Lab professionals use many options to overcome problems.
Once upon a time, stat orders for patient testing signaled real life-threatening conditions. But times change. To pressure the lab to process their tests faster, physicians were tempted to order more tests—even routine ones—as stats. Stat overload is widespread, and lab professionals are using a variety of options to overcome the problem.
The Meaning of Stat
Patricia Mullenix, BS, MT(ASCP)SH, says her perspective comes from many years of working in the clinical lab environment. She currently serves as Hematology/Satellite abs Technical Manager at Memorial Health University Medical Center, Savannah, Ga.
According to Mullenix, automation of chemistry and other laboratory processes can help improve turnaround time provided you are not automating a broken system. In that case, she says, automation serves to make things go wrong faster.
“It makes sense to spend some time and possibly money up front getting efficient processes in place before automating an inefficiency,” Mullenix says. “For example, if the instruments are so far removed from the specimen-processing area that the samples can’t be delivered by the automation, consideration should be given to locating the pieces of the process closer together so they can be linked.”
Mullenix says the major time savings created by these systems is in the area of preanalytical testing. Analytical instruments are now pretty fast, she says, but automated receipt into the lab, centrifugation, decapping, aliquotting, delivery to instruments, and balancing workload between instruments can generate more efficiency than doing all the steps manually. Specimen storage and retrieval on the other end is also faster than hunting manually through hundreds or thousands of specimens.
Mullenix says that stats are not overused because of a general misunderstanding about the importance of speed. “If we deliver blood to the trauma unit after a patient has already bled to death, it isn’t very helpful. That is an extreme example, of course, but speed is often very important,” she says.
According to Mullenix, some of the overuse of stat orders is attributable to physicians who aren’t satisfied with their routine turnaround times and decide to order things stat as a way to ensure that test results will be available when they need them. “In my experience, it seems that the more satisfied physicians are with routine turnaround times, the less stat abuse we see,” she says. Excessive stat requests can often lead to loss of efficiency within a laboratory and delays in both stat and nonstat testing.
“I certainly agree that the misuse of stat orders leads to overall inefficiency and ends up delaying everything, including the stats,” Mullenix says. “This leads to the proverbial ‘catch-22’ situation where the stats delay the routines so the physicians perceive the turnaround time as slow and respond by ordering more stats, which further delays the routines and they order even more stats.
“Pretty soon the stat volume is so high nothing is handled stat because there aren’t any routines to interrupt,” Mullenix continues. “We don’t interrupt stats already on the instrument when another stat comes in so the new stat is just queued with all the others. It might as well have been routine. Unfortunately, we don’t know at that point which stats are really for life-threatening conditions.”
According to Mullenix, hospitals have employed a variety of methods to police the use of stat test ordering. In some cases, labs have required that a copy of the actual physician’s order specifying the test as stat accompany all stat specimens. “Sometimes, that does help when there is abuse by the nursing staff ordering tests stat when the physician has not requested it,” she says.
Another approach: Facilities arrange to have their directors of pathology sit down with other members of their medical staff for a thorough discussion of guidelines related to stat testing. A common theme is that stat abuse not only delays routine testing but can also delay real stats results. Many hospitals have adopted lists that spell out exactly which tests are eligible to be designated stat.
“In some cases, these hospitals refuse to perform tests stat unless they are on the approved list,” Mullenix says. “That reflects the belief that a test that doesn’t lead to an immediate treatment decision in a life-threatening situation probably shouldn’t be allowed to delay other testing by being ordered stat.”
So what can hospitals do to limit stat testing requests to true life-threatening situations? Mullenix says that issue has been debated for as long as she has been involved in testing. “I think a campaign to educate hospital staff in general and physicians and nurses specifically about the impact of stat abuse and the delaying of a true life-threatening test result by a ‘stat for convenience’ order would be a good start,” she says. Mullenix says she would welcome a move by the College of American Pathologists or other lab organizations to take on the problem with an advertising campaign or even case studies in nursing and medical journals. “In some cases, the problem may well be one of lack of awareness,” she says.
Automation Gains Appeal
Ron Berman, worldwide director of product management for Beckman Coulter’s automation and information systems, says his company’s automation and middleware data-management products focus on improving overall laboratory efficiency. The result: Physicians are not as prone to order everything stat. He says Beckman Coulter, with a 65% market share, is the leader in automation placements in the United States.
