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Stats too high, yet labs cope.

OUR ACCURACY is rarely questioned," says the chief technologist in the lab of a large not-for-profit hospital in suburban Tennessee. At this facility, however, between 35% and 40% of total test orders are Stat, the laboratorian reports.

"Turnaround time is the major issue of the 1990s for physicians and lab management," he says. "TAT on outpatient lab work and inpatient Stat work will most likely change the traditional laboratory as we know it."

Stats are already changing the lives of laboratorians, and hardly for the better, according to respondents of MLO's 1993 survey of TAT (see Part 1, "Turnaround time down sharply, yet clients want results faster," p. 24). In written responses to questions on the survey, laboratorians react vehemently to what they see as Stat abuse by physicians. MLO asked, "Do physicians contribute to poor TAT by misusing Stat ordering?" The response was a resounding "yes."

* Stat wars. "Forty-five percent of work is Stat," says the lab director at a large, not-for-profit hospital in a Tennessee city.

"For the first 3 months of 1992, the average percentage of Stat testing for the chemistry department was 42%," reports the laboratory administrator at a large, not-for-profit hospital in New York City.

"Seventy-five percent of all tests we receive are ordered as Stat or |now,'" says the lab supervisor at a small, not-for-profit hospital in rural Kansas. "A tech cannot do everything |now.' There must be priorities."

"Up to 40% of the laboratory tests are Stat," says the pathologist at a smaller, public hospital in New York State.

We have "30% Stats," says the lab supervisor at a large, not-for-profit hospital in North Carolina. "It slows everything down."

"Over 40% of our tests are requested Stat," reports the lab manager at a larger, not-for-profit hospital in Colorado.

"Sixty-five percent of our workload is Stat," says a laboratorian at a large, not-for-profit hospital in Florida.

"Basically, our lab is a big Stat lab for the physicians' convenience," reports the lab manager at a small, proprietary hospital in Arizona.

* Political issue. "Forty-five percent of our total workload is Stat," says the lab computer coordinator at a smaller, not-for-profit hospital in suburban Florida. "TAT is a political issue within most hospitals," this laboratorian maintains. "The doctor or service that makes the most noise and orders everything Stat gets the best service. Hospital and laboratory administration are reluctant to go against these power plays."

This laboratorian tells of efforts by various units to establish satellite laboratories. Those facilities "do not always improve turnaround time but do increase TAT in the main lab due to reduced staffing." He cites this example: "Adding a therapeutic drug profile instrument to the Stat lab caused an increase in TAT. The instrument remains due to politics and the current trend toward point-of-care testing."

* Great expectations. "Too many procedures (approximately 32% of our total test requests, excluding microbiology, blood bank, and histology/cytology) are ordered as Stat," reports the lab director at a smaller, not-for-profit hospital in Pennsylvania. "Even our sophisticated instrumentation cannot produce those results as soon as expected by the staff."

Do physicians abuse the power of Stat? According to a laboratorian in a small, not-for-profit hospital in Texas, MDs order Stats "for their own convenience. They need to go home, supper is waiting and they want to have everything done before they leave."

A section head in the lab of a small, proprietary hospital in Illinois claims that physicians abuse their authority by ordering as Stats tests that should have been ordered previously as routines. "Lab personnel are busy doing these Stats, causing a delay in TAT with routine tests," this laboratorian says.

The lab supervisor in a larger, not-for-profit hospital in Rhode Island blames laziness. "We're a teaching hospital, and one resident may not look at the patient record to see if a test has been ordered. Therefore, he orders it Stat. Now we have both routine and Stat orders for the same test on the same patient."

The lab manager of a small, not-for-profit hospital in Missouri faults physicians who "demand Stats on esoteric testing."

* Major problems. While Stats aroused the most ire, laboratorians described a plethora of other problems that affected TAT in their labs.

