A STAT list is a relic of a time when it was common for labs to have call, labor intensive
tests, and batch testing. If your lab has any of these, you may also have a STAT list. It’s a
list of tests that your lab performs STAT, and anything not on the list usually isn’t. If, for
example, a B12 and Folate is not on the STAT list, a provider (in theory) can’t order these STAT
in the middle of the night. If your lab batches a test to be run two or three times a week, same
I worked at a lab many years ago in which if a provider did want a test not on the STAT list
STAT e.g. a uric acid, we called a pathologist to get approval. And guess what? Every single
time the pathologist said, “Run the test.”
What does a STAT list mean? Is it informational or restrictive? Refusing to run a test is
risky. The tech working on the bench is not the person assuming the responsibility for patient
care. Neither is the pathologist. It’s one thing if the test really can’t be done STAT e.g. AFB
culture, but quite another if your lab does the test in house. If you can do it, why not?
For ED patients, a STAT list may violate EMTALA (the Federal Emergency Medical Treatment and
Active Labor Act). EMTALA provides that patients must be provided with “appropriate medical screening” before a hospital decides to treat or transfer. If your laboratory batch tests
microalbumin, for example, and an ED provider orders one, not performing the test could violate
EMTALA. Lab techs can’t decide what’s appropriate.
A STAT list may be symptomatic of a lab that lacks efficiency and clear lines of
communication. Laboratories adopting continuous flow work models strive to reduce variation,
eliminate batch testing, and produce a consistent output. My guess is these labs don’t have a
need for a STAT list. They may even have less STAT abuse, if successful.
How about your lab? Do you still use a STAT list?
NEXT: We’re All in This Together
How many old methods are being performed in your laboratory? Old technology gives way to new at varying rates. Examples of “old” technology include Westergren sedimentation rate, Miller disc
reticulocyte estimates, and bleeding times.
These and others have generally been surpassed by newer, better, and more reliable technology. It is the laboratory’s responsibility to make physicians aware of these changes as they occur. Most will
accept a change if it means better numbers or greater sensitivity and specificity.
I remember performing Miller disc reticulocyte counts, for example. This labor intensive test has poor precision (around 30-50% on latest surveys). Automated counts are faster, more reproducible, and
probably cheaper. I suspect the manual method tends to underestimate reticulocytes as well. Does this matter to a clinician? Perhaps. Our agenda is to give the most reliable answer possible.
We all know those physicians who want what they want. There’s always a doc who wants a manual differential count, for example, even though an automated count is far superior in terms of precision and
accuracy. The proliferation of 6-part differential technology may change this, it may not. A 100-cell differential banged out with a counter under a scope is pretty old technology, for the most part. Most labs still
reflex to a manual differential if certain parameters are abnormal. Should they report this instead of absolute numbers that are available?
Laboratories also want what they want. In many cases we continue to do something because it’s the way it’s always been done. Your laboratory may still report bands, recheck urine dipstick values with
manual tests, or perform any number of tests “just because.” If it doesn’t improve the result or add value to the report it’s wasted effort, money, and time.
An annual survey of methods is one approach to keeping technology up to date. Is a method the best, the cheapest, the fastest? Is it better to keep in house or send out? Is it time to consider a completely
different method? Keeping on top of these issues brands your laboratory as technologically progressive, building trust with your docs.
NEXT: Do You Still Use a STAT List?
Laboratories are so complex that no two are ever alike. There are so many choices in meeting test menu needs: instruments, personnel, vendors, physical layout, workflow choices. Do phlebotomists
deliver work to workstations, or do the techs retrieve specimens from buckets? Does everyone do phlebotomy? Are tests batched, or is a continuous flow model employed? Is every instrument interfaced? Is
everything still tracked on paper? All these factors and more affect (much more than software) how quickly a certain number of productive hours get work done.
