Physician satisfaction and emergency (stat) laboratory turnaround time during various developmental stages

Peer reviewed ORIGINAL ARTICLE Physician satisfaction and emergency (stat) laboratory turnaround time during various developmental stages AJ Groenewald (PhD) HD Potgieter (M Tech) Department of Chemical Pathology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: Dr Dries Groenewald +27 51 405 2915 groenewaldaj@ufs.ac.za Abstract The aim of this study was to compare physicians' perceptions of turnaround time (TAT) with measured TATs for potassium and troponin T, (i) before installation of a pneumatic tube system (PTS), (ii) after installation of the PTS, and (iii) after installation of the automated chemistry analytical system (ACAS). Physicians were in general more satisfied with the TAT of the emergency (stat) laboratory after installation of the ACAS. This finding is in contrast with the TATs for potassium, which worsened significantly (p<0.0001) with each developmental stage, probably because of simultaneous installation of other point-of-care (POC) systems at strategic places. We concluded that our emergency test TAT deteriorated with each developmental stage and decided to update communication systems, introduce a stat line for fast registration of specimens, prioritise chemistry requests from various intensive care units, wards and hospitals, and appoint more pre-analytical staff. A follow-up study will be necessary to reveal whether these precautionary measures were successful or not. Keywords turnaround time; emergency; physicians; survey; pneumatic tube; automated chemistry analytical system; ACAS Introduction The turnaround time (TAT) of laboratory specimens is a critical component of laboratory services and a key factor in client satisfaction. [1] TAT, more than anything else, is the norm by which physicians judge the performance of laboratories. [2] A rapid TAT on some tests can also be essential for proper patient care, preventing delays in treatment, and reducing the cost of hospitalisation. [3] Laboratory personnel generally view the TAT as the time from receiving the specimen in the specific pathology department, to the time of completion of the test. However, most physicians feel that the TAT starts on request for a specific laboratory test and ends when they view the result. [3] The handling of any laboratory test can be divided into three phases: (i) pre-analytic (requesting, collection and transport of specimens); (ii) analytic (preparation and analysis of specimens); and (iii) post-analytic (time required to report back to physician). [1] Delays can occur in any of the three phases. Literature has shown that in general, the laboratory is not primarily the area of delay with respect to TAT. [1] In a study of outlier TATs (>70 minutes), Steindel et al. [4] showed that only 28% of delays occurred during the analytical phase of the total testing process, and most delays were encountered in the preanalytical or post-analytical processes. [3] A 90% completion time (sample registration to results reporting) of <60 minutes for common laboratory tests is suggested as an initial goal for acceptable TAT. [5] Handorf states: "Good quality, low cost, or fast turnaround times you only can have two". [6] Good quality and rapid results tend to be expensive; good quality and low cost are likely to be slow; and low cost and rapid results are available at a sacrifice of quality. Test TAT statistics can help laboratory managers to understand and evaluate operational performance better. The acceptable 'within laboratory' TAT (beginning from when the sample is received in the laboratory) must be defined for each test, usually after consultation with the appropriate clinical staff. [7] The area (pre-analytical, analytical or post-analytical) and factors contributing to delays also need to be identified. The factors influencing TAT can be classified in two groups, namely those that the laboratory management have control over, and those that cannot be controlled (institutional/hospital factors). The factors that can be controlled by the laboratory management need to be targeted in order to improve TAT and thus client satisfaction. A balance between the speed, quality and cost of the test needs to be sustained. With pressure from physicians to improve TATs in the laboratory, new concepts and technologies have been created. Some proposed solutions for decreasing TATs are pneumatic tubing systems (PTS), point-of-care (POC) testing, satellite (stat) laboratories, and improved computer technology. [1] Diagnostic laboratories at the Universitas Academic Hospital in Bloemfontein recently faced a number of structural changes: (i) the