"Front-end processing delays TAT," says the lab supervisor in a large, not-for-profit hospital in Missouri, reflecting a widespread feeling that everything is fine once the specimen reaches the lab.

The laboratory quality assurance coordinator at a not-for-profit hospital in Illinois suggests that missing in the recent TAT debate are solid data on just how long it takes specimens to reach the lab. "When we computerized, we lost the ability to capture preanalytic TAT that we had when we wrote down the collecting time on requisitions," she says, noting that most computers log the time the specimen is received in the lab. "The phlebotomist could be running around carrying the specimens on her rack for an hour. We don't have the ability to capture that information," the lack of which lengthens preanalytic TAT, while testing time remains unchanged or is shortened by faster technology. "Perhaps the only way now to get the actual collection time is to capture it on a computer peripheral device at bedside," thereby adding a layer of expensive technology that few hospital administrators would be willing to acquire.

"The problem with turnaround time is at specimen acquisition and transport," says the lab manager of a large, not-for-profit hospital in Ohio. "Once a specimen hits the lab, the Stats are turned out within an hour."

The director of the lab at a large, not-for-profit hospital in Tennessee blames "the transport of specimens from areas without a tube system. The timed collection for 4 a.m. results in an overwhelming number of specimens arriving at 5 a.m."

"Drawing the entire hospital so that all results are reported by 7 a.m." is the biggest TAT problem for a section head at a small, not-for-profit hospital in California.

"Specimens are not transported from nursing units in a timely manner," says the lab supervisor at a large, not-for-profit hospital in Ohio.

The senior medical technologist at a large, not-for-profit facility in California notes, "Specimens get hung up in central processing, or, if drawn by an RN on the floor, don't get tubed to us in time (or we forget to check the tube system)."

* |But I took it to the lab.' Analogous to failing to check the pneumatic tubes is a problem reported by the operations manager of the lab in a large, not-for-profit hospital in Illinois. During the third shift, when floor nurses draw specimens and bring them to the laboratory, "They just drop the specimens of in central processing and do not bring them to the techs" on the bench. There is no one working in central processing during the third shift.

"We send our micro to a nearby sister hospital," reports the lab manager of a small, not-for-profit hospital in Arizona. "We have a courier twice a day on weekdays, once on Saturday, and none on Sunday. If specimens aren't collected by courier times, they may be delayed by one-half to 1 full day."

The lab manager at a small, not-for-profit hospital in Wisconsin blames "orders added on a specimen that's already being processed and lack of communication regarding what's routine, ASAP, |today,' or Stat."

* Technology missing in action. The lab supervisor at a large, not-for-profit hospital in Rhode Island speaks of "not having terminals on all floors, which means we have to call in all Stats and critical values." That lab also suffers from a lack of bar coding, she says.

The assistant manager of the laboratory's chemistry section in a large, not-for-profit facility in Connecticut cites "specimen processing time, including bar coding limitations, a large volume of specimens arriving between 8 and 9 a.m., and slow throughput on our high-volume analyzer."

The lab supervisor at a large, not-for-profit hospital in Florida cites computer downtime, lack of personnel (other than MTs) to process specimens for analysis, specimen quality and quantity, and "bare bones' staffing." This laboratorian also reports "different expectations on when TAT should be measured (for example, order to result versus received to result)." Varying definitions of turnaround time are anathema to laboratorians.

Another example is offered by the lab supervisor in a large, not-for-profit hospital in Massachusetts, who complains, "Floors count TAT from the time of draw, while the lab counts TAT from the time the specimen is received in the lab. There are often delays from time of draw to time arrived in lab." A Wisconsin laboratorian notes: "Ordering by hospital floors days in advance in the computer system falsely elevates data."

