April 2010
Feature Story

Anne Ford

When Julie Langseth, director of laboratory services at Austin Diagnostic Clinic, Texas, walks into the area of her lab that contains the Beckman Coulter UniCel DxI 800 analyzer, it’s not that instrument that she checks first. Instead she consults an intangible, but arguably just as important, instrument: the “vibe-o-meter,” which gauges the stress level of the medical technologists working there.

“The vibe-o-meter is very calm in that area, because they’re not having to run around frenzied, taking stuff from here to there,” she says. “The stress level has gone way down. People who work in that area are so much more satisfied with what they do every day.”

Why is that? Because the UniCel DxI 800, as well as similar instruments from Roche, Siemens, Abbott, and Ortho-Clinical Diagnostics, allows laboratories to run chemistry and immunoassay tests on the same system. Of course, that’s nothing new; such integrated analyzers have been around for some time, and laboratory directors have already grown familiar with their benefits, including broader testing menus and shorter turnaround times.

But what the laboratories that have acquired integrated chemistry-immunoassay systems are realizing is that these systems can have a remarkable effect on the morale and efficiency of the people who operate them. And in a market in which medical technologist positions are becoming harder and harder to fill, that’s no small benefit.

Since implementing Roche’s Cobas 6000 integrated system, “the vast majority of times we have a nice quiet lab, an efficient lab,” says William Daley, MD, a clinical pathologist at the University of Mississippi Medical Center. “The techs seem happy. They seem not stressed. There’s laughter again in the laboratory. The system works very, very well.” However, he cautions, it has taken a little while to get to that point. Immediately after implementing the Cobas 6000 in late 2008, the ambience among the medical technologists was less “Whistle while you work” and more “What the heck is this?”

The technologists’ initial dismay centered on the fact that the Cobas 6000 is a wet chemistry system, whereas the laboratory had used a dry chemistry system for more than a decade. The wet system’s more frequent calibration requirements, and its accompanying greater level of complexity, took some getting used to, particularly among the evening- and midnight-shift MTs, Dr. Daley says. “The system is inherently a little more complex than we were used to. There were painful moments, but I believe that’s a given whenever a lab changes its core chemistry systems. It was worth the work and the effort and the little bit of pain,” he says.

“I’ll tell you, at the get-go, it was tough,” says Marilyn Bray, MT (ASCP), director of laboratory services at the University of Mississippi Medical Center. “But with budget cuts and all, especially when you’re state-funded like we are, to try to consolidate on dry chemistry was almost impossible. The tests offered on dry chemistry were much, much fewer than on the wet system.” So wet it was.

The shift from wet to dry wasn’t the only major change in the laboratory. In addition to implementing the integrated analyzer, UMMC decided to add front-end automation, a fairly formidable undertaking given the space requirements. “Because the front end connects to the instruments themselves, we had to literally knock down the wall between front-end processing and the chemistry section in order to place these instruments where they needed to be,” Dr. Daley explains.

But now that the dust has settled, so to speak, Bray and Dr. Daley say the benefits of the new instruments are far outweighing the discomfort of the transition period. “The front-end automation has really done an amazing job. We were a little dubious that it was going to do everything we thought it would, but it really has,” Dr. Daley says. “When it is down for some reason and we have to revert to the old methods, the techs just don’t like it. They take it for granted now that the majority of samples are quietly coming down that track, going to the analyzers without very much intervention.”

In addition, he says, “We notice that we don’t tend to have the outliers we used to have. Right now our turnaround time is somewhere around 38 to 42 minutes for stat chemistries. Before, it was around 44 minutes. So although we haven’t seen a huge change, I think we’ve eliminated those outliers and gotten a more consistent turnaround time.”

Tammy Posey, chemistry supervisor at St. Joseph’s Health System, Atlanta, is also counting outlier reduction among the benefits of an integrated chemistry-immunoassay system, in this case the Abbott Architect ci8200, implemented there in 2006. “Within the first year, we were able to reduce our outliers by 50 percent,” she says. “One year after we went up, we had consistently 95 to 96 percent troponins reported in less than 60 minutes. This January, we had an average of 96 percent cross-shifts turn around in less than 60 minutes, with less than four percent outliers. In fact, we’re actually thinking about moving our goal of less than 60 minutes to less than 45 minutes, because right now we’re reporting about 85 to 89 percent, depending on the shift, in less than 45 minutes. And that’s from receipt. It’s wonderful.”

It was troponins, as a matter of fact, that led to her laboratory’s decision to use the Architect ci8200 in the first place. “Since cardiology is one of our specialties as a tertiary care hospital, the troponin assay is very important to our emergency room and to our cardiologists. We were having problems meeting our stated turnaround time for troponin, because we had to physically move the tube between the chemistry analyzer and the immunochemistry analyzer. We were looking at point-of-care testing versus in-lab testing, and the expense for point-of-care is very high. Plus the values were not as accurate, I don’t think, as the chemistry platform value.”