The only sensible benchmark is number of tests, but even that has variation between small labs with or without in-house microbiology. For all these reasons there is no meaningful standard for laboratory
It would be great, for instance, to say “For 150,000 tests a year a lab needs eight technologist and four phlebotomist FTE.” But there is too much variation. Depending on instrumentation and workflow,
many laboratories have a tremendous surge capacity to handle more testing.
If we know how fast work is processed, how many specimens are received, and how many people are working, we can calculate how many tests are performed, how many are left over, and how this affects
the day’s workflow. This approach can be used to improve efficiency using your own data.
- Productivity - this should be expressed as the average number of tests completed every hour or half hour. The raw data is the number of billables divided by hours worked.
- Throughput - this should be expressed as the average number received every half hour or hour.
- Fill rate - this should be expressed as the number of bodies times the productivity index. In other words, if your lab’s average productivity is 4 tests every half hour and there are 5 people working, your lab
completes 20 tests in that period.
Using Excel, for example, all this can be mapped by staff vs. half hour (or hour) of day to create a visual map of a staffing plan. The great thing about this approach is you can move people around and see
what happens to the numbers.
NEXT: Old Methods
The proliferation of physician order entry and EMR interfacing has brought us closer to a paperless order entry process. Of course laboratories still accept paper requisitions. According to CLIA a requisition has to ask for the following:
- Name and address or other identifiers of the ordering provider or lab submitting the test. Who is responsible for receiving the results?
- The patient’s name OR unique identifier. Interestingly, the law does not require both. It’s probably a good idea to spell this out in some detail in a lab policy e.g. nicknames, SR. and JR., etc.
- The sex AND age or date of birth of the patient. Often, sex is missing from a requisition. While it is often implied, it is legally necessary to provide age and sex appropriate interpretations and ranges.
- The test(s) requested.
- The source of the specimen, if that’s important. For providers, this usually refers to urines or other sources of culture.
- The date and if appropriate time of collection. (I rarely, if ever, have seen this on a requisition. But so long as it is available somewhere, it works.)
- Anything else needed to ensure “accurate and timely” testing.
An example of the latter may be diagnosis. While it’s not necessarily relevant to interpreting the results, it makes bean counters happy and keeps the doors open.
In addition, CLIA standard 493.1241 states: “The patient's chart or medical record may be used as the test requisition or authorization but must be available to the laboratory at the time of testing and available to CMS or a CMS agent upon request.”
I’ve seldom had access to outpatient medical records, although I’ve received copies of pages from them. The intent here seems to be to ensure that the proper tests were ordered, but I’ve never audited outpatient charts. Who has that kind of time?
Finally, CLIA requires that a lab that transcribes information into an information system has a way to make sure the information is entered accurately. In other words, all labs transcribing orders have to check slips. Does everyone do this?
NEXT: Scheduling By The Numbers
Most laboratories have or have a need for a communication logbook to share information between techs and shifts. Recently, I discovered Microsoft OneNote for this purpose, mostly because it is on all our workstations. I was curious if it would fit our needs.
As an Evernote and Google Docs user I wasn’t familiar with OneNote, but the program is intuitively easy to use. You title a page, click somewhere, and start typing. Information can be copied and pasted, including images, videos, links, pages, documents, etc. It was really the attachments I was looking for: we needed an online communication tool that included an ability to add PDFs, images, etc.
OneNote includes templates for pages, such as meeting minutes, so I added these. You can also create your own templates and set any template to be a default when a new page is created. The entire process is simple and quick to set up.
OneNote notebooks are in two flavors: local or web storage. I chose local within the laboratory, because they may contain ePHI. But for my personal notes that do not contain patient data I chose the web. For that you need a Microsoft account, which is free and takes a few seconds to set up.
Finally, there is the real strength of an application such as OneNote: the ability to share and collaborate in real time. Notebooks can be opened locally or shared across Microsoft accounts. You can even share with yourself, if you have two accounts. I have one account for work and a personal account at home. This powerful feature adds utility to using this as a communication tool. It’s faster than email, more versatile, and available on a number of platforms, including Windows, Android, and Apple. And, of course, notebooks can be searched quickly for any information.
