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Total lab automation takes teamwork.

Within two miles of each other in western Pennsylvania are the two largest hospitals among those served via the University of Pittsburgh Medical Center (UPMC) system. UPMC Presbyterian, a 997-bed academic hospital, is designated as a Level 1 Regional Trauma Center. UPMC Shadyside is a 517-bed tertiary care facility. In 2008, Presbyterian and Shadyside clinical chemistry laboratories processed 47.5 million and 13.09 million reportable results and billable tests, respectively. With test volumes increasing yearly by 8% to 10%, implementing technologies to meet their high-volume 24-hour testing demands was critical. In a concerted effort to standardize laboratory testing and improve patient care, UPMC sought total laboratory automation.

Choosing an automated system

The laboratory leadership employed a multidisciplinary group to evaluate, select, and implement the "best fit" automation system. The Laboratory Automation Group (the Group) included laboratorians (clinical chemists, pathologists, and medical technologists), laboratory information system (LIS) analysts, clinicians, nurses, and representatives from the offices of UPMC's Facilities Management, as well as its Center for Quality Improvement and Innovation.

The overall goal was to improve patient care through accuracy and consistency in laboratory analyses. The strategic goals of the UPMC Automated Testing Laboratories were to:

* install new chemistry and immunochemistry analyzers, and an automated platform with sample management capabilities;

* integrate sample analyses and sample management;

* improve and standardize test turnaround times (TAT), and improve the management of analyses through interactive management software (middleware);

* reduce multiple blood collections and aliquot preparation; pre-analytical, analytical, and post-analytical errors; and operation costs;

* minimize laboratory staff exposure to biohazards associated with sample processing; and

* increase test-volume growth potential. The Group's first overall task was to identify companies with commercially available laboratory-automation systems capable of satisfying the overall objective. The Laboratory Automation Group was then separated into five teams. While supporting the Group's main objective--improving patient care through accuracy and consistency in lab analyses--each team delineated its specific needs. The Sample Management team sought automation technologies requiring minimal operator intervention for sample acquisition, sample integrity assessment, centrifugation, aliquoting, stroage, and sample retrieval.

The Instrument and Methods team wanted automation systems that offered comprehensive chemistry and immuno-chemistry test menus with the potential of test expansion. At the time of the project, the labs' analyzers were supplied by a variety of companies; identifying one that offered both general chemistry and immunochemistry analyzers was important. Cost of operation, as well as system reliability and flexibility, were equally significant.

The LIS team itemized the cost of potential software upgrades needed to ensure the highest performance of the automation system. The system's scalability and its ability to satisfy security and regulatory compliance were also determined.

The Site Planning and Facilities Preparation team assessed the facility infrastructure needed to support the new automation system. This included evaluation of such factors as appropriate space accommodation for both staff and instruments, wiring for normal and emergency power, additional lighting, water access and drainage, and appropriate ventilation.

The Transition to Automation System team evaluated the companies' technical support, user training courses, and continuing education sessions. This team identified areas in the laboratories' current workflow processes that needed to be addressed prior to the implementation of the new automation systems.

Automation improves workflow

After a thorough review of four commercially available automated laboratory systems, the Group selected one that demonstrated cost efficiency, user friendliness, reliability, and robustness. The total laboratory automation system installed in March 2009 at Presbyterian (February 2009 at Shadyside) is comprised of sorters, centrifuges, aliquoters, general chemistry and immunochemistry analyzers, and a refrigerated storage (stockyard)--all connected to a robotic track. Samples are automatically managed once loaded into the inlet station by the operator. The system scans the bar-coded sample, and the patient demographics and test requests are downloaded.

Periodically, samples are scanned as they are transported along the robotic track, allowing the operator to be cognizant of samples' locations at all times. The system loads and unloads centrifuges, de-caps samples, and detects sample volume. Samples requiring additional offline testing are aliquoted from primary tubes to daughter tubes by the system. Samples analyzed online are routed to the online chemistry and immunochemistry analyzers.

Following analysis, samples are re-capped and transported to the stockyard (stores up to 3,200 samples). In the event that a physician requests additional testing from an earlier sample, the automated system will retrieve the stockyard sample and transport it to the appropriate analyzer. Samples analyzed offline (in-house or send-out testing) or those requiring special attention are diverted to the outlet station for operator intervention.

The automation system manages samples from beginning to end. The middleware autoverifies results that pass pre-established criteria and files results to patient records electronically; alerts the operator of abnormal results that require further review; notifies the operator of the sample's pre-analytical status; and prompts the operator of samples that require offline dilution.

