THE IMPACT OF STAT LABORATORY SERVICE ON PATIENT MANAGEMENT

1. THE IMPACT OF STAT LABORATORY SERVICE ON PATIENT MANAGEMENT DR.SHIREEN MANSOOR CONSULTANT CHEMICAL PATHOLOGIST DEPARTMENT OF PATHOLOGY AND MICROBIOLGY AGA KHAN UNIVERSITY AND HOSPITAL

2. INTRODUCTION • Quality can be defined as the ability of a product or service to satisfy the needs and expectations of the customer. • Laboratories have traditionally restricted discussion of quality to technical or analytical quality, focusing on imprecision and inaccuracy goals. • Clinicians however are interested in service quality, which encompasses total test error (imprecision and inaccuracy), availability, cost, relevance and timeliness.2 Clinicians desire a rapid, reliable and efficient service delivered at low cost. • Of these characteristics, timeliness is perhaps the most important to the clinician, who may be prepared to sacrifice analytical quality for faster turnaround time (TAT).2This preference drives much of the proliferation of point-of-care testing (POCT) seen today. • Laboratorians may disagree with such a priority, arguing that unless analytical quality can be achieved, none of the other characteristics matter.

3. INTRODUCTION • Nevertheless, TAT is one of the most noticeable signs of a laboratory service and is used by many clinicians to judge the quality of the laboratory. • Delays in TAT elicit immediate complaints from users while adequate TAT goes unremarked.7 • Unsatisfactory TAT is a major source of complaints to the laboratory regarding poor service and consumes much time and effort from laboratory staff in complaint resolution and service improvement. • Despite advances in analytical technology, transport systems and computerisation, many laboratories have had difficulties improving their TATs. • Emergency department (ED) TATs have not improved over several decades. • In 1965 a mean ED TAT of 55 minutes was reported, in 1978 a mean of 55 minutes was reported while in 1983 mean collection to report TAT was 86 minutes for a chemistry panel including potassium

4. INTRODUCTION • A College of American Pathologists (CAP) Q-Probes survey of ED TAT in 1998 showed low satisfaction rates concerning the laboratory’s sensitivity to urgent testing needs (39%) and meeting physician need (48%). • Laboratory TAT was felt to cause delayed ED treatment more than 50% of the time (43%) and also increased ED length of stay (LOS) over half the time (61%). • With the increasing interest in the extra-laboratory phases of the testing process, more laboratories are including TAT as a key performance indicator of their service but often have problems meeting their internal goals.

5. In clinical laboratories, the time from when a test is ordered to when the results are verified is defined as the turnaround time (TAT). The effects of TAT have been studied to a high extent, with correlations being drawn between emergency department treatment and length of stay (Hawkins, 2007). As a result, TAT is often considered the most significant measure of a laboratory’s service and is used by many clinicians to judge its quality. Total lab TAT is broken down into three main stages as shown in Figure TOT (TURN AROUND TIME)

6. Definition and Measures of Turnaround Time • Inspection of the literature reveals a variety of different approaches to definition of TAT. TAT can be classified by • 1. Test (e.g. potassium), • 2. Priority (e.g. urgent or routine) • 3.Population served (e.g. inpatient, outpatient, ED) and • 4.Activities included. This last area is the greatest source of variation in reporting of TAT. The steps in performing a laboratory test were outlined by Lundberg, who described the brain to brain TAT or “total testing cycle” as a series of nine steps: 1.ordering 2.collection 3.identification 4.transportation 5. preparation 6. analysis 7.reporting 8.interpretation and 9.action.

7. Methods to Improve Turnaround Time • Between 1993 and 1998, the mean 90% completion time (collection to reporting) for potassium and haemoglobin in the CAP Q-Probes program improved minimally from 60 and 45 minutes to 57 and 44 minutes respectively, demonstrating the difficulty in improving TAT service. • The CAP programs help identify factors associated with faster performance and provide suggestions for service improvement.

8. Methods to Improve Turnaround Time • Pneumatic tube systems can speed up TAT without reducing sample quality. • Fernandes et al. examined the effect of a pneumatic tube system on ED test TAT (order to report) and sample haemolysis rates. • Use of the pneumatic tube system reduced mean haemoglobin TAT from 43 to 33 minutes and mean potassium TAT from 72 to 64 minutes with no significant difference in haemolysis rate (6% with a pneumatic tube system and 10% with a human courier). • Individual studies have demonstrated improved TAT with savings in transport staff costs.

9. Methods to Improve Turnaround Time • Introduction of instrumentation can also improve TAT. • Berry examined the effect on TAT (order to result) of introduction of automated urinalysis. • Use of the automated system showed a 30% increase in availability of reports at 30 minutes, 9% improvement at 45 minutes, and 3.2% improvement at 60 minutes. • Use of satellite laboratories in the ED can improve TAT and reduce patient LOS. • Lewandrowski et al. described an average reduction of 51.5 minutes in test TAT, an ED patient LOS reduction of 41 minutes and an increase in physician satisfaction.