What’s interesting here isn’t so much OneNote - although it’s pretty cool - but that it was right under our noses. Its unique features, speed, and versatility do what paper - and many applications - can’t and without a lot of extra work. Isn’t that what we all want from computers?
The website Investopedia defines “Make-or-Buy Decision” as “The act of choosing between manufacturing a product in-house or purchasing it from an external supplier. In a make-or-buy decision, the two most important factors to consider are cost as availability of production capacity.”
While laboratories are not production assemblies in the industrial sense, we do often have a make or buy choice between running a test in-house vs. sending it out to a reference lab. Common examples are iron studies, fungal cultures, fibrinogens, antibody identification, and reticulocyte counts.
In days past it was common for laboratories to bring tests in-house to justify staffing and equipment costs, but these days these kinds of choices are often cost driven. Factors to consider:
- Is it really cheaper to do in-house? Remember to factor in non-billable costs that include external quality control, proficiency testing, discarded reagent, and sample repeats. If the non-revenue generating cost is 30% or more, it may not be worth bringing in house.
- Is it really better medicine to do in-house? Do doctors really need it when they say they need it? Nice-to-have vs. life-or-death are two completely different issues. Often it’s better for lab techs to spend their valuable time on diagnostic testing that best benefits patients, especially in small hospitals.
- Is it really better quality to do in-house? Lower volume testing has the disadvantage of a smaller normal patient population as a control. Imagine, for example, if your lab only ran four tests a day of a particular analyte, and three of the four were usually abnormal. Would that result in more repeats, more controls? Consider that a larger number of normal patients in a run makes the unexpected results not only stand out but seem more statistically viable.
If a reference lab test offers much better technology e.g. an automated vs. manual reticulocyte count, a laboratory runs a risk of seeming out of touch with basic quality issues. In this case a choice should be made between speed and convenience vs. accuracy and precision. But all things being equal, new and improved is just that.
NEXT: Paperless Notes
In The Office David Wallace asks Michael Scott about his greatest strengths, and Michael replies that his greatest weaknesses are actually strengths. It’s funny but like all good comedy has an element of truth.
We all have strengths and weaknesses. No one is good (or bad!) at everything, although it can seem that way with people quite different from ourselves. It’s an interview question not so much to decide to hire but to decide self-humility and character e.g. do you have the maturity to know yourself?
A corporate culture focused on errors forces employees to hide weaknesses and rely on strengths. Our society teaches us to do the same. That works in general, because it forces us to depend on the strengths of others to get a job done. It’s also a basic strategy of teamwork regardless of culture.
But a manager who tries this will fail. Why?
First, what works in a team doesn’t work in a leadership position. A manager’s approaches to problem solving and communication not only have to fit all situations but all employees. A manager who relies on only strengths will be too one-dimensional and quickly create unsolvable problems that make his or her weaknesses blindingly obvious.
Second - and especially true if promoted from within - employees know and will exploit your weaknesses. It’s human nature to desire control, and we all exploit others to varying degrees to get it. If, for example, you are a new manager who is seen as a person who avoids confrontation, employees will use that knowledge to come in late, take extra time for break, bully others, or leave work unfinished. C’est la vie.
While we can’t rely on our perceived weaknesses or pretend that they don’t exist, we can and should focus on improving them as an active strategy to become a better leader. Awareness of weakness implies a willingness to work on self-improvement, after all. In the above example, a new manager might quickly address all personnel issues, unpleasant or not, and in the process discover that confrontation is not as scary as it seems. (It isn’t.)
NEXT: Make Or Buy?
For most of my career I’ve heard about how computers will transform our lives. The first laboratory I worked in had an air conditioned room filled with hardware, spinning drums, and enormous, deafening printers. The inevitable march of progress has brought countless promises of paperless, instantaneous, limitless, cheap, and other adjectives, alongside clunky, slow, expensive hardware and stupid software.