"The middleware technology enabled us to implement autoverification for all chemistry and immunochemistry testing. With the elimination of manually resulting normal results, the lab staff have more time to manage critical results," says Raymond Bezila, MLT, administrative director for Automated Testing.

In addition to installing total laboratory automation, the Group also took advantage of re-educating the hospital staff on sample management. Prior to the automation install, the clinical chemistry labs relabeled between 40% to 60% of samples received. Relabeling reduced lab performance because it added a minute to TAT for results. Relabeling has the potential to introduce identification errors and is not cost effective. Moreover, the laboratory received a high volume of samples with accompanying paper requisitions that required manual order entry. Paper requisitions added three minutes per test order and increased TAT for results.

Another area of concern was tube sizes and types. Before automation, the lab accepted samples in a variety of tube sizes and types. It was necessary, however, to standardize the tube sizes since the new system requires 13x100 vacutainer tubes. The UPMC Automated Line Implementation Improvement Project was instrumental in developing a learning module entitled "Correct Collecting, Labeling, and Sending samples to the Lab: The Right Way Every Time." The laboratory has seen significant improvement in sample labeling. The installation of label printers on hospital units has significantly reduced (by 21%) the volume of paper requisitions received by the lab. To date, correct tube sizes have been stocked on every unit, and tube sizes are now standardized between the two hospitals; 89% of samples received can be placed directly onto the laboratories' automated systems without operator intervention.

Laboratory optimization

Nine months have passed since the conclusion of the total laboratory automation project, and performance has been enhanced significantly. The automation system directly affects the laboratory staff, the hospital community, and, most importantly, the patients.

"The automated line project represents state-of-the-art in high-volume laboratory testing," says Alan Wells, MD, DMSc, and vice chairman of Pathology. "Laboratorians now have the technology that improves workflow of routine testing and creates the capacity to focus closely on the most difficult cases."

The first six months of operation challenged the operators as they increased their familiarity with the technology, while the hospital community became compliant with revised sample-processing procedures. Since both Presbyterian and Shadyside have identical automation systems, each campus can perform its own testing; and the need for sharing samples between the laboratories is reduced. Testing is now standardized between the two because it is not unusual for patients to receive treatment at both hospitals.

A meaningful reduction in the recorded volume of samples that med techs manually handle translates to reduced exposure to biohazards and reduced risk of injury. Med techs have more time to devote to troubleshooting critical cases, performing quality-improvement research studies (in collaboration with residents and researchers), and researching and developing new assays. Currently, the laboratory staff is being cross-trained, which not only presents development opportunities for individuals but also creates depth and flexibility for laboratory operations.

The hospital community has benefitted from the faster STAT and routine turnaround times, which are surprisingly comparable and suggest that in the future, distinguishing STAT from routine testing will be unnecessary, because all samples will be analyzed STAT. The TATs for add-on testing have improved and are directly related to the automation system's ability to retrieve the sample with minimal human intervention. Med techs no longer have to physically locate and retrieve the specific sample, which once could take a half hour.

Prior to implementing the automation system, serum indices were graded by visual inspection. The lab has begun the process of standardizing the assessment of serum indices. Hemolysis, lipemia, and icteria are detected via a spectrophotometry method, and semiquantitative unitless values are provided for each sample on the chemistry analyzer. Standardization of the pre-analytical, analytical, and post-analytical phases has an enormous impact on ensuring the reliability of test results. Patients have benefited with the consolidation of testing because the volume of blood necessary to perform testing has decreased, reducing the need for multiple blood draws, thus saving the patient time and discomfort.

The success of total laboratory automation at Presbyterian and Shadyside is a direct result of teamwork among the vendor, laboratory leadership and staff, and the hospital community. Implementation of total laboratory automation requires change for the laboratory staff as well as for the hospital community (nurses, phlebotomist, and clinicians). Automation is not a substitute for laboratory personnel but a complementary technology that aids in optimizing laboratory performance.

As performance through automation continues to be optimized, the clinical chemistry laboratories at Presbyterian and Shadyside now are truly living up to their names as UPMC Automated Testing Laboratories.

By Octavia M. Peck-Palmer, PhD

Octavia M. Peck-Palmer, PhD, is assistant professor in the Department of Pathology at the University of Pittsburgh, and medical director at the UPMC Presbyterian and Shadyside Automated Testing Laboratories in Pittsburgh. UPMC includes 15 general hospitals in western Pennsylvania, related clinics and healthcare facilities, and partnerships in five international hospitals.
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Article Details
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Title Annotation:LAB MANAGEMENT; University of Pittsburgh Medical Center
Author:Peck-Palmer, Octavia M.
Publication:Medical Laboratory Observer
Geographic Code:1USA
Date:Oct 1, 2009
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