stat laboratory (henceforth referred to as the stat lab) which was situated near the emergency departments of the hospital, was replaced with a sample depot; (ii) a PTS was installed to connect the depot with a new service laboratory; and (iii) a new automated chemistry analytical system (ACAS) was installed in the service laboratory. The question is whether all these changes will improve TATs and consequently, consumer satisfaction? The objective of this study was as follows: (i) Phase 1: to determine physician perceptions on TAT before installation of the PTS, after installation of the PTS and after installation of the ACAS; and (ii) Phase 2: to compare measured TATs for potassium and troponin T before installation of the PTS, after installation of the PTS and after installation of the ACAS. Methods Phase 1: Physician satisfaction survey In a retrospective comparative study, a survey was done to de- 20 www.smltsa.org.za ISSN 1011 5528

termine physicians' (including both doctors and senior nursing staff) perceptions of the Universitas Academic Hospital stat laboratory services. This survey was done in three stages, namely (i) before installation of PTS; (ii) after installation of the PTS; and (iii) after installation of the ACAS. Four medical students conducted the consumer satisfaction survey. They provided five physicians in four different emergency departments' (EDs) with the questionnaires. These departments included the cardiothoracic intensive care unit (ICU), coronary ICU, multidisciplinary ICU, and referrals. In total, 60 questionnaires were collected, 20 from each stage of the survey. The first four questions of the questionnaire determined whether various ED physicians were satisfied with the TAT of the stat lab. Physicians were asked to use a 6-point scale for responses on these four questions: always (95% of the time), usually (76%-95%), often (51%-75%), sometimes (26%-50%), rarely (5%-25%), never (<5 %). The last two questions determined what the perceptions of ED physicians were of TAT. The following questions were asked: Is the stat lab sensitive enough to the stat (immediate/ emergency) needs of the physicians? Does the stat lab meet the stat needs of the physicians? Does laboratory TAT delay treatment of patients in EDs? Does laboratory TAT increase ED length of stay of a patient? Which one of the following would you define as the correct definition for the beginning (start time) of TAT? (order entry, when the blood specimen is drawn, or laboratory receipt of the specimen). Which one of the following would you define as the correct definition for the end (end time) of TAT? (physician's request for a specific test, verification of results, or when the requesting ED gets results). Completion of the questionnaire was anonymous. The purpose of the questionnaire was clarified if necessary. Phase 2: Turnaround times The outcome of the abovementioned survey were compared to real TAT values obtained for potassium and troponin T collected over a period of one week before and after structural changes were approved. The TATs of the following intervals were studied: Draw-to-receipt TAT: the period from the time of specimen collection to the time of receipt by the laboratory. Receipt-to-test TAT: the period from when the specimen was received in the laboratory until the test was completed. Test-to-verify TAT: the period from when the test was completed until the result was verified and reported. Receipt-to-verify TAT: the total period from when the specimen was received in the laboratory until the result was reported. Potassium represents frequently requested profiles such as urea and electrolytes. Troponin T, frequently requested by cardiologists, has a longer incubation period. Before and after installation of the PTS, potassium and troponin T were analysed with Beckman CX 7- and Elecsys 1010 analysers, respectively. After ACAS installation, potassium was performed using a Cobas 6000 and Trop T on a Cobas e 601 immunoassay system from Roche. The PTS connects the depot with the service laboratory 250 meters away. It operates on a vacuum-driven system to deliver sample capsules filled with tubes to the service laboratory within 55 seconds. Ethical considerations Approval to conduct the investigation was obtained from the Ethics Committee of the Faculty of Health Science at the University of the Free State in Bloemfontein (ETOVS nr: 12/07). Statistics Physician satisfaction survey Numerical values between 1 and 6 were allocated to the six different levels (from "always" to "never") of satisfaction/dissatisfaction of the consumer satisfaction survey (see first four questions of the survey). Depending on the question, the best (experienced as most satisfactory) answer would be either "never" or "always". The score values allocated to the spectrum from "always" to "never" depended on the most satisfactory answer. For example, if the option "always" was selected, which reflected "experienced as most satisfactory", it was allocated a value of 6 and the converse "never" was allocated a value of 1. If "never" was the best (most satisfactory) answer the value attributes were reversed. The satisfaction/dissatisfaction of the physicians of the different units was expressed as a percentage of the maximum score. Turnaround times Descriptive statistics, including means, medians, ranges, standard deviations, percentiles and frequencies were used to enumerate the TAT process. The t-test was used to measure the significance of differences (p 0.05) between data. Data are also presented visually in the form of histograms and/or box-whisker plots where, in the latter, the box represented the median 25 th percentile and the 75 th percentile values and the whiskers the 10 th and 90 th percentile values. Results Phase 1: Physician satisfaction survey From the physician satisfaction survey, the percentage satisfaction for each question during the various developmental Figure 1: General satisfaction of four different departments on stat needs (n=60). ISSN 1011 5528 www.smltsa.org.za 21

stages was calculated as described in Methods. Due to the small number of participants it was decided to report the general physician satisfaction of the four different departments (Fig. 1) as well as the four questions (Fig. 2) during the various Figure 2: General physician satisfaction on certain needs to be met (n=60). Figure 3: Physicians' definition of start time of TAT (n=60). Figure 4: Physicians' definition of end time of TAT (n=60). developmental stages. Physicians representing the cardiothoracic unit and referrals indicated only 44% satisfaction after the PTS had been installed (that is, after closure of the stat lab). These units gained satisfaction after ACAS installation to 60% and 69%, respectively (Fig. 1). Physicians were in general more satisfied after ACAS installation, which was the final stage of development (Fig. 2). During the various developmental stages, most of the physicians agreed that TAT starts when blood was drawn (Fig. 3). As shown in Figure 4, physician perception of end time of TAT changed from "when results are verified" (after PTS) to "when physician gets results" (after ACAS). Phase 2: Turnaround times The number of tests included in the study is shown in Table 1. Before installation of the PTS, 1 063 potassium and 200 tropinin T tests were requested; after installation of the PTS 857 potassium and 293 troponin T tests; and after installation of ACAS 1 580 potassium and 87 troponin T tests. The percentage of draw times displayed on request forms for potassium before installation of the PTS, after installation of the PTS and after installation of the ACAS were 76%, 74% and 68%, respectively. During the same periods, the percentage of draw times displayed on request forms for troponin T were 52%, 57% and 72%, respectively. The mean draw-to-receipt TAT for potassium was significantly longer (p<0.02) after the stat lab was replaced with a PTS (64 and 78 minutes, respectively). Draw-to-receipt TATs for troponin T was shorter. No significant change in draw-to-receipt TAT for troponin T before and after the stat lab was replaced with a PTS, was observed (33 and 41 minutes, respectively). The box-whisker plots in Figure 5 and Figure 6 represent the receipt-to-test, test-to-verify and receipt-to-verify TATs for potassium and troponin T, respectively. Turnaround times of potassium and troponin T were compared before installation of the PTS, after installation of the PTS and after installation of the ACAS. The significance of above mentioned changes are reflected in Table 1. Turnaround times of potassium in- 22 www.smltsa.org.za ISSN 1011 5528

creased significantly with every developmental stage. The testto-verify TAT of troponin T improved significantly (p<0.001) after installation of the PTS in 2007, but worsened significantly (p<0.001) after installation of the ACAS in 2010. These changes accordingly influenced the receipt-to-verify TATs of troponin T. Discussion Phase 1: Physician satisfaction survey In general, physicians were more satisfied with the TAT of the stat lab (Fig. 1, Fig. 2) after installation of the ACAS. This finding is in contrast with the TATs of potassium, which worsened significantly with each developmental stage (Table 1). Physicians were probably satisfied because of simultaneous installation of point-of-care (POC) systems capable of measuring