Most laboratories I’ve seen still have paper procedures in binders on shelves. Online procedures displayed as PDFs are still designed to look exactly like paper. The reasons for this are cultural as well as technological. We are unable to imagine writing without paper (including the screen I am writing this on).
Eventually many of the promises of our age will come true in one form or another, and that includes replacing books, binders, and procedures with something better. (I don’t count a PDF as better. It’s a missing link between paper and what comes next.)
What will future procedures look like?
Science fiction imagines flashy heads up displays such as Minority Report. Whatever. But information is still in linear, paper-based fashion. Imagining the future involves putting oneself in a place that does not exist where “new” technology is mundane. We want technology to save us time, money, but ultimately make our lives easier. We want to work faster with fewer mistakes.
I’d like to think 2001 is closer to the future with easy to use, lightweight multimedia tablets and conversational artificial intelligence, or at least AI smart enough where you don’t have to repeat yourself twenty times to open a file when you can click an icon. Kubrick’s vision was technology as background noise. That’s what we want. Ain't it?
To all the paperless Luddites out there: there is nothing wrong with paper. There’s nothing wrong with a lot of other technology that hasn’t changed in thousands of years. It’s the information on the paper that we need delivered in a way that makes working at the bench easier, error-free, and standardized to best practice.
To put the question another way, what do we need future procedures to do for us?
NEXT: Rookie Mistakes
In my last blog I wondered why techs use package inserts when there is a procedure on the shelf or online. For me the reasons boil down to pictures (everyone loves pictures) and availability (it’s right there in the box!). It almost certainly isn’t that a package insert is easier to read. Far from it! I usually end up scanning it or downloading a PDF and zooming in. My eyesight has limits.
The real question is if techs use package inserts because they are easy to find or have pictures despite their flaws, why are procedures formatted like Area 51 government documents and kept on a shelf in binders?
We all know what easy feels like. Smartphones and Amazon Kindles have taught us that much. Electronic access to information should be instantaneous, remember what we’ve looked at, and adaptable to different conditions such as lighting, screen size, and user eyesight. It’s not a bad idea to be able to hear the text, too, using TTS (Text To Speech) technology. I often will do this after writing an article draft using a Chrome extension called Talking Web.
We don’t want a LAB 9000 supercomputer to sing A Centrifuge Built for Two. But we do want computers to meet us halfway. And we want them to do something that paper can’t. In paper terms, a package insert beats a heavy binder every time. Easy.
A paper habit is hard to beat. Online procedures are usually kept as PDFs, which looks exactly like a printed page. How is this an improvement? While it can be zoomed, rotated, and searched, it doesn’t translate as well to all platforms e.g. smartphones.
And this, in a DOS shell, is what we want: compatibility. We want the same thing on our desktop, tablet, and smartphone. We want it to look, feel, and sound the same in Windows, IOS, and Android. We want information, not more work. (No one wants more work. Do they?)
Imagine buying each workstation a cheap Kindle (they start at $55) pre-loaded with laboratory policies and procedures. Forget clunky servers and workstations. Why not?
NEXT: Future Procedures
Laboratories spend a lot of time developing, writing, reviewing, updating, and maintaining procedure manuals. But it’s common to see a tech pull a kit from a refrigerator, remove the package insert from the box, and use that to run the test.
CLIA standard 493.1251 for procedure manuals spells out what your laboratory needs, and it isn’t complicated. Interestingly, it states that textbooks may supplement written procedures. It does not mention using package inserts.
However, the CLIA Interpretive Guidelines (D5405) states that manufacturer's test system instructions and operating manuals are acceptable, so long as all the requirements are met. Extending this to package inserts is stretching this a little, I think, since all laboratories do things a little differently. I’ve always interpreted this as referencing specific procedures that are detailed far better e.g. maintenance in an operator’s manual.
Package inserts also won’t address specific reporting requirements such as alert values, interpretive comments, etc. Laboratories will have preanalytical rejection criteria also not covered. There are all kinds of reasons not to use a package insert. But of course all techs do this. Why?
