QIPS TIPS: Improving Laboratory Operations in the ED
Shari Welch, MD
The efficiency of laboratory operations in the ED is important, as a critical component of ED workflow and patient flow. That said, we have a lot of work to do as a specialty to determine best practices for the ancillary services that support the ED. Improving laboratory turnaround times can improve overall length of stay (Storrow AB et al 2008).
Emergency departments typically manage lab specimens in one of three ways, and some use a combination of all three:
1) An ED Stat Lab
2) Point of Care (POC) Testing
3) An ED based Lab Technician
Both ED based Stat Labs and POC testing have been shown to improve ED efficiency (Singer AJ 2008, Altinier S 2001). But the verdict is still out on which strategy is the most efficient.
Today’s hospital laboratories are fully automated and the turnaround time from arrival of the specimen in the lab until the results are received in the ED is typically under 30 minutes. Therefore, attention to the collection of specimens and their delivery to the lab is becoming an appropriate focus.
There is no published data yet on the efficacy of placing a dedicated lab technician in the ED to manage lab specimens. However the Advisory Board began recommending a dedicated ED lab technician as a strategy for eliminating delays and improving efficiency in its sentinel publication Building the Clockwork ED in 2000. In addition (though also never published) VHA, through its survey database, identified the ED based lab technician as a best practice in 2005 and this finding was presented at numerous conferences about ED operations (Thompson 2005, 2006). Whichever model you adopt you will need a convenient space to work with appropriately placed supplies for the collection and labeling of specimens for the lab. In the stat lab and POC models you will need a place to actually process the specimens as well.
Additionally it has been shown that whichever method of lab specimen management is adopted, there is no question that a hospital pneumatic tube system for transporting specimens to the lab (and medications from the pharmacy and paperwork between units) is considered a best practice (Fernandes CM et al 2006). It has been recommended by the Advisory Board, VHA and Premier.
As a consultant who has been in over 100 EDs, there are two touch points in the workflow of laboratory operations in which EDs frequently fall down:
1) Collection of the specimens (particularly urine)
2) Pushing the results to the provider
Often this is a result of poor assignment of the steps in the processes of collection. Many EDs do not clearly articulate time benchmarks for the collection of specimens nor who is responsible for each step. By carefully flow-mapping the steps in the collection of the most commonly ordered tests and assigning both benchmarks (for instance, 15 minutes for the collection of blood from order entry) and to whom the responsibility of each step belongs, new operational efficiencies can be achieved.
Making it a physician task to chase test results is a waste of the increasingly precious physician resource. A better strategy is to assign another team member, for instance, the Health Unit Clerk (HUC) or the Patient Flow Nurse, to monitor results and push them to the physician with an adequate cueing system. Hand in glove with lab operational improvements are the IT systems that allow them to transmit data to the ED. The advantages of an electronic whiteboard or tracking system in the ED have been recognized (France DJ et al 2005). The best systems send an electronic cue to the ED when a patient’s lab tests or X-rays results are available and providers can access the results through the electronic white board.
Is it time for you to take another look at your ancillary services and fine tune the Laboratory Operations that support ED workflow?
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