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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Labs and Physicians Need to Talk About TAT

Published November 27, 2011 9:41 AM by Glen McDaniel

The College of American Pathologists (CAP) just conducted a Q-Probe looking at laboratory turnaround times (TAT) for the ED. Ninety participants monitored order-to-report times for creatinine, urinalysis with microscopic, and CBC.  The mean TATs were 48 minutes, 46 minutes and 31 minutes respectively.

Depending on where you work, these times may seem very reasonable or even impressive. A survey of ED doctors conducted at the same time indicated they expected a maximum TAT of 30 minutes, while laboratories reported they generally aim for a maximum TAT of 60 minutes. This difference in expectations is typical and is responsible for much of the frustration from labs on the one hand, and ED physicians' dissatisfaction with laboratory TAT on the other. In fact on a 5 point scale ( with 5 being excellent), 262 participants rated physician satisfaction with stat TAT a mere 3.6.

I recall working at a hospital a few years ago where the findings were pretty similar. The ED physicians  with the acquiescence of the pathologist fought for several changes such as increased point of care testing, additional phlebotomy staff for the ED and so on. They thought the laboratory was responsible for both ED overcrowding and excessive wait times. The ED chief of service and administration were therefore mystified when 3 months after all the expensive changes were made, wait times and overcrowding were essentially unchanged.

Curious, I did a cursory study and found very quickly that overcrowding and wait times were being impacted by many factors like bed availability for admissions, waiting for medications from pharmacy, ED staffing,  the method of triage and the need for other services such as imaging.

The ordering pattern of physicians was also very interesting and enlightening. Although the hospital encouraged electronic order entry, the physicians were very slow adopters and did very little computerized physician order entry (CPOE).  A physician would go from exam room to room, write orders in the chart and then hand a stack of charts to the busy unit clerk who would then "interpret" and enter the orders in the computer.

The phlebotomist flooded with multiple orders would struggle to keep up. Sometimes there was an additional wait while an IV was started or other nursing care was given. It was typical to draw a patient about 30 minutes after the order was placed. In the central lab, a CBC was resulted in 10 to 15 minutes after receipt. Month after month the lab got hammered by the ED   (and pathologist) even as the laboratory felt they were performing like a hamster on a wheel.

This CAP study- as well as my experience- points up the importance of active laboratory involvement in studies such as these. The entire process from order to resulting must be looked at in segments (patient sign in to triage, triage to order entry, order entry to specimen collection, collection to receipt in lab, receipt to analysis, analysis to result in chart). Physicians often think in terms of brain-to-brain expectations: their clock starts ticking from the time they think about an order and write it down or give it verbally. Their expectations do not usually involve the realities of processes (including ED processes), technological capabilities, quality control, repeats, rejected specimens and the like.

They are equally baffled by variation: why do I get a CBC back in 20 minutes one day and 40 minutes the next?

Without a dialogue there is likely to be what the laboratory sees as unrealistic expectations from the ED; and the laboratory is likely to be blamed for any delay, regardless of the reality or complexity of causes. Physicians and laboratorians have the same goal, but often operate in two different worlds until they speak to each other.

My experience is that physicians (pathologists included) will listen -as long as we offer a solution and not just excuses. On the other hand if we do not dialogue, physicians will often fill the silence with their own assumptions, correct or not.

5 comments

Is there national standards for TAT? I know we try to satisfy doctors and also try to best each other by coming up with shorter and shorter  TAT. But I would liek to know 1. is there national standards or best practices and 2. is there any study that shows how TAT affect patient care? Doctors I think are just not very patient or realistic. If they want it they think it is possible to give it to them. A X ray involves  patient on a table and afew zaps. There is no invasive technique, no analysis to be done, no verification by a tech. It is basically taking a picture. To expect the lab and radiology to have the same TAT is just not realistic.

Jason Tomati, MT December 4, 2011 9:31 AM
Los Angeles CA

Efren: that is pretty impressive. Please share how your lab manages to accomplish those TATs. Are these performed as POC tests or are the specimens transported to the lab? Do you have a STAT lab?

One thing I find is that very often TATs are measured using different start/end times. The lab sometimes does not have  a lot of influence on the collection/transport portion of the process (depending on the situation).  Therefore many labs ignore that portion and use TAT to mean "time received in lab to time resulted." But if physicians think"brain to brain"  i.e from the time they place the order to the time they have the result, then we should try to standardize the meaning of TAT (at least for STATS).

Glen McDaniel December 1, 2011 11:46 AM

Scott: you are right; variation always complicates matters. In manufacturing it compromises quality and increases cost. In medicine (including MLS) it affects quality and complicates expectations.

We are all familiar with doctors who order lots of  STATS. Physicians have admitted to me that they use STAT not to indicate clinical urgency, but to get their specimens to the front of the line. If we reduced variation and improved workflow then I suspect physicians would be happier even if the TAT of one individual specimen actually increased. They would know when to expect a result and would have fewer surprises.

Glen McDaniel December 1, 2011 11:38 AM

Glen,

I think you have hinted at the solution in reducing variation.  Physicians are still thinking "STAT or ASAP or routine," but today's labs can and should be built on a continuous flow model.  I suspect, for instance, a CBC turnaround of 30 minutes 95% of the time might work better for everyone.  Reduced variation eliminates "delay."

Scott Warner December 1, 2011 7:14 AM

OmygreatG! You guys should come work at our lab! Our ED TAT is  <5mins for blood gas, <10mins for CBC, <15mins for U/A with microscopy. And everybody in the lab loves and enjoys it!

Efren Ventura, Medical Technologist November 29, 2011 11:50 AM
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