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Turnaround time down sharply, yet clients want results faster.

TURNAROUND time for routine testing has shrunk dramatically in the 13 years since MLO first surveyed readers on the matter, according to the results of the 1993 survey of our Professional Advisory Panel. In 1980 it took an average of 2 hours and 50 minutes to turn around a glucose determination, for example.[1] That same test took 2 hours and 11 minutes in 1988,[2] and only 1 hour and 16 minutes this year.

* Speedy results. Figure 1 shows a list of common tests, seven of which MLO has tracked in terms of turnaround time (TAT) over the course of three surveys. Prothrombin time, for example, had the fastest TAT (2 hours) in the 1980 survey.[1] The results of the 1988 survey showed that PT was 2 hours and 14 minutes.[2] This year the time had shrunk to 1 hour and 19 minutes.
Figure 1
Actual TAT for a specimen collected
in the morning draw, then and now
 1980 1988 1993
 Hr. Min. Hr. Min. Hr. Min.
Glucose 2 50 2 11 1 16
CBC 2 40 2 19 1 25
Urinalysis 2 40 2 18 1 31
Electrolytes 2 55 2 17 1 22
BUN 3 05 2 25 1 26
Crossmatch 2 35 2 26 1 35
Prothrombin time 2 00 2 14 1 19
Blood gases NA(*) NA(*) 0 31
(*) Not asked.


"We triage specimens a lot better these, days," says Bernard Statland, M.D., Ph.D., vice president of National Health Laboratories in Nashville, Tenn. "Hospitals have computers on the floors for order entry. They have pneumatic tubes to deliver specimens to the lab. There are people who say, |Hey, get these onto the fast analyzer.'" In addition to the technology and the organization, Statland says, we live in a world that places a premium on speed, an attitude that is a mixed blessing.

"Turnaround time, more than anything else, is the yardstick by which laboratorians are judged," he says. "Even if one lab has a 2% analytical error and another has a 10% analytical error, it's very hard for the clinician to distinguish one from the other. Another laboratorian might be horrified at the prospect of a 10% error rate, but for the most part the clinician only sees turnaround time. MDs want to get results quickly so they can get back to their offices."

The 1993 survey was conducted among 1,043 hospital laboratorians who are members of MLO's Professional Advisory Panel (see "Survey methodology," p. 24). The results show that while actual TAT has been sharply reduced, there are many ways in which it could be better. So say the laboratory's principal clients--doctors and nurses.

Respondents' experience with TAT and their suggestions on how it might be improved will be examined in Part 2 of this report, but first, let's look at how the survey was executed and view some of the results.

* Mini-studies. As in the two previous surveys, MLO asked panelists to conduct mini-studies of their own. Participants gave us their actual TATS, then asked an internist and a nursing supervisor at their hospitals to estimate reasonable TATs for the morning and evening draws, which were arbitrarily placed at 6 a.m. and 6 p.m., respectively. The lab clients gave their opinions on what constitutes reasonable TATS for blood gases and for the seven tests studied in previous surveys: BUN, CBC, crossmatch, electrolytes, glucose, prothrombin time, and urinalysis.

Figure 2 lists the results of those mini-studies. Nursing supervisors believed, for example, that glucose should be done in a mean time of 61 minutes in the morning and 62 minutes in the evening. Internists suggested times of 65 and 66 minutes, respectively, while laboratorians thought that 84 and 89 minutes were more reasonable. The actual times were 77 and 74 minutes.
Figure 2
TAT expectations and actualities in minutes
 Nursing
 Internist supervisor Laboratorian Actual TAT
Test AM PM AM PM AM PM AM PM
Blood gases 27 29 28 32 31 33 31 34
BUN 78 80 77 75 96 95 86 81
CBC 72 73 70 69 90 91 85 79
Crossmatch 80 82 83 86 102 103 95 97
Electrolytes 70 72 72 74 89 90 83 77
Glucose 65 66 61 62 84 89 77 74
PT 67 68 67 67 85 85 79 82
Urinalysis 78 78 83 80 94 97 91 94