It isn’t because a package insert is necessarily easier to use than a procedure. Many inserts are printed in microscopic fonts, printed in multiple languages, and folded in a way that would make Rand McNally blush. Others have multiple procedures depending on the specimen, when your laboratory only accepts one e.g. heterophile screening using plasma or whole blood.
I think it boils down to two common elements: the package insert is right there in the box and easier to use than a bulky binder on the shelf or computer screen, and it probably has pictures. I love a thumbnail procedure with easy steps in pictures. If your laboratory is like most and counter space it at a premium, you don’t have the space to open a binder and run the test. A package insert is easier to hold and in some cases the procedure is on an index-sized card or flap of the box. Even better.
Do you prefer package inserts? Why or why not?
In 2008 I blogged “Big Brother Has Mail,” about justified paranoia that employers may be reading the emails of employees. I didn’t read email then, since, or now. It’s a waste of time when a manager is doing a good job.
But hospital environments are changing. In the interim I saw four security cameras turn into thirty two cameras, keyloggers installed on servers, and other tracking software. While this could protect employees and the interests of the organization, it also sends a chilling message.
I stopped using email except as a last resort. We were reminded too often of how “discoverable” and thus dangerous it is. I wouldn’t be surprised if greater surveillance or its mere threat leads to similar changes in behavior.
The legal web site NOLO tells us that some email systems make copies of emails that are sent or received, so deleting them doesn’t matter. Courts have ruled that employers are free to read emails as long as there is a valid business reason for doing so.
If this hasn’t happened at your workplace, it will. All it takes is one virus or piece of malware to get through the system to change a policy. I don’t blame employers for protecting sensitive information, but reading emails is a bit creepy for my taste.
Email is a tool to foster relationships and business communication, and as such it should contain a lot of non-business related information. Our telephone conversations, after all, contain pleasantries about weather, family, sports, and other topics not related to the subject. Is this personal? If all phone calls were recorded, the message sent to employees would surely change what people say.
Email is also quick, efficient, and doesn’t interrupt the other party like a phone call does. Email can be addressed and answered on the terms of the receiver, increasing productivity. It can be pondered and answered with deliberation, unlike the first thing we might think of saying. How is all this affected when we know our emails are being read? I wonder.
How about your workplace? Do you still email at work?
NEXT: Package Inserts or Procedures?
I hope I’m not the only one who gets confused about sensitivity and specificity. Every now and then I have to rethink this.
Sensitivity defines the true positive rate, or the number of people correctly identified as having a disease. A highly sensitive test has few false negatives. Here’s the formula:
# of true positives
# of true positives + # false negatives
A highly sensitive test may have false positives, but since it identifies more people with disease that’s not the point. The value of sensitivity is in a desired low number of false negatives. A positive test may
not prove disease, but a negative test rules it out.
Specificity is yin to this yang. It defines the true negative rate, or number of patients without disease. Here’s the formula:
# of true negatives
# of true negatives + # false positives
In other words, a highly specific test rarely gives a positive result in those patients without disease. A negative test does not necessarily rule out disease.
Typically screening tests such as RSV, influenza, and other rapid kits are sensitive. They are used to rule out disease. Confirmatory tests such as antigen and toxin testing are used to rule in disease and
weed out false positives. But this oversimplification doesn’t consider how sensitivity and specificity interact or are affected by the prevalence of disease. Here things get really confusing.
Sensitive tests are not only useful to rule out disease, they are often inexpensive, fast, and simple. They make sense in an emergent setting. If your test correctly identifies patients without a condition that
gives a doc very good information.
While it sounds great to have tests with high sensitivity and specificity, that isn’t always practical or needed. A D-dimer, for example, has high sensitivity and low specificity. A negative test can rule out a deep
venous thrombosis or a pulmonary embolism, but a positive test means a clot has formed and been lysed.
Sensitivity and specificity choices depend on the laboratory, too. I suspect small hospital labs use more rapid screening tests, for example. Our experience with these tests vary with the focus of our
NEXT: Do You Still Email at Work?
