By Joanne C. Kendrick, MT (ASCP), Kuruvilla George, MBA, MT (ASCP) and C. Joyce Greathouse, M.D.

Core lab automation achieves productivity goals, improves quality measuresThe path to laboratory automation may include both mayhem and marvel. But based on our experience at Carraway Methodist Medical Center (CMMC) in Birmingham, Ala., there’s a clear payoff at the end of the rainbow.

photoBefore LAS: The main laboratory at Carraway Methodist is filled with instruments and personnel.

Two years after installation of a LAB-InterLink/Labotix RRUSH laboratory automation system in our core lab, CMMC is realizing substantial benefits:

  • Routine turnaround times for CBC, PTT, protime and chemistry profiles have been cut to less than 45 minutes (from 60 to 90 minutes in the past).
  • Human errors and potential safety hazards—dropped or lost specimens, pouring errors during aliquotting and broken tubes —have been reduced to almost zero.
  • Lab capacity has increased, leaving room for outreach testing.

We calculate that our automation system will pay for itself in approximately 1.8 years as a result of productivity gains. Improvements in testing, from improved turnaround times to reduced errors, are simply additional benefits.

Planning to realize goals
Carraway implemented a Core Lab concept in 1996. The lab is on track to process some 1,050,000 billable procedures in 2001 including chemistry, hematology, blood bank, microbiology and anatomical pathology. Chemistry accounts for about 40 percent of our volume, while hematology represents about 30 percent. The lab is geared to high-volume testing, focusing in particular on the needs of our Level I trauma unit, coronary care unit, multiple intensive care units and cancer center. In addition to the 617-bed CMMC, the lab provides outreach testing to the Norwood Clinic (a multi-specialty physician practice), Carraway Medical Foundation and Carraway Clinics.

photoBefore LAS: Keying results into the laboratory information system is nearly a full-time job.

Labor savings, the most frequent justification for buying a laboratory automation system (LAS), figured heavily in our reasoning as well. In 1997, we were budgeted for 107.3 FTE employees (including technical, phlebotomy, clerical and management staff). Today, we operate with fewer than 70 FTEs. And that’s after CMMC acquired and closed the 16-FTE Norwood Clinic in July 1998. Today’s core lab runs with five or six employees vs. 12 prior to automation.

After evaluating several potential LAS systems, we found substantial differences in flexibility. Some automation systems showed a marked bias toward specific instrumentation. We wanted an open system that would accommodate a potpourri of instrumentation.

We also wanted a system that would accommodate front-end, pre-analytical processing. According to published field studies, up to 70 percent of a technologist’s time is associated with loading and unloading the centrifuge, capping and re-capping, aliquotting and sorting specimens. The remaining 30 percent is dedicated to specimen analysis. Our goal was to automate that 70 percent, freeing our technologists to concentrate on analysis.

Finally, we wanted an integrated system. Our goal was three-way communication among the lab’s Cerner LIS, the robotic LAS and individual instruments to eliminate double-entry of patient data.

After a number of site visits to potential vendors, we chose the Labotix RRUSH LAS because it worked with our variety of instruments, and the company agreed to develop the pre-analytic processing component.

Other lab vendors also participated in our move to automation. Ortho-Clinical Diagnostics was involved every step of the way and helped to facilitate the entire project. Finding vendor partners who are experienced in automation systems implementation can make the transition much smoother.

Integrated system layout
So, how does our lab automation system work? The Cerner LIS generates barcode labels for each specimen. When samples reach the lab, each tube is placed in a specimen carrier with four spring-loaded steel fingers and a round base, on the robotic track. The various instruments that operate in conjunction with the robotic track utilize the same 13 mm x 75 mm tube (volumes vary from 3.5 to 4.5 ml but tube size is standardized). The loading station is rated at 1,000 specimens per hour.

photoBefore LAS: Countertop areas used by Keila MacNeal and Tish Bagley are cluttered with instruments, disposables and computer terminals.

The routing for each tube is determined by the Automation System Controller, which is programmed with logic developed by our lab. The Controller is a Pentium-based PC operating in a Windows environment and communicating with instrument and LIS components using TCP/IP, HL7 and ASTM 1394. Barcode readers preceding each instrument/workstation on the track identify each tube to the Controller, which then determines whether the tube should be processed at that instrument or bypass it. The track’s dual-lane configuration allows tubes to proceed on whichever course is appropriate, without unnecessary delay.

Tubes for CBC analysis are routed directly from load station to the Roche Sysmex HST 430-II. Tests requiring centrifugation proceed directly from load station to a centrifuge module which houses four Eppendorf centrifuges. In this module, tubes are robotically lifted off the track, centrifuged, and placed back on the track. Following centrifugation, tubes travel to an decapper, then to the appropriate instrument. Typically, since chemistry testing represents the biggest volume in our lab, a tube is first routed to one of two Vitros 950AT chemistry systems from Ortho-Clinical Diagnostics. The LAS automatically balances workload between the two Vitros 950 Systems; it may send five samples to one of the Vitros analyzers, then the next five samples to the other system. The most common tests are on both instruments. A Vitros 250AT system, with a smaller menu of specialized tests and for auto dilutions, also is online as part of the track system.

When online testing is complete, samples requiring additional testing route to the Specimen Manager. It sorts for offline, manual hematology procedures such as sedimentation rates and immunochemistry/therapeutic drug monitoring (TDM), which are analyzed offline on an Abbott AxSym. An automated aliquotter on the track is used almost exclusively for the 3 percent of referral tests that will be sent outside the lab. Prior to automation, aliquotting was a big job because chemistry and TDM were done in separate areas, and separate samples were required to meet our turnaround time targets. With automation, one instrument runs a sample, releases it, and it travels to the next defined routing destination.

photoAfter LAS: Laboratory Assistant Kathy Widner loads tubes onto the Labotix RRUSH automation system in the clinical lab.

