It isn’t that an emergency department (ED) wants anything unusual; there is little variation in the types of lab tests ordered by emergency medical professionals. It’s just that the ED wants the results faster … like now.
“We consider that all of our lab tests need to be done stat; and, of course, emergency personnel get a little upset if things don’t come back quite as fast as we think they should,” says Douglas Hill, DO, FACOEP, FACEP. He practices at North Suburban Medical Center, Denver, and is a professor of emergency medicine for the College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences (Kansas City, Mo). He quickly adds that when it comes to timing, the blame for many delays lies neither with the lab nor the ED, but rather in demanding schedules in both areas that are increasingly becoming the norm. “I think the first challenge is for us to realize the limitations lab personnel have and for them to realize what kind of conditions we are working under.”
Trauma patients aren’t the only ones putting pressure on the ED staff. Very few health care organizations in the country have more beds than they can fill. Because of a limited number of available beds—and ever-growing throngs in the waiting room—emergency-medicine physicians shoulder much of the burden of patient throughput.
For ED doctors, making a decision about disposition—admit or don’t admit—is fundamental to avoiding a backlog.
“Everyone’s concerned about turnaround time, but the emergency room is dealing with patients where lab tests or radiologic studies are determining the key decision of whether a patient does or does not get admitted, or how they might be treated,” says Kent B. Lewandrowski, MD, associate professor of pathology at Harvard Medical School and associate chief of pathology (operations) for Massachusetts General Hospital (Boston). “Their patients have to wait until all of the results come in, which means clinicians are singularly focused on the turnaround time of a limited set of tests.”
Turn, Turn, Turn
On the surface, it may seem there is little to discuss. The ED staff wants speed; the lab is working hard to provide it. But dig a little deeper, and things become less obvious. Even the concept of “fast” needs some definition.
“The laboratory perceives turnaround time from the point they get the specimen to the time they turn out the results,” Lewandrowski explains. “The doctors and nurses perceive turnaround time from the moment they order the test to the time they get the results.”
Because of the amount of multitasking required from nurses—drawing blood, hanging IVs, and assessing vital signs—delivering samples to the lab often takes a backseat. Still, shuttling tubes back and forth is often only a small part of the equation. There are a multitude of steps that occur between a physician’s initial exam of a patient and getting the lab results in hand—and delays can occur at any stage. One common holdup is caused by improper collection and identification of specimens.
“Consistent patient identification is really critical and another key issue is the proper collection of blood specimens. It is important for ED staff to avoid drawing specimens above lines and to be proficient in the use of certain needle sizes that can present problems,” says Stephen E. Kahn, PhD, DABCC, FACB, interim chair of the Department of Pathology and professor of pathology and cell biology at Loyola University Medical Center (Maywood, Ill). “And that’s a matter of our staff providing an in-service to the nurses, because—let’s face it—the emergency department is a very busy, sometimes chaotic, high-patient-demand area, and it’s challenging to get everything done the way all the hospital-based ancillary departments want them done.”
Talk It Out
Seemingly simple things can often lead to sizable frustrations, so many agree that whether it comes in the form of regular meetings, impromptu e-mail threads, or casual hallway tête-à-têtes, the most vital component to any successful relationship between the lab and the ED is communication.
Some agenda items are obvious— when tests are being discontinued or introduced, for instance—but it is also critical for the lab to communicate equipment issues to the ED. Problems with an analyzer that returns cardiac-marker results can significantly postpone results, which can make a difference in how physicians approach patient care. If delivery methods, such as the lab’s computer system, are slowed for any reason, there must be a process in place to get that information to the caregivers.
“It starts with having a good relationship; the laboratory needs to have a good rapport with the ED director,” says Alan HB Wu, PhD. He is the chief of the Clinical Chemistry and Toxicology Laboratories in the Department of Laboratory Medicine at San Francisco General Hospital and a professor of laboratory medicine for the University of California, San Francisco. “I would definitely have the laboratorians spend some time in the ED during their peak times, to see the issues and demands that the ED staff is facing.”
Peeking into each other’s world and building relationships goes a long way to developing lasting, effective bonds between the two departments.
“There has to be a very, very strong collaborative effort between the clinical labs and the emergency medicine physician—our emergency medicine physicians and our clinical lab directors know each other personally, we work together very closely to try and alleviate a lot of the pressures emergency medicine specialists are currently under,” says James Januzzi, Jr, MD, FACC, assistant professor of medicine, Harvard Medical School, and associate medical director of the Coronary Care Unit at Massachusetts General Hospital. “The fact is that the only way this problem will be resolved is with everyone working together and sharing that common goal.”
Part of that solution involves setting realistic expectations for both ED staff and lab professionals. One example is providing clinicians with basic times expected for tests to run.
“I want to know what the expectation is for turnaround time on something, because if it takes 30 minutes to run, I don’t want a call at 31 minutes asking where my test is,” Hill says. Not only does it prevent time-consuming follow-up, but it can help the ED manage their own collection process. “If I have a 30-minute turnaround expectation and at 45 minutes I still don’t have it, I want to know that, because maybe a specimen got lost or it didn’t get drawn, or maybe I think I ordered the test, but I didn’t—whatever it is, we can take the initiative to find out what happened.”