“So we had to find a way of improving our turnaround time,” she continues. “At the time, the Architect was one of the few analyzers that combined immunochemistry and chemistry with a front sample handler that could be programmed for stats and retests and dilutions, and it had a high throughput. The design was such that it wasn’t first in, first out. It had the benefits of a track without the expense, and it kept the tech from having to move the tube physically from one instrument to the other. And it worked.”

Like her counterparts at the Austin Diagnostic Clinic and UMMC, Posey discovered that adding the integrated instrument resulted in expected positive staff-related changes. “Now stat lab techs and chemistry techs are both trained on the ci8200s, so now we’re actually covering staffing in the stat lab with chemistry techs. So we’re becoming a more integrated laboratory, and I think that’s helping staff morale,” she says. “It’s really building teamwork.”

It helped, too, that her laboratory introduced testing on the new instrument in phases. “The thing we wanted to move first was BNP—we do 10,000 BNPs a year—and that went very smoothly. That was in October. Then we brought the cardiacs online in November and kind of let them get used to that. Then we brought the rest of the chemistry testing online in January,” says Posey.

Another way to keep a medical technologist happy: give them an instrument with few maintenance requirements. So discovered Christine Wright, chemistry supervisor at Elliot Hospital, Manchester, NH, whose laboratory, she says, was the first in the country to use two “twinned,” or connected, Siemens’ Dimension Vista 3000T instruments. “The Vista definitely has no maintenance,” she says. “When a company tells you no maintenance, I’ve been a tech long enough to know they’re probably lying to you. But this one really isn’t. The other system that we looked at had a downtime of an hour a day, so you were actually only able to run it 23 hours a day instead of 23 hours and 45 minutes, which is what the Vista does, so that was a big deterrent for us.”

Easy quality control was a big selling point too, she says. “With the Vistas, we can keep QC onboard, and we can keep calibrators onboard, so it’s not an extra step for the technologists. The instruments are programmed to run QC at a certain time of the morning, and they just go. If they need to calibrate, they just go.”

It was volume that led her laboratory to pursue integration. “Before the Vistas, we were running probably about 95 percent capacity on the [previous] analyzers, and honestly, the volume was killing us,” she says. “There were many tests—so many, in fact, that we had to batch test. And in this day and age, we really didn’t want to do the Monday–Wednesday–Friday thing. We really wanted tests to be coming in and going out after they got completed.”

When it came time to shop around for an integrated system, “we took staff on site visits, and we relied a lot on what the staff thought about the systems, and how they functioned,” Wright says. “Obviously we could not take everyone, but we took a group from different shifts. It wasn’t just the day shift that made this decision. Then we all sat together, and we talked about it.”

Barry Fish, Elliot Hospital’s laboratory director, chimes in: “We let our staff make the decision, the people that were using the instrument. It’s very critical that you involve people from all three shifts, and it not be just a day-shift decision.” The approach works, Wright says: “Staff are happy. Unhappy staff do not make it easy to work. But they really do enjoy working this analyzer.”

Easy maintenance was a selling point, too, for the medical technologists at Boulder (Colo.) Community Hospital, says Lynel Vallier, corporate compliance and privacy officer and laboratory director. His laboratory just implemented its second Ortho-Clinical Diagnostics’ Vitros 5600 integrated system. “My techs find it easy to follow the directions that are online on the analyzer,” he says. “They go to the touchscreen, and it shows them exactly what to do for weekly and monthly maintenance, and the instrument will help track that. The maintenance is quite minimal.”

His technologists are also pleased, he says, that the lab has gone from six platforms to two. “So we have to maintain two instruments now instead of six, and we have to do service contracts on two instruments instead of six. The two instruments are exactly the same, so my techs only have to learn to run one instrument now.”

Like many laboratory directors, Vallier expects that integration will help offset the worsening medical technologist shortage. “Because of staffing decreases, we need to integrate as much as possible to decrease the amount of labor needed to do the test,” he says, hastening to add that his laboratory has not had to lay off employees. “I started looking at integration probably four years ago. It had to do with what I thought the staffing levels were going to be in the future, what I thought the future of lab testing and reimbursement were going to be.”

And Langseth at Austin Diagnostic Clinic? Happily, she doesn’t anticipate the needle on her lab’s vibe-o-meter swinging back to “stressed” anytime soon. In addition to the integration factor, which has allowed for “much less running back and forth,” she says, “the pivotal part is that the UniCel DxI 800 has closed-cap piercing. We don’t have to uncap and recap the tubes, and at our volume, that is really huge. We do more than 4,000 billable tests a day. It’s just one of those menial tasks that [previously] took time,” she says. “It was an annoyance. Anytime you don’t have to deal with that, it makes for greater job satisfaction. As the tech population ages, we start thinking about those things more.”