* Disappointment index. Figure 3 shows what might be called the TAT disappointment index. Internists believed that electrolytes were taking 13 minutes longer than they should, for example, while nursing supervisors thought the test was 11 minutes too slow. Laboratorians, on the other hand, thought that TAT on electrolytes was running 6 minutes faster than what should reasonably be expected.
Figure 3
Disappointment index: How many minutes behind
(or ahead of) hopes are morning draw results?
Nursing
 Internist supervisor Laboratorian
Blood gases +4 min. +3 min. 0 min.
BUN +8 +9 -10
CBC +13 +15 -5
Crossmatch +15 +12 -7
Electrolytes +13 +11 -6
Glucose +12 +16 -7
PT +12 +12 -6
Urinalysis +13 +8 -3
How to read the chart: Laboratories thought that morning
urinalysis results were arriving 3 minutes faster than was
reasonable to expect. But internists thought the same were 13
minutes slow. Similarly, nursing supervisors thought that
the urinalysis were taking 8 minutes
too long.


As TATs have decreased, clients' expectations have risen. In the 1980 survey, physicians found a 3-hour turnaround time acceptable for most tests.[1] In 1988 they expected most results in about 2 hours.[2] But this year physicians' expectations for reasonable TAT on the seven analytes, drawn in the morning, averaged 1 hour and 13 minutes.

* Defining TAT. MLO asked respondents how their lab calculates TAT, including the starting point and the endpoint. One out of three labs (34%) measure TAT from the time the specimen is received in the lab, while 31% figure it from the time the request is received in the lab. Eighteen percent believe that TAT begins when the specimen is obtained from the patient; 14% figure TAT from the moment the order is placed on the floor. Two percent use other starting points. (Note: In the text of this article, failures to add up to 100% are due to rounding or to the presence of small, "other" responses that are not always noted.)

Larger hospital labs (see "Hospital size," p. 25) were more likely than smaller facilities to start counting turnaround time when the specimen is received in the lab (39% versus 30%). Smaller hospitals, conversely, tended to calculate beginning TAT at the time the specimen is obtained from the patient (24% as opposed to 11% of larger institutions).

* Ending time. Nearly two thirds (62%) of respondents figure the endpoint of turnaround time as being when the test is completed and the result is verified. Twenty-one percent define the endpoint as the time that the result is sent to the floor; 12% as when the result is received on the floor; 3% as the time the result is placed on the chart; and 2% had other determinants.

* Shift differences. Nine out of ten labs (90%) perform routine testing on more than one shift. Of the 10% that run routines on only one shift, 97% use the regular day shift and 3% do routines on weekends.

Of the vast majority that perform routines on multiple shifts, 54% said that TAT does not vary from shift to shift. Forty-six percent noted the variations shown in Figure 4.
Figure 4
TAT by shift
 Regular Regular Regular Regular
 day evening night weekend
 shift shift shift shift
Blood gases 22 min. 32 min. 26 min. 21 min.
BUN 83 75 65 82
CBC 81 72 65 80
Crossmatch 83 86 88 94
Electrolytes 82 72 65 81
Glucose 76 68 61 78
PT 74 72 63 73
Urinalysis 96 87 75 99


Eighty-four percent of those who reported variations attributed them to a diminished staff; 18% blamed less-experienced personnel; 13% said that differences were caused by Stat work only; 2% blamed TAT variance on a laboratory closing; and 1% said that differences were caused by less-available equipment (multiple responses were accepted).

* Batching tests. Nearly three out of four labs (72%) batch tests; 28% do not. Eastern labs are more likely to batch tests than are laboratories in all other regions (83% versus 70%, respectively).

Two-thirds (63%) of labs batch chemistry profiles. The other commonly batched tests are urinalysis, 44%; electrolytes, 38%; BUN, 35%; CBC, 33%; prothrombin time, 33%; and type and screen, 11%. Forty-four percent of urban and 42% of suburban labs batch electrolytes; only 20% of rural labs do likewise. Thirty-eight percent of urban and 40% of suburban labs batch BUN; only 22% of rural labs do the same.

Figure 5 lists commonly batched tests and the frequency with which they are performed. Respondents said that an average of 26% of their lab's total test volume is batched. Twenty-nine percent, mostly smaller and rural laboratories, batch less than 10%. Twenty-two percent batch between 10% and 19% of the total test volume; another 22% batch from 30% to 50%; 16% batch between 20% and 29%; and 12% of laboratories batch 50% or more.
Figure 5
The frequency of commonly batched tests
 Daily frequency
 Three
 Once Twice times Other(*)
Chemistry profile 19% 18% 33% 30%
Electrolytes 12 12 28 48
CBC 18 8 30 43
Prothrombin time 20 14 24 42
Urinalysis 13 16 31 40
BUN 10 16 26 48
Type and screen 25 25 13 38
(*) Respondents who cited "other" most often specified "as
needed/when we reach a minimum."