The lab supervisor at a smaller, not-for-profit hospital in California cites the time it takes to log specimens into the computer (there also are printer problems). He is not alone. "We have no LIS, so we must manually type all results into the computer, which then transmits the results to the floor," reports the manager of the lab at a small, not-for-profit facility in North Carolina. Furthermore, this laboratorian says, "The hospital computer is down for 1-1/2 hours at a critical time weekday mornings." That prevents the lab from transmitting results to the floors. Nonetheless, "Physicians order tests to be collected at 6 a.m. and then expect results by the time they make morning rounds." One outcome is TAT complaints over which the lab has no control.

* It's not my fault. MLO asked respondents to comment on such complaints, and many did.

The Rhode Island lab supervisor lists the most common ones: "The test wasn't ordered, the specimen was incorrectly drawn or labeled by nurses or doctors, or we never received the specimen."

The supervisor of the lab in a large, not-for-profit hospital in California adds another common reason for TAT complaints: "The phlebotomist was unable to draw the patient due to the patient being out of the room."

"Nursing waits too long to enter the order into the computer system, then complains that the result is too long in the process," says the lab supervisor at a larger, not-for-profit facility in Indiana.

"Our messenger service provides a limited service--only several sweeps throughout the day," says the lab administrator at a large, not-for-profit hospital in New York City. "This increases apparent TAT."

* Transport by snail. "The ER draws its own blood work, and often batches of patient specimens are all brought to the lab at once," reports the lab supervisor at a large, not-for-profit hospital in Connecticut. "Naturally, testing is delayed when the specimens are waiting in the ER for transport."

A laboratorian in a small, proprietary hospital in rural Texas has a unique problem that, she says, occurs but rarely. "Our send-outs take longer than expected to get results," she says. "They go 120 miles by bus."

"Orders are written on the chart yet not sent down until 2 hours later," says the assistant chief technologist at a small, not-for-profit facility in Michigan. "It looks like the lab delayed drawing."

Analogous to the laboratorian who fails to watch the pneumatic tubes is the nurse who fails to check her fax. The administrative technologist at a small, proprietary hospital in Iowa says, "The report may have been faxed to the nursing unit, but the ward clerk or RN doesn't retrieve the reports from the fax machine."

Sometimes, "A large volume of morning work ties up the CPU of the laboratory information system," reports a technologist in a smaller, not-for-profit hospital in Pennsylvania. "Orders then do not download to on-line instruments."

* Most successful efforts. When MLO asked respondents to name their most successful efforts to reduce TAT, laboratorians told us the expected (implementing a bedside testing program for glucose or acquiring a faster, analyzer, for example) and the more elaborate.

"We started a clinical pathology TQM group between the ED and the lab, agreed on goals, and have met them 85% to 95% of the time," says the lab manager at a small, not-for-profit hospital in New York.

"We were having problems getting results on the morning bilirubins on neonates back to the floor by the time they were required--9 a.m.," says a lab section head in a large, not-for-profit hospital in New Jersey. "We brought in a phlebotomist at 6 a.m. who was specifically assigned to the nursery only. This has been working well."

The chief technologist in a smaller, public facility in Texas says, "Adding an additional chemistry analyzer to support outpatient clinics and the ER has helped greatly."

Finally, a technologist in the lab of a small, not-for-profit hospital in New York cited, perhaps sarcastically, "removing the word |Stat' from the nursing vocabulary." No prescription for achieving that goal was offered. Numerous other laboratorians, however, supplied their most successful tips for lowering TAT (see Figure 1).

* Least successful efforts. All the admonitions to laboratorians to meet with clients to solve turnaround time delays come to naught when the problem is the one described by the lab manager at a smaller, not-for-profit hospital in Wisconsin. "A physician complained about TAT from microbiology but refused to meet with the lab staff to discuss the problem," this laboratorian said.

Most other cases wherein respondents discussed their least successful efforts to reduce TAT were more mundane. Equipment requests, such as those for pneumatic tubes, bar coding, more extensive computer systems, faster instruments, or additional FTEs, were denied. Physicians were recalcitrant. Nurses were uncooperative.