10. Methods to Improve Turnaround Time • There is some evidence that use of computerised clinician order entry (CCOE) systems can reduce both intra-laboratory and total TAT. • Thompson et al. examined the effect of CCOE on timeliness of urgent laboratory and imaging tests in an ICU in a tertiary teaching hospital.88 • Median time from ordering to obtaining laboratory specimens decreased from 77 to 22 minutes, median time from ordering to laboratory result being reported decreased from 148 to 74 minutes, and median time from ordering to imaging completed decreased from 97 to 30 minutes.

11. Factors that effects Turnaround Time • Multifactorial analysis shows TAT to be affected by a variety of factors that can be placed in two categories.8 • The first are uncontrollable institutional factors, such as: • Institution type, bed size, location, which are probably surrogate markers for staffing levels, governance, case mix and geography. • The second are controllable process factors, which should be the focus of quality improvement activities.These include the: • nature of the phlebotomy staff, extent of computerisation and method of specimen transport.

12. The different approaches that can be taken are best summarised by Howanitz in his paper on errors in laboratory medicine and practical lessons to improve patient safety.He lists more than 20 published suggestions for improving TAT

13. Despite technical, transport and information technology improvements in recent decades, TAT continues to be a cause of customer dissatisfaction with the laboratory service. • Laboratory staff can feel frustrated when the effects of improvements in intra-laboratory TAT are diluted by pre-analytical and post-analytical factors seemingly outside their control. • Observations such that 45% of the results for urgent laboratory tests requested by the ED were never accessed or were accessed too late do little to encourage efforts by the laboratory to provide a faster service. • Clinician TAT expectations that are unrealistic or infeasible are also a source of friction. • In 1993, Howanitz reported that the fastest intra-laboratory TAT technically possible for serum glucose was 24 minutes, which was too slow for one third of physicians.21

14. The review of the literature illustrates the difficulty in recommending any universal evidence-based goals for laboratory TAT for two reasons. • Firstly, the wide range of work practices (clinical and laboratory) and timing data availability hinders common agreement on TAT definitions. • Secondly, there is little indication that decreased TAT improves patient care or hospital LOS.There is a need for well-designed studies of the effect of laboratory TAT on patient outcomes.

15. LACK OF EVIDENCE? • Given this lack of evidence, should one dismiss TAT as an important quality measure ? • Howanitz and Howanitz argued that if laboratory results provide essential data for patient management, it follows that more timely results will improve patient care and that, despite the lack of evidence, it is reasonable to assume that timeliness of laboratory results affects physician efficiency and hospital LOS. • They felt that all common laboratory tests should ideally be reported as fast as possible by methods yielding high quality results, suggesting 60 minutes or less from sample registration to reporting under optimal conditions.

17. THE AKUH SERVICES - Aga Khan University Hospital, Karachi (AKUH) provides a broad range of latest and technically advanced diagnostics and therapeutic services. -Over the years, the hospital has developed a health care network, which covers all areas of Karachi through Off-site Medical Centres (Integrated Medical Service Units) and Home Health Services. -The extensive laboratory network, currently with 193 laboratory specimen collection units, provides Accessibility to high-quality laboratory services in all major cities of Pakistan.

18. Garden Lab Karimabad Lab Kharadaar Lab Rawalpindi Lab CMS Lab MAIN LAB Regional Lab Lahore Regional Lab Hyderabad Peshawar Lab Hyderabad AKMCCC Lab Sukkhur Lab Multan Lab Quetta Lab

19. The clinical laboratories of the Aga Khan University Hospital have launched an e-Reporting service • The Clinical Laboratories of Aga Khan University Hospital on Monday launched an e-reporting service. The patients will get their reports online, if they wish, instead of collecting them from the laboratory collection centres. AKUH Clinical Laboratories facility would provide greater convenience to the patients and save their time and money adding that it would also enable faster report turnaround as the patients would not be required to visit the laboratory or the collection centres to collect their reports.-dded. The e-reporting portal is very simple and easy to use. Patients will need to go to the e-reports web page www.aku.edu/labreports and log on through the user ID and password printed on their lab receipt. The patients will be able to reports of their specimen and receive the report through email. • "We hope this easy to-use service will be a convenience for our patients that would help them to receive their results quicker and with minimal effort," SohailBaloch (Clinical Laboratories Administrator). • Online Laboratory Reports format :

20. Limitations • The user ID and password is only valid till 15 days after the last reporting date this portal provides electronic report(s), original report(s) can be obtained from the location printed on the receipt. Histopathology reports cannot be emailedCompanion reports (graphs) can be obtained from main laboratory at AKUH (Stadium Road) / Lab Collection Point. .If you have questions on reports privacy statement and limitations, please contact us at +92 21 3493 0051 Ext. 1552/3. • Note: E-Reports are in PDF (Portable Document Format). In order to read a PDF file, you need to have Adobe Acrobat Reader installed on your computer. You can download the latest Acrobat reader free from Adobe's website.

21. Online Laboratory Reports format :

22. QUALITY CONTROL OF LABORATORY RESULTS IN REAL TIME QCREAL TIME QC • An integrated informatic system may have an important role in identifying and reducing those errors which affect the reliability of laboratory results. • By means of a computer connected with laboratory instrumentation, allows monitoring of global error (bias, random, gross) using classical statistical quality control systems, integrated by auxiliary methods built on a database stored in the computer. • These methods succeeded in greatly reducing bias and random error in the most frequent laboratory tests

23. THANKS