“Stats can be disruptive to the central laboratory process and more expensive at point of care,” Berman says. “I am seeing fewer stand-alone stat laboratories as investments in automation and middleware occur.”
Physicians are dictating improvements in the quality of overall services, including quality of results and overall consistency of turnaround times by reducing the variation of the average time. “Staying competitive for a hospital means keeping doctors and patients happy,” Berman says.
Beckman’s approach offers some flexibility for hospital customers. The company offers four levels of automation: system-based, discrete, integrated and comprehensive. “I see more and more facilities under 200 beds looking at real front-end automation,” Berman says.
Doing Away With Priority Designation
At the Oklahoma University Medical Center (OUMC) in Oklahoma City, clinical practitioners and lab staff worked together on a program that nearly eliminates stat testing and has improved turnaround times for patients confronting potential emergency problems. That change generated enough cost savings for the lab to operate the following year without any expansion of its budget.
Kenneth E. Blick, PhD, ABCC, FACB, who directs the Chemistry and Immunoassay/Endocrine laboratories at OUMC, says his lab simply stopped assigning priority to stat requests from physicians. Now, the OUMC core laboratory processes stat and routine tests the same way.
Key to the improved processing was the lab’s decision to do away completely with batch processing of patient samples and make a full conversion to real-time techniques, beginning with the collection of specimens by nurses and returning test results to physicians in real time.
“Before our change, stat orders had reached 54% of tests. Now, our tests for legitimate life-threatening conditions are around 3%,” Blick says. “That other 51% of stat orders probably reflected the frustration of physicians who were fed up and wanted to get their tests to the head of the line.”
Blick says his lab’s investment in data management and effective automation tools—keys to real-time performance—made stat testing unnecessary because the system improved turnaround times on all testing levels. His lab processes specimens on a first-in/first-out basis, without queues, so no special stat designations are required. The change hasn’t stopped the medical center’s physicians from submitting stat requests. But those requests just get processed on the automation line along with routine orders.
A frequent lecturer who travels widely, Blick says every lab in the world is feeling pressure to scrap batch-and-rack systems and adopt real-time testing. “It’s a lot more than putting in a pneumatic tube transport system,” he says. “That’s just the start. You need automated bar code labels, walk-away/automated as well as redundant analyzers, autoreceive, autocentrifugation, and robotics. Expert rules to identify problems with specimens and results along with autovalidation are critical.”
At OUMC, tests are done either in real time through the core lab or at point of care. His lab now offers continuous testing and real-time handling on more than 100 varieties of tests on a 24/7 basis. “People don’t schedule their heart attacks between 6 am and 3 pm, so we are here, offering great service around the clock,” Blick says. “That’s not how labs traditionally operated.”
Blick sees spending on real-time testing as essential for any hospital lab that hopes to remain competitive and deliver the level of care patients now expect. “In fact, the lab may be the most important department in a hospital,” Blick says. “It’s where 70 to 80 percent of the objective evidence comes from.”
The Case for Cooperation
Investing in real-time lab processing technology didn’t stop her hospital from refining the handling of time-sensitive testing, says Denise Uetwiller-Geiger, PhD, DLM(ASCP), administrative director and clinical chemist at New York’s John T. Mather Memorial Hospital.
With its comprehensive automation platform, the lab can perform all preanalytical, analytical, and postanalytical operations hands-free. Of special concern is the ability of the lab at Mather, a certified stroke center, to meet mandated standards requiring turn-around on stroke-related tests in 45 minutes or less.
“We’ve tried to break the habit of everything as stat,” Geiger says. “Since January, we’re using a special code orange to alert everybody from the ER to lab about the most time-critical tests,” she says. Lab officials have held “lunch and learn” sessions with each department to get the message out.
Stat orders are demanding for the hospital’s team of phlebotomists. They respond immediately to rapid response, code orange, code blue, and emergency-department requests. For routine testing, the hospital has begun scheduling phlebotomists for rounds of specimen collection at 2-hour intervals throughout the day. Geiger says, “These rounds create more efficient collection, but they depend on cooperation and collaboration between lab, physicians, and nurses.”
Nicholas Borgert is a contributing writer for Clinical Lab Products.
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