* Reporting TAT. Three out of four laboratorians (74%) said that their lab prepares reports on actual turnaround time; 26% said that their facility does not. Eighty-nine percent of larger hospital labs prepare reports; 60% of smaller facilities do likewise.

Among those that prepare TAT reports, 92% use the information in their lab's QA report. Sixty-two percent said that actual TAT reports were used for comparison with previous figures for purposes of internal control; 49% share the information with other departments.

* Communicating. Seventy-five percent of labs use computers for test reporting; 25% do not.

Nearly all larger facilities (97%) use computers for test reporting; only 55% of smaller institutions do likewise. Urban and suburban labs are more likely to use computers than smaller facilities (90% and 76% versus 51%, respectively).

Most labs that use computers for test reporting communicate with all floors (84%), with ICUs (90%), and with the emergency room (90%).

Thirty-nine percent of all laboratorians who responded to the survey use a pneumatic tube system for specimen transport; 62% do not. Of those laboratories that get specimens through a tube system, 88% connect with the emergency room; 77% with an ICU; and 58% with all floors.

Eighty-eight percent of those using both computers and pneumatic tubes report that those measures have reduced turnaround time; 12% reported that TAT was unaffected.

Of those laboratories in which TAT has been reduced by the use of computers and pneumatic tubes, the average reduction is 30%.

The mere existence of a computer system does not mean it will be used efficiently or even as designed. A section head in the lab of a smaller hospital in suburban Florida notes that the main problem affecting TAT in that facility is getting nursing to release orders in the computer so that we can receive a requisition in the lab."

"Physicians want to see printed results--it's a medicolegal issue," says a West Virginia laboratorian. "We, the laboratorians, have been sold the pipe dream that physicians can just look up the result. Most physicians work at several hospitals and have no desire to learn multiple [computer] systems. Most of us can barely get our staff to handle the LIS. Why should physicians be forced to learn two or three?"

* Bar coding. Slightly more than half the survey respondents (51%) use bar coding; 49% do not. Larger facilities were more likely to use bar coding than smaller ones (70% versus 32%, respectively).

Of those that do use the technology, 85% use machine-side bar coding to label specimens for loading onto an analyzer; 38% have a bar code collection list system. Nine percent employ other types of bar coding systems (multiple responses were accepted).

Respondents were asked how bar coding has affected operations. Nearly half (46%) said that it has greatly decreased specimen ID problems. One out of four (28%) said that bar coding has greatly improved TAT, and 13% noted that the technology has greatly reduced the number of repeat analyses.

Bar coding is a structural change in the system, in keeping with TQM, that can help reduce such variability as specimen ID errors," says Bernard L. Kasten, M.D., associate director of laboratories at Bethesda Hospital in Cincinnati, Oh you factor in the time savings due to the automation of a previously manual procedure--transcribing and entering specimen identification numbers--you see why so many people report that bar coding has had a beneficial effect on TAT."

* Demanding doctors. Eighty percent of respondents told MLO of an increase in the demand by clinicians for faster turnaround time over the last 5 years. (Forty-nine percent reported that clinicians were much more demanding; 31% that they were somewhat more demanding.) Two percent noted that clinicians were somewhat less demanding, and 1% said that they were much less demanding. Seventeen percent thought that clinicians are about the same with respect to turn-around time demands.

Physicians were more likely to be much more demanding at larger than at smaller hospitals (60% versus 39%, respectively). Clinicians were more likely to be much more demanding at urban and suburban labs than at rural ones (53% and 52% versus 39%, respectively).

When asked "if clinicians are more demanding about TAT, what do you believe is their motivation?" 90% of respondents replied "for their own convenience." Only 10% felt that the demands were based on medical and legal grounds. Of the 288 laboratorians who answered the question, not one checked the boxes for "patient convenience" or "to increase efficiency in a cost-containment environment."

Nearly three out of four laboratorians (73%) said that their lab publishes guidelines to inform other departments of expected TAT; 27% said that their labs do not. Eighty-three percent of larger facilities publish guidelines; 65% of smaller ones do. Urban and suburban labs were more likely than rural facilities to publish guidelines on TAT (81% and 79% versus 56%, respectively).