potassium, sodium, chloride, lactate and blood gas, placed inside the multidisciplinary and cardiothoracic units, theatres, neonatal unit and paediatric intensive care unit. The POC systems are normally used to measure blood gas in arterial whole blood samples. These changes were made after installation of the PTS and before installation of the ACAS. Previous research showed that a POC chemistry analyser was capable of reducing median door-to-clinical-decision time of central laboratory tests from 86 to 46 minutes [8]. In our setting, the POC chemistry analysers are able to test liver and renal functions, pancreas enzymes, lipid profiles, electrolytes and blood gases, and are set up in the EDs. Most physicians felt that the TAT starts on the physician's request for a test and ends when they view the result [3]. Most delays occurred in the pre-analytical or post-analytical prosesses [3]. During all three developmental stages of our study, most of the physicians defined that TAT starts when blood is drawn (Fig. 3). In our setting, laboratory personnel have no control over preanalytical (draw-to-receipt) TAT, and therefore, we could only concentrate on TAT after laboratory receipt of the specimen. Figure 4 shows that physician perception of end time of TAT changed from "when results are verified" (after PTS) to "when physician gets results" (after ACAS). This change in perception of end time was probably due to a 10 minute delay in communication between the DISA computer system in the laboratory and the Meditech system in the hospital. The DISA system has recently been replaced by the TracCare computer system. Phase 2: Turnaround times Two separate studies found that the median and mean TATs of sodium and potassium were 9.2 and 8 minutes, respectively, shorter after installation of a PTS. [9, 10] In our study, the drawto-receipt TATs of both potassium and troponin T frequently were not displayed on request forms. Request forms are often completed before venesection and draw times are used as a reminder for nursing staff to draw blood. Therefore, draw-toreceipt times are not trustworthy, as shown in Table 1. Troponin T is used as a marker for myocardial infarction and often requested by cardiologists. The analysis time of troponin T is longer due to a longer incubation period (Table 1). In all stages of development, immunoassay testing for troponin T got priority above that of chemistry (potassium). The test-to-verify TAT of troponin T was significantly increased (p<0.0001) after installation of the ACAS (Table 1). Samples received in the pre-analytical section are batched and loaded on the Modular Pre-Analytic (MPA), which forms part of the ACAS. It takes approximately 9 minutes for the MPA to centrifuge and aliquot samples into analytical cups, which are then moved to the ACAS for analysis. If fewer samples are loaded onto the MPA it causes a delay on the MPA centrifugation process, because if any other samples are to be loaded onto the MPA, they have to wait for the samples already loaded to finish centrifugation before they can be released for analysis. In a previous study, pre-analytical and analytical times increased with 15 and 24 minutes, respectively, when tubes were centrifuged in the MPA instead of prior to processing. [11] ISSN 1011 5528 www.smltsa.org.za 23

Other causes for delay is failure of the MPA due to stuck samples, inability to release the caps from the tubes, clots in tubes, barcode failure and communication failure between the DISA computer and the Total System Management (TSM). However, when the MPA is "down", centrifuged samples can be loaded manually onto the ACAS. Due to a large standard deviation (SD), the analytical (receipt-to-verify) TAT of troponin T was not significantly affected by the delay in verification (see Fig. 6 and Table 1) and remained almost the same throughout the various stages of development. Looking at the box-whisker plots, the longer period of time it took for 90% of tests to be completed (whiskers Fig. 6; percentiles Table 1) after installation of the ACAS, was of great concern. Whiskers (percentiles) of both receipt-to-test and test-to-verify TATs indicated that it took much longer to complete 90% of tests (see receipt-to-verify, Fig. 6, Table 1). The analytical TAT of troponin T can be reduced by decreasing the time it takes to register (receipt-to-test) and verify samples. Potassium is frequently ordered as part of the test profile for urea and electrolytes. A previous study involving 690 hospital laboratories reported that 90% of potassium results were ordered and reported in 69 minutes or less. [3] In another study, 90% completion time (sample registration to results reporting) of <60 minutes