A proactive approach works for the lab, too. “The biggest thing is for the laboratory to go to the ED and say, ‘You are important. Our performance in your mind is important,’ ” Lewandrowski says. He strongly advises against a “that’s their job, not mine” mentality in labs. “If you take that attitude and approach, from an organizational perspective, you are doomed for failure. If the ED is satisfied with your services, it’s good for them, it’s good for the patient, and it’s good for the lab.”
| Because of the amount of multitasking required from nurses—drawing blood, hanging IVs, and assessing vital signs—delivering samples to the lab often takes a backseat. Still, shuttling tubes back and forth is often only a small part of the equation. There are a multitude of steps that occur between a physician’s initial exam of a patient and getting the lab results in hand—and delays can occur at any stage. One common holdup is caused by improper collection and identification of specimens. |
Working Together
For many hospitals, the best way to improve turnaround times is to put med techs directly into the ED. Doing so eliminates any potential concern about how tests are being performed, regulatory compliance, or whether information is correctly entered into the hospital’s electronic medical record. It also provides a ready solution to any preanalytical obstacles that may crop up.
“We realized that because of complex preanalytical delays, we were not going to be able to get the emergency-room lab test turnaround time to an acceptable level no matter how fast we measured them in the clinical lab,” says Lewandrowski, whose lab closed the gap by moving into the ED. An on-site lab kiosk provides testing for cardiac markers, urinalysis, urine pregnancy testing, whole-blood glucose, and influenza, as well as rapid strep testing.
Whether or not such a relocation is possible is determined largely by the health care organization’s size and budget. When it isn’t feasible to open a lab in the ED, the next best thing could be identifying one or two techs who work exclusively with the emergency team.
“Some hospitals have emergency departments that are so small that you could never justify having a lab in the ED, so they just have a person from the lab down there,” Hill says. Tasks for these individuals could range from simply ferrying samples through the test process to drawing blood or performing the tests themselves. “It works to have a dedicated person that works really well, even if they don’t have their own dedicated space,” Hill says.
Still another option is establishing a “triage” procedure for all specimens entering the lab. “We have an emergency-department specimen triage process that expedites the handling and analysis of specimens through the core laboratory,” Kahn says. However, the coming fiscal year could bring significant changes to the Loyola ED. “There may be an opportunity to implement a small laboratory in the emergency department. This could be a single phlebotomist or a patient care tech or more complex models, depending on what is chosen.”
However it is configured or staffed, perhaps the most important consideration is exactly what is on the menu. After reviewing the average length of a patient’s stay in the ED as a function of laboratory turnaround time, it became clear to the team at Massachusetts General Hospital that the factors involved extended far beyond simply returning all results faster.
“We found certain laboratory results had a rather significant effect on patient disposition from the emergency department,” Januzzi says. One such area was cardiac-testing results. “It was obvious that rapid turnaround for our cardiac troponins would have a very favorable effect on decision-making with respect to patient triage in the emergency-department setting, but that it wasn’t absolutely necessary to have a blistering 15-minute turnaround time for every single analyte that we were testing for.”
Influenza testing at the point of care also proved to be quite helpful in freeing up beds. Because those hospitalized with the virus must be isolated, “the ability to identify whether the person has influenza or chronic obstructive pulmonary disease (COPD) exacerbation with bacterial pneumonia is very important in terms of how you manage your beds in a hospital,” Lewandrowski says. “And it doesn’t suffice to get an influenza test the next day.”
Implementing this type of prioritized testing reduced the lab’s turnaround time by roughly 85% and decreased the average patient stay by 41 minutes.
Sharing the Wealth
The knowledge and experience clinical lab professionals possess are riches to the physicians working in emergency medicine.
“We are looking for rapid results, but it’s no longer sufficient nor acceptable to merely deliver rapid results; we need to be able to say that the results delivered rapidly are also of high quality,” Januzzi says. He believes it is imperative for clinicians to have a good understanding of the technologies available for testing in the ED setting. “We have a lot of nice options available to us—all of these newer tests that are very useful—but you have to understand how to use them; and without education from the lab, you end up getting frustrated.”
Wu agrees that educating physicians about the limitations of tests is essential.
“They get frustrated because our tests aren’t good enough, but it’s often not an issue of reporting results, it’s more what the results mean and whether they were used correctly,” he says. “For example, toxicology results are often misinterpreted by ED staff, because they don’t realize the limitations the lab has in turning out results.”
Clinicians are also eager to benefit from the laboratory’s input on the types of tests being ordered. “Maybe their literature shows that a test isn’t indicated or perhaps there’s a better test available that we don’t know about. If there are certain tests we order that are just ridiculous, they need to let us know that because we can change our ways,” Hill says. “On the other hand, we, as emergency physicians, utilize certain specific assays in our algorithms that are part of clinical decision-making. To change from one methodology to another may be inappropriate to our clinical policies. For example, the American College of Emergency Physicians’ Clinical Policy on Pulmonary Embolism utilizes the rapid ELISA D-dimer. When the lab at our hospital substituted another assay without our knowledge or input, the entire decision-making algorithm became muddled. A quick meeting brought us together to discuss everyone’s needs, and the lab went back to the D-dimer we wanted and all parties benefited. Just keep the avenues of communication open!”
Get Out of the Lab
No matter how bumpy the relationship with the ED, one thing is certain: The lab’s success comes from reaching out.
“If you’re the lab, you’re in the service business. So it behooves you to be constantly seeking opportunities to be useful to the hospital by building relationships and creating an environment in which an interdepartmental, collegial effort can be engaged,” Lewandrowski says. “If you take that approach, they’re going to work with you, and it’s going to be very good for the reputation and standing of the laboratory, it will help patients, and it will help the hospital run more smoothly and efficiently.”
Dana Hinesly is a contributing writer for Clinical Lab Products.