After a sample undergoes testing on all the required instruments, the track routes it to a recapper, and finally, to a refrigerated storage unit. It’s important to note that because the system routes the primary tube first for on-track testing and then for offline testing, our blood-draw volume is reduced and specimen integrity is maintained.

Assessing success
Overall, the track has achieved the goals we established for it. It has reduced costs, positioned us for future growth (with a proportionate growth in revenue), improved routine turnaround time and reduced errors.

Our system also handles pre-analytical processing with aplomb. It centrifuges, uncaps, aliquots (when necessary), recaps and stores samples when testing is finished. Our technologists are no longer highly-paid tube handlers, but testing managers and problem-solvers.

photoAfter LAS: Tubes requiring testing on the vitros 950AT chemistry system are identified by a barcode scanner, then held for sampling by the Vitros systems.

The original plan was for the LAS to run from 4 a.m. to 8 p.m. daily, and shut down entirely on weekends. Two months after it went online, the staff voluntarily had the track operating 24 hours per day. People may grumble about the daily hiccups of the automation system, but if you want to hear real screaming, wait until someone hits the emergency stop button and brings our automated track to a standstill. Our technologists have come to depend on the automation system to make their working hours easier and more productive.

Routine maintenance is simple. It takes about 30 minutes a day to clean and fill the capper and aliquotter with supplies.

However, it wasn’t always so easy. During the system’s initial weeks, we worked 15 hour days to keep the system running and learn its idiosyncrasies. Mechanical aptitude is clearly an asset with an LAS — even more so than with traditional lab instrumentation. We had some problems with the centrifuges meeting their claimed throughput of 450 tubes per hour, and the automated refrigeration units didn’t perform as promised. But after 18 months of debugging, our system is consistently operational.

Planning for expansion
Today, our lab competes for regional lab business with some of the nation’s largest reference labs. Our instrumentation and track system are capable of a three-fold increase in volume. Before automation, we were doing 400,000 billable procedures annually. Our volume is currently at nearly 1 million. Our goal is to reach 2-2.5 million billable procedures.

photoAfter LAS: Not all samples are loaded onto the robotic track; samples can also be tested manually if necessary. Here, Harry Gaston, MS, MT, CLS, RHE loads tubes directly on a vitros 950 AT system for chemistry testing.

Not all testing is automated on the track system yet. We still plan to add: a Diagnostico Stago STA-R Hemostatis analyzer, a Bayer Atlas for urinalysis and new immunochemistry instrumentation.

The track has changed the rules in our lab in important ways. In the future, one of the first questions we will ask a potential instrument vendor is, “Is your instrument automation friendly?” Our LAS is configurable and expandable, so we’re not locked into a static form.

Advice to labs considering automation
Our journey to successful automation was years in the planning and execution—in part because CMMC was a guinea pig/pioneer. We participated in the development of a number of modules on our system.

The best advice we can offer to other institutions considering automation is to visit existing sites. Learn from the experience and insights of others. CMMC regularly welcomes visitors looking into automation options today.

photoAfter LAS: A diagram of the robotic track, accessible at the Automation System Controller workstation, lets lab personnel specify which instrumentation is online at any time.

Consider how your existing space will accommodate the automation system. We were fortunate to have plenty of room and existing concrete-reinforced floors. But during remodeling, we had to move our Vitros Systems, AxSym and coagulation instruments into an adjoining room. We worked in cramped quarters for longer than expected as the room was being readied for automation.

Plan for automation when replacing or upgrading individual instruments. Instrument vendors are realizing that future sales may well depend on an instrument’s automation capabilities. Vendors have a new reason to anticipate long-term relationships with institutions. Once integrated with an automation system, an individual lab is more likely to continue using a given vendor and methodology.

At the time we began planning our automation, the CMMC lab was using a different chemistry analyzer. We eventually moved to the Ortho-Clinical Diagnostics Vitros Chemistry Systems in part because of its automation-friendly design. They set the standard for the industry for point-in-space sampling. In addition, our techs have greater confidence that the result from a Vitros Chemistry System will be right, and that fewer tests will have to be repeated. As we prepare to take on a greater workload in outreach testing, quality considerations like that become increasingly important.

Consider how an LAS will be justified. When we began this process at CMMC, labor saving was the driving force in cost justification. It’s still the simplest way to show return on investment. But be clear on what else you hope to accomplish through automation, too. In most cases that means reducing costs and improving workflow. In the coming years, there will be added focus on revenue by increasing testing quantity and improving the quality (faster turnaround times, reduced sample size and errors).

Finally, despite all your planning and analysis, be prepared to proceed on faith. Investing in automation is akin to being asked to predict the future. Your institution will be making a long-term investment without being privy to knowledge about the futures of individual instrument vendors or the economic forces that will drive your own marketplace. Look for flexible systems that promise to be good investments even over a fairly short run.

Then buckle your seat belt and prepare for a change in your work environment like you’ve never experienced before.

Carraway Methodist Medical Center, a 617-bed acute care hospital, is the flagship facility for Carraway Methodist Health Systems, headquartered in Birmingham, Ala. The system serves a 14,000-square-mile area of central and northwest Alabama through its hospitals in Birmingham, Winfield and Haleyville, as well as its clinics and other programs.

Joanne C. Kendrick, MT (ASCP), is manager, Clinical Laboratory Operations, Kuruvilla George, MBA, MT (ASCP) is Exec. Dir., Ancillary/Diagnostic Svcs., and C. Joyce Greathouse, M.D., is Medical Director, Clinical Laboratory and Chairman, Department of Pathology at Carraway Methodist Medical Center.