was suggested as an initial goal for acceptable TAT. [5] In our study, the analytical TAT of our stat potassium results increased significantly (p<0.0001) with each developmental stage until the TAT of 90% of results were 154 minutes, which was substantially longer than the suggested <60 minutes [5] (Table 1). The receipt-to-test TATs of potassium increased significantly after installation of the PTS and ACAS because all specimens (routine and stat) were treated equally at the registration desk, which has to handle both emergency and routine requests. The receipt-to-test TAT of potassium increased further after installation of the ACAS, because potassium was performed on two Cobas 6000 analysers connected to two Cobas e 601 immunoassay systems in tandem. The Roche systems give priority to immunoassay (troponin T) over chemistry analysis. To improve the receipt-to-test TAT of stat tests, it was decided to introduce a stat line for fast registration of urgent requests. Priority was also given to use one of the tandem systems for fast analysis of requests from the multidisciplinary, surgical, cardiothoracic, cardiology and neurosurgical intensive care units, various 24 www.smltsa.org.za ISSN 1011 5528 Figure 5: Box-whisker plots for TATs of potassium before installation of the PTS, after installation of the PTS, and after installation of the ACAS. Figure 6: Box-whisker plots for TATs of troponin T before installation of the PTS, after installation of the PTS, and after installation of the ACAS. wards and other hospitals, blood gas samples, cerebrospinal fluid (CSF) biochemistry, and requests for procalcitonin (PCT), pro-brain natriuretic peptides (BNP), heart-type creatinine kinase isoenzymes (CK-MB), ammonia, lactate and ph on fluid and urine. Furthermore, the test-to-verify time for potassium increased after installation of the PTS and ACAS because emergency tests compete with routine tests for verification. It increased even further after installation of the ACAS for the same reason that the test-to-verify time of troponin T increased. We concluded that our stat test TAT deteriorated with each developmental stage. Since this study was conducted, we are hopeful that our stat TAT improved after (i) the DISA

computer system was replaced with the TracCare computer system; (ii) introduction of a stat line for fast registration; (iii) prioritising chemistry requests from various intensive care units, wards, hospitals and requests for certain tests; (iv) more pre-analytical staff were appointed to improve receipt-to-test TAT; and (v) a phlebotomist was appointed at the sample depot. However, a follow-up study will be necessary to determine whether we have succeeded in our attempts to improve our stat test TAT. Acknowledgements Medical students for conducting the survey; Dr. Daleen Struwig, medical writer, Faculty of Health Sciences, University of the Free State, for technical and editorial preparation of the manuscript. References 1. Manor PG. Turnaround times in the laboratory: a review of the literature. Clin Lab Sci 1999; 12: 85-9. 2. Jahn M. Turnaround time, Part I. Turnaround times down sharply, yet clients want results faster. Med Lab Obs 1993; 25: 24-30. 3. Steindel SJ, Howanitz PJ. Physician satisfaction and emergency department laboratory test turnaround time. Arch Pathol Lab Med 2001; 125: 863-71. 4. Steindel SJ, Novis DA. Using outlier events to monitor test turnaround time. Arch of Pathol Lab Med 1999; 123: 607-14. 5. Hawkins RC. Laboratory turnaround time. Clin Biochem Rev 2007; 28: 179-94. 6. Handorf CR. College of American Pathologists Conference XXVIII on alternate site testing: introduction. Arch Path Lab Med 1995; 119: 867-71. 7. Kaplan LA, Pesce AJ, Kazmierczak SC. Clinical Chemistry. 5 th ed. New York: Mosby; 2010. 8. Lee EJ, Shin SD, Song KJ, et.al. A point-of-care chemistry test for reduction of turnaround and clinical decision time. Am J Emerg Med 2011; 29: 489-95. 9. Guss DA, Chan TC, Killeen JP. The impact of a pneumatic tube and computerized physician order management on laboratory turnaround time. Ann Emerg Med 2008; 51: 181-5. 10. Fernandes CMB, Worster A, Eva K, Hill S, McCallum C. Pneumatic tube delivery system for blood samples reduces turnaround times without affecting sample quality. J Emerg Nurs 2006; 32: 139-43. 11. Tornel PL, Ayuso E, Martinez AP. Evaluation of the turnaround time of an integrated preanalytical and analytical automated modular system in a medium-sized laboratory. Clin Biochem 2005; 38: 548-51. Wanting to advertise in Medical Technology SA? Call Karen Adamson tel 021 783 5817 email karen@adamsonfive.com for the latest rates and material specifications. ISSN 1011 5528 www.smltsa.org.za 25