The volume has grown 8% to 10% annually the past several years at University Hospital’s chemistry lab at the University of Michigan—which runs nearly 7 million tests per year and shows no signs of a slowdown. The 900-bed facility in the southeastern part of the state houses a trauma center, a comprehensive cancer center, and a newly dedicated cardiovascular center. Some 70% of its patients are admitted from communities or regional hospitals beyond the Ann Arbor area, and the transplant program draws patients nationwide. The lab serves the main hospital, the CS Mott Children’s Hospital, Women’s Hospital, 120 outpatient clinics, 30 health care centers, and is a reference lab for facilities throughout Michigan and northern Ohio.

Siemens’ automated systems have helped Sue Stern and Eric VasBinder nearly double the automation testing volume.

Aging instrumentation prompted administrators to mull change. The lab installed immunoassay equipment first because little stat testing was involved. “We didn’t have a line yet when we started using the Centaurs,” said Sue Stern, the hospital’s administrative health care manager, referring to the Advia Centaur immunoassay system from Siemens Medical Solutions Diagnostics, Deerfield, Ill. It was a plus that samples could be loaded manually. Some 4 months later, the lab installed CentraLink middleware, to go live with the automation line. Most staff members had never worked with liquid chemistry, but they embraced the challenge because the old systems were struggling to keep up with the workload and required frequent repairs. The sheer volume of tests demanded automated chemistry and immunoassay systems that worked together online, with a footprint that dodged the need for major construction to house it, and a price that was right.

Stern, a 29-year veteran of the department, supervises some 65 technologists. Before switching to the Siemens instruments, the lab utilized dry slide technology instruments for its chemistry testing. This type of testing had moved the laboratory away from continuous flow analysis to discrete individual test analysis. Prior to the line, the lab had five chemistry instruments and three techs divided the workload. Immunoassay instruments have become more prevalent and robust, and one finally became available that could be attached to an automation line directly.

On the Line

The lab nets specimens from central processing, and sorting is guided by what goes on the 56-foot automation line and what does not. The LIS logs in tubes and tracks their whereabouts within the lab. Due to the high volume of stat requests, stat samples are separated from routines and spun offline to decrease their processing time.

“We load adjust based on the time of day to maximize the line efficiency by limiting routines during peak volume times,” says Eric VasBinder, the lab supervisor for automation, who has logged 20 years on the job, 7 in automation. “All routines spun and unspun are loaded directly on the automation line as we have online centrifuges that spin the routines and handle decapping for us as needed.” Samples are loaded depending on stat and nonstat, capped, and noncapped into various drawers in the sample managers that robotically load the line. The line routes sample tubes to instruments based on needed tests—it checks the test menu and scouts available instruments and whether centrifuging is needed.

Processing 10 to 20 comprehensive profiles took 40 to 50 minutes before, but fast forward to liquid chemistry where the process takes 10 to 15 minutes. Autovalidation also brought changes. The techs had previously manually verified every sample’s results. It took a while for them to adjust to processing the results. “Before, we had a mixture of normal and abnormal results,” Stern says. “Now, all they see is abnormal results for review. The process is now much more team-oriented.” Instead of areas being divided up between technologists, one tech puts tubes on the line, another replenishes reagents and performs quality control, and another validates results.

Less Is More

“We use a lot less reagents than we used to. It’s a totally different way of operating,” Stern says. “The whole system together allowed us to do things we couldn’t do before.” Before, a technologist had to move a sample to another instrument to perform an automated dilution for a particular test or to repeat a test due to a high or critical result value. “Now, the software and instrument have been programmed to know when to repeat and perform dilutions based on result values.

“The automation and software have also helped us with our add-on test request process—that was all manual—every tech had their own rack of specimens with validated results in it,” Stern says. When physicians called, a technologist had to find the technologist who validated the results. Then, they had to find the sample tube and put it back on the instrument. “Now, if the sample tube is on the line, the system does all the work.” The technologists try to store 3 to 4 hours of specimens in the sample manager on the line for automatic add-on purposes. If the specimen is in the sample manager at the time the add-on is created, the sample is automatically retrieved and processed without manual intervention. If it’s been longer than 4 hours, the technologist searches for the sample in CentraLink, determines the tube position in the sample tray and in which refrigerator the tray has been stored, and quickly retrieves the sample.

“The automation line has greatly reduced the number of tubes we handle and need; it reduced the number of samples we require for testing,” VasBinder says.

“We consolidated testing from other platforms, combined tests,” Stern says. “Now, we receive one serum tube, and have the ability to perform any menu of tests on the line as long as they are serum tests.” For outpatient testing, the lab has reduced by two-thirds the number of tubes phlebotomists need to draw.

Bottlenecks are isolated to sheer volume, and at peak times overloading is a risk. The lab’s turnaround time for stat tests meets the industry standard—60 minutes—but the lab aims to trim it to less than 50 minutes. “We’re down at 50 minutes 95% of the time,” Stern says. “We’re striving for 45 minutes.”

Some 30,000 tests per month for clinical pathology outreach services include work for 125 physicians’ offices, full reference lab services for 13 hospitals, and a select menu of reference work for 25 hospitals. The lab performs about 20,000 PSA tests annually for the National Prostate Cancer Coalition, a federal project.

Automation did not trigger downsizing. It has helped broaden the lab’s testing menu. About 32 staff members work shifts in the 24/7 automation section. Ten people work days; five operate the system. “We haven’t lost any positions since we implemented automation. We’ve brought in more esoteric testing that we would normally have sent out, such as Vitamin D analysis. We are also looking at bringing in-house allergy testing,” Stern says.

Outreach brings in some revenue, but more importantly, it brings in more referrals for hospitals, VasBinder says. “It gets our name out there—there’s a lot of competition in the southeast corner of Michigan. We’re over maximum capacity with beds, and we’re 100% full.”

Judy O’Rourke is associate editor of CLP.