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Turnaround time: speeding up, but is it fast enough?

At the beginning of the 1980s, average laboratory turnaround time often satisfied clinicians and nurses. Now it lags behind their expectations, even though it has gotten faster through automation and other efficient practices.

These are among the salient findings of an MLO survey on turnaround time for routine, nonStat testing. The survey also covered typical TATs for common laboratory procedures, variances in TAT by shift, the extent of batching, bottlenecks in the hospital and laboratory, and successes and failures in attempts to improve turnaround time.

Part I of this special report will examine the way things are today. Part II will consider methods for obtaining better TATs.

Forty-four per cent of the laboratory managers and supervisors polled by MLO-all members of the magazine's Professional Advisory Panel-said turnaround time had speeded up since the 1983-86 phase-in of nationwide prospective payment. Another 47 per cent saw no change, and 9 per cent said TAT became slower after prospective payment (see Figure 1).

MLO had a basis for comparison-a 1980 survey covering the same ground as the current one. Both surveys called for panelists to conduct mini-studies at their hospitals. They asked a physician in internal medicine and a nursing supervisor to estimate reasonable turnaround times on 6 a.m. and 6 p.m. requests for seven types of tests.

Panelists also recorded their own estimates of reasonable TATs along with their laboratories' actual turnaround times. The tests involved were glucose, complete blood count, urinalysis, electrolytes, BUN, crossmatch, and prothrombin time.

Means of measuring TAT vary. Some laboratories start the clock when they receive the test request, others when the specimen is collected, and still others when they receive the specimen. The end point may be when the test result is entered on a laboratory form, or when it is sent to the floor, or when it is received on the floor. While this may affect average TATs, it doesn't change relative outcomes, such as doctors' expectations against nurses', or comparisons between one shift and another.

The labs represented in the latest survey shaved 20 to 40 minutes off the turnaround times reported in 1980 for most of the seven common tests. Physicians and nurses, however, expect lab results to come back considerably faster than in the past. Whereas doctors once found a three-hour turnaround acceptable for most of the tests, today they want to see the data in two hours or less. Nurses have tightened their TAT expectations by 40 to 60 minutes in most cases.

As in 1980, nurses are the most demanding. Figure II shows that they now seek results up to 16 minutes faster (depending on the lab test) than physicians deem reasonable and up to 28 minutes faster than laboratorians deem reasonable.

Results on six of the seven tests performed in the morning come back an average of 18 to 25 minutes later than nurses expect, 12 to 27 minutes later than physicians expect, and 3 to 26 minutes later than laboratorians expect. Urinalysis is the only test that meets or does better than everyone's average expectations, both in the morning and evening.

For nurses, the slowest of the morning tests are BUN (a 25-minute lag behind expectations) and CBC (24 minutes behind); for physicians, crossmatch (27 minutes)and BUN (24 minutes); and for laboratorians, prothrombin time (26 minutes) and BUN (12 minutes).

Evening turnaround time improves over morning performance by 20 to 30 minutes on all but one of the tests, and by eight minutes on the other (crossmatch). Results on all of the evening tests except the crossmatch are out more quickly than physicians' expectations of a reasonable TAT. For nurses, four of the seven tests surpass expectations, and for laboratorians, five tests surpass expectations.

As might be expected, 55 per cent of the panelists report that routine TAT varies from shift to shift and also on weekends. For the most part, weekend turnaround runs 15 minutes longer than daytime TAT. Some of the procedures are completed more quickly on the evening and night shifts; others take longer.

Routine crossmatches show the most consistent turnaround time from shift to shift-two hours and 49 minutes on days and evenings, two hours and 46 minutes at night-but they take nearly 40 minutes longer on weekends.

Another notable trend to emerge in the survey is a move away from holding specimens till enough have been accumulated to run tests in batches. As a senior technologist at a small Midwest hospital put it: "With prospective payment, the doctors need to treat the patient as quickly as possible and often need our test results as soon as possible. We try to oblige when we know they're in a hurry. Then we don't batch."

True, 93 per cent of the laboratories surveyed batch at least some tests. However, these labs are setting fewer specimens aside overall, and they are not waiting as long to perform batch runs.

