, but reagent rental and leasing arrangements will become more frequent, a comparison of Figures II and III reveals.

Instrument prices are going up, the comparison also shows. The average budgeted value for a major routine chemistry analyzer is $111,400, up $14,800 from the average for chemistry analyzers currently in labs.

Test methods used in respondents' laboratories are listed in Figure IV: endpoint (at 87 per cent of labs); kinetic enzyme (84 per cent); enzyme substrate (76 per cent); and a variety of immunoassay techniques, led by enzyme immunoassay (55 percent), RIA (46 per cent), and ELISA (38 per cent). We did not ask about such specialized methodologies as electrophoresis, chromatography, and flow cytometry.

Downtime, mentioned by 24 per cent of the panelists, tops the list of significant instrument problems at the surveyed laboratories (see Figure V). Bunched closely together, at frequencies ranging from 21 per cent down to 16 per cent of labs, are an array of other factors: cost per test, reagent costs, in-house repair ability, service provided by the instrument vendor or a contractor, labor requirements, throughput, and the amount of staff training needed to operate instruments,

These levels of discontent mean, of course, that a large majority of laboratories do not have problems in each of the categories mentioned. And 27 per cent of all labs cite no significant problems of any kind with their instruments.

Here's what some panelists have to say about instrument and manufacturer shortcomings:

*Cost per test was higher than the manufacturer promised, and some of. the reagent costs are much higher."

*Chemistry panels are too expensive in-house because of labor and reagent costs. We can send out to a reference lab cheaper than we can do entire panels ourselves."

*Reagent cost was our main motivator for getting a new chemistry analyzer. Downtime and the cost of the service contract were the main reasons we replaced our hematology analyzer."

*We have had no significant problems with our instruments. Our workload, however, indicates a need to look at further automation that will allow us to bring panel testing in-house, especially large chemistry panels. We also need as much walkaway capability as possible to increase efficiency with current staff."

*Our latest analyzers were closely looked at before acquisition to minimize problems. The major analyzers are still new enough to be working pretty well. Instruments in general seem to be better designed now than in the past."

*We keep getting different answers on troubleshooting and maintenance, depending on whom we talk to."

*All of our major instruments are five or more years old, and downtime is becoming more frequent and expensive."

*Downtime is a problem because the manual does not give us enough information to undertake repairs. The service person is 150 miles away. In addition, parts have to be shipped to our Midwest lab from California. "

*Our chemistry instrument is much touchier than expected. It requires more training than we were led to believe it would before the purchase."

*In-house service through trained biomedical engineers has greatly reduced cost and downtime."

*With staffing levels cut to the bare minimum, it was hard to find the time to train personnel adequately on some of our instruments and keep up with the routine workload. Finding quality, uninterrupted time was rare."

*Although the instrument is new, there is too much downtime because too many employees are not adequately trained to use it."

*Because of an increase in Stat requests, a higher throughput is essential. Forty per cent of our volume consists of Stat requests."

Asked what type of reagents their laboratory's main chemistry analyzer uses, 61 per cent of the panelists said wet, 35 per cent dry, and 4 per cent both (Figure VI). When the time comes to replace the chemistry analyzer, 37 per cent of the panelists believe one with wet reagents will be chosen, and 22 per cent lean toward dry reagents; 41 per cent don't think the type of reagents will matter in selection of a new chemistry analyzer.

The main chemistry analyzer at 51 per cent of the laboratories is a closed-reagent system, requiring the labs to use only the instrument manufacturer's reagents. These laboratories were asked if they would prefer an open reagent system-27 per cent said they would, 37 per cent said they would not, and 36 per cent said it doesn't matter.

"Open-reagent systems appear to be less expensive," a chemistry supervisor in a large Kentucky hospital says, "but you lack the backing of the instrument manufacturer if you do not use the manufacturer's reagents."

A number of panelists would switch from a closed to an open system only if there was no loss in reagent quality. The blood bank supervisor at a small Virginia hospital notes: "We have tried using other reagents in our instruments and have run into minor problems, such as instrument malfunctions and erroneous test results."

"If the change would give me the same reliability at a cheaper cost or longer reagent outdates, I would buy from a company other than the instrument manufacturer," says the laboratory manager at a small Kansas hospital.

The survey looked into three aspects of instrument flexibility. Current instrumentation permits eight out of 10 labs to change the makeup of profiles and add new tests as needed (Figure VII). Six out of 10 labs have been able to to consolidate workstations with new instruments.

Panelists also furnished this picture of the current state of laboratory computerization (Figure VIII):

*Fifty-eight per cent of the laboratories in the survey have a laboratory information system.

*About half the labs acquired their LIS since 1986.

*At 84 per cent of the laboratories, the LIS interfaces with instruments.

*ln hospitals, 79 per cent of the laboratories with computers receive patient ID from the hospital information system, and 64 per cent receive test requests. Eighty per cent of the LISs can send test results to terminals outside the lab.

Finally, 38 per cent of the panelists' laboratories plan to expand their information systems significantly in the next two years, and 18 per cent plan to replace their LISs in that period (Figure IX).

That concludes our look at the status of major instruments and computers in clinical laboratories. Turn to Part II to see how lab management is persuading administrators to approve proposed acquisitions. n
COPYRIGHT 1989 Nelson Publishing
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Article Details
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Title Annotation:part 1
Author:Benezra, Nat
Publication:Medical Laboratory Observer
Date:Aug 1, 1989
Previous Article:Reequipping the lab: how to win approval for acquisitions.
Next Article:Preparing your lab for an inspection.

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