"The intensive care units wanted to have their results available by 8 a.m.," reports a section head in the lab of a large, not-for-profit hospital in New Jersey. "The nurses and doctors recommended that bloods be drawn at 4 a.m. and processed in the Stat lab. We put additional staff on the 11 p.m. to 7 a.m. shift to accommodate this and results were available by 8 a.m. We are finding, however, that the tests for which we draw at 4 a.m. are being reordered for the 7 a.m. rounds on the same patients." This attempt to improve TAT was, the laboratorian says, "a total disaster and a terrible waste of time."

Figure 2 lists other failed efforts of laboratory professionals to improve TAT. In contrast with them is the experience of a section head in a smaller, public hospital in Texas. He reports no failed TAT improvement attempts. "Most efforts were fairly successful," he says.

* Further improving TAT. The assistant chief technologist in the lab of a large, proprietary hospital in Florida would further improve turnaround time by "purchasing highspeed, bidirectional, random access analyzers and limiting the number of Stats and timed specimens to those analyzers that are Stat- or timed-eligible."

How would other respondents improve their labs' TAT performance? "Do Stats as they come; leave routines for batch testing times," says the lab director of a larger, not-for-profit hospital in Alabama.

"Replace as many manual tests as possible with automated ones," says the lab supervisor of a large, not-for-profit hospital in New York. "Batch as many tests as possible and run them more frequently."

"Switch as many tests as possible to plasma," advises the lab supervisor of a larger, not-for-profit facility in Tennessee.

"Restructure draw times and add staff to evening and night shifts because of increases in service demands during those shifts," suggests the lab supervisor at a large, not-for-profit institution in Illinois.

The lab supervisor at another large, not-for-profit hospital in Illinois suggests an increase in whole-blood testing and hopes that institutions "force physicians to themselves order from computer lists."

"Have floaters to help in crunch times," suggests a technologist at a smaller, not-for-profit hospital in Georgia. "We are trying, on a temporary basis, having two techs in blood banking to help with workload and turnaround." "Limit the number of tests orderable; no one patient needs five CBCs per day," says the lab supervisor in a large, not-for-profit hospital in Massachusetts.

* A world without Stats. "Our system works very well, eliminating |Stat' and replacing it with |life threatening' and then adding 1- and 2-hour turnaround times," says a pathologist at a small, not-for-profit hospital in Kentucky.

The lab supervisor at a large, not-for-profit facility in California, reports on "proactive communication by our night shift. They notify floors of their workload, then work out schedules with them."

"Long-run improvement will only come when all medical personnel (physicians included) are trained in strong communication skills and proper time management techniques," says the assistant supervisor of chemistry in the lab of a smaller, not-for-profit hospital in Mississippi.

The lab manager of a large, not-for-profit hospital in Illinois takes a philosophic approach to the issue of TAT. Technology creates its own abuses, she suggests. "Because instruments have improved, allowing more expansive in-house testing, those outside the lab believe that all tests can be obtained at all times," she says. "Expectations are infinite, while staffing is finite." Furthermore, "Administration expects the maintenance of or a reduction in FTEs, while users are expecting decreased TAT even though the total number of procedures ordered increases."

Despite the emphasis placed on it by hospital administrators, laboratory managers, clinicians, nurses, and the manufacturers of fast and bedside analyzers, does turnaround time even matter? The lab manager of a small, not-for-profit hospital in Oregon suggests otherwise, calling to mind the World War 11 truism that a convoy is only as fast as its slowest ship. "Most improvements in TAT do not significantly improve patient care," this laboratorian writes, "because the rest of the hospitalization process still grinds at a predetermined rate."

Figure 1

Respondents' most successful efforts to reduce TAT

* Integrating hospital ordering, performing, and reporting systems (total HIS).

--Lab supervisor, small, not-for-profit hospital, Florida. * Batching all thyroids daily. In the past we were doing them 2 days per week.