* TAT complaints. Seventy-nine percent of respondents seldom get complaints about routine TAT. Fourteen percent receive complaints often; 8% never get complaints about routine turnaround time.

Over one-third (35%), often receive complaints about Stat turnaround time. Sixty-two percent seldom hear complaints about Stat TAT, and 3% never do. Larger labs were more likely than smaller ones to hear complaints about Stats (47% versus 24%, respectively). Urban and suburban labs were more likely than rural facilities to often get complaints about Stat TAT (43% and 37% versus 19%, respectively).

Seventy-seven percent of the complaints came from the emergency department. In the 1980 survey, the ER generated 40% of the complaints[1]; in 1988 that department originated 57% of the gripes.[2]

"The main thrust of TAT pressure remains the ER," says Kasten. "From MLO's data, it seems clear that certain observers of TAT, namely internists and nursing supervisors, have a realistic expectation of what routine TAT should be. They are pretty generous, in fact. That must mean that the exceptions and the particularly urgent cases that call for Stats are what result in complaints."

Seven out of ten respondents (70%) reported receiving complaints about delays in TAT due to the failure of the floor to transmit requests to the lab. Sixty-one percent reported complaints due to the failure of floor personnel to transmit specimens in a timely manner. Nearly as many (57%) received complaints due to the failure of floor personnel to properly collect or label specimens; 12% received no complaints due to the aforementioned problems.

* Problem areas. Two out of three respondents (66%) said that the chemistry section generated the most problems with regard to TAT. Figure 6 shows the other lab sections most likely to draw criticism.
Figure 6
Lab sections that generate
the most TAT complaints
 1988 1993
Chemistry 64% 66%
Hematology 29 44
Microbiology 24 16
Blood bank 14 13
Surgical
 pathology 11 11
Immunology 5 5
Other 9 14
Total exceeds 100 due to multiple
responses.


In the 1988 survey, hematology was cited by 29% of laboratorians as generating the most complaints.[1] This year the figure rose to 44%. Microbiology, which caused the most complaints according to 24% of respondents in the 1988 survey,[2] reduced that figure to 16% in the current study.

Respondents at smaller hospital laboratories were more likely than their larger counterparts to say that the microbiology section generated this year's most TAT problems (20% versus 12%).

* Misuse of Stat ordering. Most 1993 respondents (81%) said that physicians contribute to poor TAT by misusing Stat ordering. Nineteen percent disagreed.

Eighty-nine percent of large hospital laboratorians felt that physicians misuse Stat ordering; 74% of laboratorians at smaller institutions agreed. Stat misuse was also viewed as being an urban, more than a rural, problem (85% versus 75%, respectively).

"If nursing forgets to place an order, it is then ordered Stat," says the hematology supervisor at a smaller proprietary hospital in suburban New York. "When a patient wants to go home, it is ordered Stat. If the physician wants the answers before he leaves the building," the test is ordered Stat.

"Our TAT is so poor historically that physicians must use Stat to get results," says the lab director at a large proprietary hospital in West Virginia. "It's a vicious, non-trusting situation." More laboratorians sound off about Stat abuses in Part 2 of this report.

* Not my fault. Nearly nine out of ten laboratorians (88%) reported receiving complaints about delays over which they had no control; 12% did not.

As turnaround time has fallen over the last 13 years, so has the percentage of TAT complaints that laboratorians see as being valid (Figure 7). This year, only about one-quarter (26%) of TAT gripes struck respondents as legitimate.
Figure 7
What percent of
complaints are valid,
then and now?
1980 57%
1988 45
1993 26


* Discussing TAT. Most laboratorians (82%) told MLO that their lab has held meetings with other departments over the last 3 years to discuss turnaround time problems. Sixteen percent held no such meetings; 2% reported no TAT problems.

Ninety-one percent of larger and 74% of smaller hospitals held such conferences. They were also more common at urban and suburban labs when compared with rural institutions (88% and 88% versus 68%, respectively).

The lab manager represented the lab at such meetings in 69% of cases; the lab supervisor spoke for the lab at 52% of meetings. A pathologist represented the laboratory in 33% of meetings, and the laboratory director did so in 29% of cases. In three out of four cases, meetings regarding turnaround time were held with the emergency (77%) and nursing (73%) departments.

