November 2011
Feature Story

Anne Ford

For many years, Domino’s Pizza made one of the most famous guarantees in advertising, promising to make deliveries in “30 minutes or less.” Maybe that’s where some ED physicians got the idea, as revealed in a recent Q-Probes study, that the maximum stat test turnaround time should be—you guessed it—half an hour.

“We have a problem,” says Teresa P. Darcy, MD, MMM, a co-author of the CAP study, “Laboratory Services for the Emergency Department.” The problem to which she refers isn’t that 30 minutes is necessarily an unreasonable goal for stat turnaround time. In fact, some of the laboratories that participated in the Q-Probes are indeed able to turn stat results around that quickly. The problem is that the study found that in general, ED physician expectations and laboratory expectations are disturbingly out of sync regarding stat TAT. And that disconnect appears to be contributing to ED physician dissatisfaction with laboratory services.

“We’ve never really come out and said: ‘Based on our processes and workflow and equipment, this [TAT] is the best we think we can do,” Dr. Darcy says. “We’ve never sat down and said, ‘This is what we think is reasonable’ and had the ER docs say, ‘I can’t live with that; this is what I think is reasonable.’ It’s a lack of communication between the two groups.”

The study asked 90 participants to monitor order-to-report TAT for three types of tests: creatinine, urine microscopic examination, and CBC. The median number of minutes for creatinine TAT was 48, with 63 minutes at the 10th percentile and 35 minutes at the 90th percentile. For urine, the median was 46 minutes, with 88 minutes at the 10th percentile and 25 minutes at the 90th percentile. And for CBC, the median was 31 minutes, with 43 minutes at the 10th percentile and 22 minutes at the 90th percentile.

Contrast those numbers with these: For all three tests, the median number of minutes that participating ED doctors believed to be a reasonable maximum for stat TAT was 30—while the laboratories themselves believed a median of 60 minutes to be a reasonable maximum. At the same time, the ED doctors estimated that actual stat TAT on these tests for most patients was 50 minutes for creatinine, 55 minutes for urine, and 40 minutes for CBC.

If your head is swimming by now, that’s sort of the point. “There were just big gaps between what the ED thinks they’re getting and what we think is reasonable for them to get,” Dr. Darcy says. “The numbers are so far apart.” She’s not putting all the blame on the physicians, mind you: “I don’t think the lab people are basing their estimates on what’s reasonable any more than the ED people are.”

Perhaps that disconnect would be less troubling if it didn’t seem to be affecting physician satisfaction with laboratory services. As part of the study, 262 participants from 76 institutions completed surveys regarding ED physician satisfaction with lab services. The overall average satisfaction score was 3.9 (on a five-point scale, with five as “excellent”). Satisfaction with stat test TAT, however, ranked lower, at 3.6. Not only that, but “laboratory testing” was rated as the No. 2 barrier to reducing length of stay, after bed availability.

“I was surprised,” Dr. Darcy admits. “I did not think ED physicians thought the lab was as important [as other factors] in reducing length of stay in the ED. I just thought we’d progressed a lot in our relationship with the ED and that they felt we were getting tests out as fast as we could, and it was waiting for an MRI, a CT scan, a bed, that was the big barrier.” Whether reducing TAT actually reduces length of stay is beside the point in this case, she adds: “That is their perception, and I think that’s what we have to work on.”

Peter L. Perrotta, MD, a co-author of the study and medical director of clinical laboratories at West Virginia University Hospital and professor of pathology, West Virginia University School of Medicine, Morgantown, agrees that the lab is still viewed as delaying care in the emergency department. “That’s something that just doesn’t go away. Whatever TAT we can provide in the laboratory is usually never fast enough.” That’s in large part because “there are actually very few guidelines on what is an acceptable TAT for a lab test,” he says. “Physician estimates [of reasonable TAT] are based on what they perceive their needs to be and not on some of the technical limitations we know about.” The good news, based on his experience, is that “if you involve ED physicians in the process and explain what our capabilities are, they’re more accepting.”

“It’s also important to provide ED leaders with actual data on what your TATs are,” he adds. That’s because it’s human nature to remember only the outliers, “the one patient where it took two hours to get test results.”

Then, too, laboratories can improve ED satisfaction by ironing out stat TAT variability to the greatest degree possible. “Part of what I heard from my ED docs is that the variation is killing them,” says Dr. Darcy. “If we told them it’s going to be 45 minutes, and it was reliably 45 minutes, they could live with that. But if they get it back some days within 15 minutes, other days not till 90 minutes, that’s really hard to manage. ‘Should I send the patient to X-ray now, or should I wait?’ Physicians are very sensitive to variation.”

To laboratories that would like to take actions based on the Q-Probes findings, Dr. Perrotta suggests “engaging the emergency department and examining the entire process, from the time the patient arrives at the ED to the time blood is drawn, transported to the laboratory, and tested. Just by going through that, you actually can sometimes find very easy and apparent changes that can be made to improve the entire testing process.

“For example,” he continues, “our nurses have protocol orders for a lot of patients that, say, come in with chest pain or belly pain. But we found that the nurses actually were not using these protocol orders, which would allow them to draw the blood and get it immediately to the lab, so that results would be available by the time the physician saw the patient or very shortly thereafter.” Simply improving staff compliance with the protocol orders resulted in faster TAT.

“The laboratories reading the study should really look at the different parts of the TAT and say, ‘Where is our problem?,’ and then start there,” Dr. Darcy concurs. “If the in-lab TAT is way down in the 10th percentile, start there. If your laboratory performance is in the 80th or 90th percentile for in-lab turnaround time but in the 10th percentile for the preanalytical measures such as time from collection to receipt of specimens in the laboratory, then that’s where you start.”

“I think there’s an opportunity on the front end,” she says. In the study, “there were a lot of laboratories that reported a significant amount of time before the specimen got to the lab. The lab can be meeting expectations for in-lab TAT but total TAT is unacceptable because specimens don’t arrive in the lab for 20 minutes after they are collected.... I don’t think physicians always know that sometimes a specimen is sitting and waiting and not getting to the lab. Is there a reason? The person who loads them into the pneumatic tube—how do they get the signal that the tubes are ready to go? Find out where the delays are. You can help. I’ve never met ED clinicians who weren’t happy to have help from the laboratory.”

Related Links

• Most significant barrier (PDF, 57 KB)