--Technologist, large, not-for-profit hospital,

New Jersey. * Collecting all critical care patients at one sweep at 4 a.m., rather than making separate, timed requests (at 4, 5, 6, and 7 a.m.) for various patients.

--Assistants administrative director, large, not-for-profit

hospital laboratory, North Carolina. * Starting the QA process alerts doctors to a study, automatically reducing the volume of Stat requests.

--Lab manager, small, not-for-profit hospital, Missouri. * Providing on-site therapeutic drug testing; installing a pneumatic tube system and pre-accessioning bar code program.

--Laboratory administrator, large, not-for-profit hospital,

New York. * Streamlining the test menu for the OR; adding an additional phlebotomist in admitting; and color coding labels for ER and OR Stats.

--Lab director, large, not-for-profit hospital, Missouri. * Correlation collection times with the times the courier picks up for the reference lab.

--Administrative technologist, small public hospital,

Nebraska. * Understanding which tests are priority for which groups and then adjusting workflow accordingly.

--Lab supervisor, large, not-for-profit hospital, Florida. * Using plasma when possible to reduce clotting time for Stats.

--Pathologist, large, not-for-profit hospital,

Washington, D.C. * Shifting more routine batched work to evening and night shifts.

--Section head, small, not-for-profit hospital lab,

Maine. * Separating our morning batch into Stats and routines, then running the Stats first.

--Lab supervisor, large, not-for-profit hospital, Ohio. * Allowing nursing stations to fax previously hand-carried requests to the lab.

--Lab supervisor, smaller, not-for-profit hospital,

Indiana. * Faxing Stat results.

--Lab manager, smaller, not-for-profit hospital,

Missouri. * Changing morning rounds from 7 a.m. to 6 a.m.

--Section head, larger, not-for-profit hospital lab,

Pennsylvania. * Increasing communication and trust with doctors and nurses.

--Technologist, larger, not-for-profit hospital lab, Ohio. * Purchasing automated equipment with a bar code reader.

--Lab supervisor, large, not-for-profit hospital.

Michigan. * Adding another centrifuge to spin Stats; handing Stats directly to a technologist; and analyzing data in 1-hour increments to see trends or identify problems.

--Lab manager, small, not-for-profit hospital, Rhode

Island. * Setting rounds at 5:30 a.m., 11:00 a.m., 4 p.m., and 7 p.m., with under 2-hour TAT for routine testing, and processing all specimens as received,

eliminating batching.

--Lab manager, small, not-for-profit hospital, Oregon. * Sending most send-out specimens to a large reference lab; installing a direct computer and printer hookup with the reference lab to access results as soon as they are available.

--Lab supervisor, large, not-for-profit hospital,

New York. * Forming a CQI team to look at the systems we have in place; taking out unnecessary steps.

--Lab director, small, not-for-profit hospital,

Washington. * Orientation of emergency room personnel through laboratory for 2 hours.

--Lab manager, smaller, not-for-profit hospital, Florida. * Bidirectional interfacing with bar codes for hematology; increasing the phlebotomy staff at peak times.

--Laboratories, smaller, not-for-profit hospital,

Tennessee. * Getting outpatient clinic appointment schedule to help us identify those needing the fastest TAT.

--Lab supervisor, large public hospital, South Carolina. * Establishing TAT goals for the emergency department, then monitoring performance. This resulted in TAT reduction of about 50%.

--Lab supervisor, larger, not-for-profit hospital,

California. * Implementing automatic Stat label printing using bright yellow labels.

--Technologist, smaller, not-for-profit hospital,

Kentucky. * Starting TAT reports daily for all three shifts for our Stats. The computer flags those tests that were delayed beyond TAT. The tech who did the test is then counseled.

--Operations manager, large, not-for-profit hospital,

Illinois. * Accessioning staff verbally notifies testing personnel every time a Stat is received.

