Stat guidelines for laboratories.
How are we so sure there's a high level of interest? For one thing, our day-long ASCP-sponsored seminars on Stat testing have drawn more than 500 registrants coast to coast over a 2-1/2-year period. For another, prospective payment has thrust "quick response" labs, or Stat labs, into the middle of countless hospital planning discussion. In the future, we believe, the bulk of routine hospital laboratory work may be performed off premises, while an on-site Stat lab will handle both medically urgent testing and procedures that can, with quick turnaround time, shorten a patient's stay.
Our audiences filled out questionnaires on State issues. Figure I shows that 34 per cent of their hospitals already have Stat labs, either as a separate section within the laboratory or as a satellite. Stat labs are in operation in the great majority of hospitals with 800 or more beds and at roughtly half the hospitals with 400 to 799 beds. Among smaller hospitals, the percentage with Stat labs falls off considerably.
We will summarize our ideas and those of seminar participants on several aspects of Stat testing. Let's start with the way we define two key terms. Turnaround time extends from receipt of a specimen for testing in any part of the laboratory to the moment when results are available in the lab for reporting. And Stat means that the information requested is essential for immediate medical decision making on behalf of the patient--an action, a diagnosis, or a prognosis is contemplated in response to this information. As a corollary, if immediate patient care is not the stimulus, the test request is not a legitimate Stat.
Using that definition of Stat, only a limited number of tests should be made available on an emergency basis. In fact, many laboratories operate with a Stat list, which is a must in our view. A lab cannot perform any and every test Start on a clinican's sayso, because if everythign is Stat, nothing is Stat--it all then reverts to rountine testing.
Which tests belong on the Stat list? That's for each laboratory to decide in conjunction with the medical staff. The list will vary from institution to institution, just as medical services provided will vary. Nonetheless, most laboratories agree on a nucleus of procedures that are necessary to insure adequate Stat service.
Stat lists were brought to our seminars by 278 participants, and every one of them contained electrolytes, glucose, and BUN. Ninety per cent or more also had amylase, calcium, complete blood count, activated PTT, and prothrombin time. Urinalysis and CSF examination ranked close behind, on 89 and 84 per cent of the Stat lists, respectively.
A composite list of 70 Stat procedures, drawn from all the laboratories' menus, is displayed in Figure II. Twenty-seven tests (including several therapeutic drug monitoring assays) are offered Stat by bess than a quarter of the labs. Of course, seomthing like transfusion reaction workup, cited by only 14 per cent of the respondents, is misleading. The need for such as workup is rare--which is probably why it did not appear on more of the lists--but any blood bank would perform it Stat.
In response to one survey question, most seminar participants mentioned overordering of tests on a rush basis as the top Stat problem they faced. Many indicated that a menu can help somewhat by limiting what will be done Stat. When it is a set policy that everyone is aware of, it also reduces friction between clinicians and nurses on the one hand and laboratory personnel on the other.
Here's a sampling of comments on Stat abuse:
* "When and how can the line be drawn on which tests are accepted and run on a Stat basis? It seems that the variety of requests for Stat handling continues to expand."
* "There are too many so-called Stats at the same time. Which are the real Stats? I don't know how to solve it."
* "We were getting outrageous orders at all hours of the night from each new batch of residents. The solution was to revise the orientation and have medical technologists, not the pathologist, explain evening and night staffing, turnaround time, etc."
* "Why are there so many Stat requests for certain tests--such as protein electrophoresis--that don't seem to affect immediate patient care? How can we educate the medical staff not to abuse the Stat designation?"
* "The emergency room physician submits large amounts of Stat requests at one time and wants them all done first. What is the best way to establish and enforce a Stat list?"
* "Our emergency room has adopted its own ASAP policy for tests that they can wait up to an hour for."
* "How do we stop tests that are ordered Stat for the physician's convenience?"
* "Quite a few of the nursing, medical, and surgical staff try to tell technologists how to operate that Stat lab."
More than half the surveyed individuals were bench personnel, 27 per cent were lab managers and supervisors, and 14 per cent were pathologists. On the subject of controlling Stat abuse, technologists and supervisiors pointed out that laboratory directors can play a big role. As one respondent put it: "When unreasonable Stat orders come in--such as a nurse who forgot to order a test the night before and sends down a Stat order later--the pathologists are notified and make an effort to correct the situation."
Another said: "When an instrument is down and results are still needed Stat, the pathologist calls critical care and the ER, explaining the problem and telling them that results will take a little longer."
Several lab staff members called for pathologists to be more supportive and make firm decisions and then stand behind them. One respondent worked with a pathologist who "takes a fairly active role, but should be more assertive with physicians who order seemingly unnecessary Stat tests." Then there was this harsher assessment of lab leadership: "Our major problem is that we have a pathologist and lab manager who say yes to everyone. So essentially our Stat list means nothing."
Instrument and staffing problems are major Stat lab concerns. "Excessive downtime on instrumentation leads to unacceptably slow turnaround time," one manager told us. "Should we have backup instrumentation in other departments of the lab?" another asked. And a manager considering establishment of a Stab lab was completely at sea: "What kind of instrumentation should a Stat lab have as regards dependability, accurancy, maintenance, ease of repair, and hands-on time?"
One laboratorian complained that "adequate staffing is extremely important to fast turnaround time, but workloand recording data can't assist us." Administration may deem the Stat lab underproductive because it fails to see that testing isn't batched and that controls and dilutions, for example, must be repeated for each run.
Data supporting laboratory administrative decisions on Stat testing are available within each institution. To support staffing and instrument decisions, we recommend establishment of CAP workload values specific for Stat requests, based on current methods and intrumentation. Such data are imperative if laboratories are to adjust adequately to the rapidly changing environment of the 1980s.
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|Author:||Sazama, Kathleen; Haugh, Mary G.|
|Publication:||Medical Laboratory Observer|
|Date:||Mar 1, 1985|
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