Three-quarters of the managers and supervisors in the 1980 panel reported their labs batched at least 30 per cent of test volume; indeed, many in this group said more than half of all tests were batched. In contrast, fewer than half the labs surveyed this year batch 30 per cent or more of their tests, and only 12 per cent batch more than half their tests (see Figure III).

MLO asked specifically about six types of tests. Chemistry profiles are the most widely batched-to varying extents at 80 per cent of the laboratories. Urinalysis comes next, batched at 58 per cent of the labs, followed by electrolytes, 46 per cent; CBCs, 46 per cent; prothrombin times, 42 per cent; and BUNs, 34 per cent. In 1980, chemistry profiles were batched at 84 per cent of the labs surveyed; electrolytes, urinalyses, CBCs, and BUNs at 60 to 70 per cent; and prothrombin times at 53 per cent.

Since a.m. testing often fails to meet the turnaround expectations of physicians and nurses, it's not surprising that nearly 90 per cent of the panelists say their labs receive complaints about TAT (Figure IV), versus 80 per cent in the earlier survey. Complaints emanate from the emergency department at 57 per cent of the hospitals and from intensive care units at 42 per cent. A number of panel ists also cite criticism from members of the internal medicine department, the surgical staff, and outpatient clinics.

Chemistry generates the most turnaround problems, according to 64 per cent of the panelists. In addition, hematology and microbiology are each mentioned by about a quarter of the panelists.

There's a near-even split over how valid most turnaround-time complaints are-55 per cent of the panelists say they are not valid, 45 per cent say they are. A clinical chemist at a large Iowa hospital feels tumaround expectations are unrealistic: "For the most part, physicians and especially nurses want the equivalent of Stat turnaround on all tests, even the routine ones."

In a similar vein, the technical director of a mid-size Kentucky hospital lab observes: "Many physicians expect a 30-minute turnaround on tests performed on serum. They either forget about clotting and centrifugation, or they don't know what must be done to prepare a specimen."

"We cannot complete all testing by 9 a.m.," a chemistry supervisor at a 400-bed Illinois hospital comments. "The non-priority work must wait."

Among those who believe most turnaround-time complaints are valid, the manager of a small Missouri hospital laboratory says: "The complaints come because we've dropped the ball somewhere-for example, by inadvertently processing a Stat request as a routine request."

"Many of the complaints are valid," the assistant administrative director of a 300-bed Connecticut hospital laboratory says. "This has precipitated an extensive evaluation of our organization and staffing."

Frequently there are mitigating circumstances:

"Our chemistry analyzer is too slow."

"Only one person is available for draws, and he or she simply cannot be in three places at one time."

"Some of the complaints are valid, but our laboratory suffered 25 per cent layoffs last month with no time to change policies and procedures. Hospital administration wants medical technologists to draw blood in their 'spare time' while expecting 93 per cent productivity from technical areas."

Such comments tie in with major turnaround bottlenecks identified by the panelists. The most common problems are staffing shortages, excessive Stat orders, delays in specimen collection and transportation, lack of cooperation or communication by personnel, and slow or malfunctioning instruments (Figure V).

As for difficulties created in the laboratory by outsiders' turnaround-time demands, 8 out of 10 panelists cite phone calls that simply delay things further; twothirds say the demands inhibit batching, decreasing efficiency; and half mention laboratory morale problems.

MLO asked specifically whether physicians contribute to poor turnaround time by misuse of Stat ordering. Nearly 80 per cent of the panel felt they did, and many also blamed nurses for this problem. "Forty-seven per cent of our workload is Stat," one respondent noted.

Computerized result reporting is now in place at nearly half the laboratories polled. More than half the panelists from these labs say the computer has reduced turnaround time by up to 25 per cent, and another quarter say it has cut turnaround time by up to 50 per cent.

Even here, there are problems."The doctors and nurses don't feel they should have to use the computer to find results, or else they don't want to learn how," one panelist says. Another notes that it is much easier to call the laboratory and complain than to take the time to look up the results.

Part II of this special report, which follows, will examine successes and failures in lab attempts to improve turnaround time, and ways to improve TAT further.
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Title Annotation:special report, part 1
Author:Hallam, Kris
Publication:Medical Laboratory Observer
Date:Aug 1, 1988
Previous Article:HCFA asks Congress to wait for its 'manageable' lab regs.
Next Article:Turnaround time: how labs improve their performance.

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