--Toxicologist, smaller public hospital, South Carolina. * Changing to heparinized tubes for many Stats, eliminating delay for clotting; installing a tube system to Stat area.

--Lab supervisor, large, not-for-profit hospital, Ohio. * Requisitions for open-heart patients are stamped with a large "O.H." so that the specimens can be prioritized.

--Assistant chemistry manager, large, not-for-profit

hospital, Connecticut. * Focusing on one particular test, monitoring those tests for approximately 3 weeks, then relaying results of TAT to both the phlebotomists and the techs at lab meetings.

--Lab manager, small, not-for-profit hospital,

Tennessee. * Implementing two extra routine drawing times (mid-morning and mid-afternoon).

--Lab manager, small, not-for-profit hospital, Arizona. * Introducing bedside testing for glucose.

--Lab manager, small, not-for-profit hospital,

Pennsylvania. * Setting up a triage system with ER--they draw their own specimens on the most critical patients. TAT decreased 20%.

--Education coordinator, large, not-for-profit hospital,

Louisiana.

Figure 2

Respondents' least successful efforts to reduce TAT

* Trying to convince nursing that Stats shouldn't be ordered when mistakes (such as missed orders) made by them are caught.

--Lab manager, small, proprietary hospital, California. * Asking the floor nurses to call the lab prior to testing.

--Assistant chief technologists, small, not-for-profit hospital, New Jersey. * Making impact on nursing staff that correct identification of the specimen is essential.

--Lab director, large, not-for-profit hospital, Louisiana. * Trying to get nurses to coordinate orders so the lab is not running all over the hospital drawing the same people two and three times a day.

--Lab supervisor, smaller, proprietary hospital, New York. * Automating clinical microscopy for routine urines.

--Lab manager, small, not-for-profit hospital, Maine. * Forwarding complaints to the supervisor and administrator responsible for messenger service.

--Lab supervisor, large, not-for-profit hospital, Michigan. * Encouraging non-lab personnel to draw and deliver Stats.

--Lab manager, large, not-for-profit hospital, Florida. * Coordinating patient availability with other departments and floors.

--Section head, smaller, proprietary hospital lab, Ohio. * Getting the vendor of our HIS to acknowledge that the system makes it difficult to order tests. They can appear ordered when they are not.

--Lab manager, small, not-for-profit hospital, Massachusetts. * Getting hospital personnel to pay attention to published guidelines for expected TAT.

--Laboratorian, smaller, not-for-profit hospital, Tennessee. * Asking physicians to prioritize their orders resulted in all becoming "now," ASAP, or Stat.

--Lab supervisor, small, not-for-profit hospital, Wisconsin. * Giving individuals monthly reports of personal TATs on which, if they were good, they received a star and, if they were bad, they received comments. The staff considered it childish.

--Technologist, small, not-for-profit hospital, Indiana. * Placing red or green dots (for Stats and ASAPs, respectively) on requisitions and specimens.

--Technologist, smaller, not-for-profit hospital, Kentucky. * Trying to educate doctors about misuse of the Stat priority.

--Senior technologist, large, not-for-profit hospital, New York. * Installing a Stat light and buzzer at receiving area.

--Lab manager, large, proprietary hospital, Nevada. * Posting TAT for tests on laboratorian bulletin boards.

--Microbiologist, smaller, not-for-profit hospital, Rhode Island. * Flagging Stat samples with special tape, stickers, racks, etc.

--Lab manager, smaller, public hospital, Iowa. * Establishing a 30-minute TAT with the heart team. It wasn't good enough; now the surgeon wants his own lab.

--Education coordinator, large, not-for-profit hospital lab, Louisiana.
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Title Annotation:Turaround Time, Part 2
Author:Jahn, Mike
Publication:Medical Laboratory Observer
Date:Sep 1, 1993
Words:4019
Previous Article:Turnaround time down sharply, yet clients want results faster.
Next Article:Using analystical tools to make big decisions.
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