Nearly three out of ten respondents (29%) said that meetings with other departments concerning TAT were held monthly; 22% reported quarterly meetings; 11% reported yearly meetings; and 37% reported other intervals.

Interdepartmental meetings held to discuss turnaround time were judged as being successful by 93% of respondents (22% were very successful and 71% were somewhat successful). Seven percent of respondents said that these meetings were not at all successful.

* Telephone woes. Three out of four respondents (76%) said that constant phone calls have prolonged turnaround time. More than half (58%) said that outside demands have inhibited batching, thus decreasing cost-effectiveness and efficiency. Thirty-five percent blamed outside demands for causing morale problems that impinged upon TAT. Ten percent cited other outside demands as affecting turnaround time (multiple responses were accepted).

* Improving TAT. Seventy-nine percent of respondents felt that their labs could further improve TAT; 21 % said they couldn't.

When asked on which tests they might improve the turnaround time, more than half the respondents (53%) named chemistry profiles (Figure 8). Forty-six percent cited prothrombin time, and 45% named partial thromboplastin time.
Figure 8
Tests for which TAT
could be improved
Chemistry profile 53%
PT 46
PTT 45
CBC 43
Urinalysis 43
Electrolytes 42
Glucose 39
BUN 33
Enzymes 33
Drug testing 27
Crossmatch 19
Cultures 18
Blood gases 16


"A lab test is a snapshot," says Statland. "If you collect a specimen at 6 a.m. on Monday, you're getting a snapshot of how that patient was at that time. If the test results get to the MD at noon, the snapshot is 6 hours old" and of limited value. "Whereas if the result comes in at 7:30, it's only an hour and a half old. Turnaround time is all about the availability of information in a timely manner."

In Part 2 of this report, which follows, laboratorians speak out on their efforts to improve TAT and offer suggestions that may work in your lab.

References

[1.] Benezra N. Turnaround time: Demands and delays. MLO. 1980; 12(9): 33-38. [2.] Hallam K. Turnaround time: Speeding up, but is it fast enough? MLO. 1988; 20(8): 28-34.

Survey methodology

On may 3, 1993, MLO mailed a six-page questionnaire with a postpaid return envelope to 1,043 hospital laboratorians on MLO's Professional Advisory Panel, consisting of MLO readers who have agreed to participate in our surveys. The questionnaire was prepared by the editors of MLO in collaboration with the Medical Economics research department, which later compiled data based on the results.

By the cutoff date, May 31, 1993, respondents had returned 365 usable questionnaires, yielding a 37% response rate. Note: Because the sample represents a selected panel of laboratories, results may not necessarily represent the views and experiences of all laboratorians.

Of those returning usable questionnaires, 22% listed their title as laboratory supervisor, 21% as laboratory manager, 13% as section head, 12% as laboratory director, 9% as MT or MLT, 5% as pathologist, 3% as chief technologist, 3% as administrative technologist, 2% as assistant chief technologist, 1% as education coordinator, and 9% held other titles.

Seventy-seven percent are employed by not-for-profit hospitals; 10% by proprietary hospitals; 9% by Government or Armed Forces hospitals; and 4% were employed by other hospital labs.

Respondents worked in hospitals having an average of 300 beads. Twenty percent of respondents' institutions had 500 or more beds. The further breakdown is: 100-199 beds, 19%; 200-299 beds, 17% 300-399 beds, 16%; fewer than 100 beds, 16%; 400-499 beds, 12%.

Forty-three percent of respondents are employed in urban settings; 30% work in rural areas, and 27% work in the suburbs.

Respondents live in all regions of the United States: the South (33%), Midwest (29%), East (21%), and the West (17%).

Nearly half the respondents (48%) have been laboratorians for more than 20 years. Twenty-seven percent have worked in the lab for between 16 and 20 years; 17% for 11-15 years; 6% for 6-10 years, and 2% for 25 years. Less than 1% have worked under 2 years; the average is 20 years.

Hospital size

Hospitals and medical centers in this article have been categorized in one of the two following groups:
Larger hospitals 300 or more beds
smaller hospitals Under 299 beds
COPYRIGHT 1993 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1993 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:Turnaround Time, Part 1
Author:Jahn, Mike
Publication:Medical Laboratory Observer
Article Type:Cover Story
Date:Sep 1, 1993
Words:3878
Previous Article:Final budget bill to ratchet down Medicare lab payments.
Next Article:Stats too high, yet labs cope.
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