Our plumber Bob once confessed he refuses to answer his cell phone in the bathroom. Ironic or not that’s not so obvious in this age of instant communication and social media trivia. It also makes me wonder who does.
CNN describes a candidate who flushed the toilet during a telephone interview. You can’t make this stuff up. While the person on the other end doesn’t know what you’re doing or what you look like, that doesn’t mean it doesn’t matter. Knowing the difference can make, break, or flush a telephone interview.
Telephone interviews are now common. These include a screening call to check credentials and other requirements before setting up a telephone interview. It’s a cheap way to weed out candidates, and if the applicant carries a cell phone it’s fast. It also means you have to be prepared.
The big trap here is one of informality. We are so conditioned to answer the phone doing everything (unless it’s Bob) that we become casual about interruptions in grocery lines, at the dinner table, or in bed. We ignore where we are, what we’re doing, and how we are dressed. But these things matter. Monster offers these great tips:
- Treat it like a face-to-face interview. Prepare, act professional, and realize that you need to convince the interviewer that you are a serious candidate.
- Keep your resume and cover letter in front of you. One advantage of the telephone interview is having information in front of you on paper or computer screen. You should also have the organization’s website and job description handy.
- Make a cheat sheet. Prepare a list of answers to common questions, examples of things you have done or problems you have solved, and other points.
- Look the part. Shower and dress in clothing appropriate for the interview. It can’t hurt, and it will make you feel and sound more professional if you look the part.
Make sure your phone is charged and background noise is minimized. An interviewer will imagine you by sound alone, so you’ll want only your voice. And definitely no plumbing.
NEXT: Sensitivity and Specificity
The Ghostbusters reboot has me chuckling over the original. There’s a scene where an EPA official asks Bill Murray’s character to see the ghost storage facility, and Murray refuses explaining,
“Because you did not use the magic word.” In an expression typifying bureaucratic obsequiousness for the ages the EPA man asks what that is. Murray replies, somewhat surprised, “Please.”
How often are we surprised with courtesies like please and thank you?
According to Jeremy Sherman, PhD, blogging
on Psychology Today, “please” and “thank you” help stabilize accountability in relationships by signalling a favor requested and debt paid. Although he admits these are vague concepts, the point is valid.
If you work in a lab where people routinely use please and thank you you can safely conclude that relationships matter.
This is much more than politeness, as Sherman points out. It is a matter of acknowledging an indebtedness and interconnection that builds a team. Consider these examples.
Sue and Dave are working a weekend together, and she draws an outpatient. It is a STAT request for a potassium, and she drops it off in Chemistry telling Dave, “That’s STAT,” and walks off. Dave performs
the test. Dave feels he’s stuck performing the work in the middle of everything else he is doing, and Sue feels the same.
Sue and Dave are working the weekend, and when she draws a STAT potassium on an outpatient she brings it back to Dave and says, “Hey, Dave, I know you’re busy, but would you please run this STAT
potassium? The doctor is waiting in the office for the results.” Later, after Dave has completed the test Sue tells Dave, “Thank you for running that potassium. I was swamped!”
The former happens all the time. It’s work, get used to it, etc. The latter happens when people realize that success is about good relationships. We have to care about how the other person works to
improve the way that we work. It’s the foundation for all successful business. It still amazes me how few people grasp this simple truth, abbreviated by please and thank you.
NEXT: Ace That Phone Interview
I once stopped at a local Dodge dealer to buy a truck. No matter how direct I was the salesperson insisted on steering me toward a different vehicle. I even said, “Look, you’re not the only game in town. I want that truck,” pointing to one. Inexplicably he ignored me, so I left and bought a Chevy.
We all have those stories of frustrating salespeople, but just as often customer service exceeds our expectations. The trick in the lab, as in life, is to sense the latter and not waste time on the former. To do this, you need the right information from a salesperson who will always try to head you off at the pitch.
Example: “This new kit uses revolutionary technology, and I’ve just signed several big clients. A lot of big hospitals are interested in it. It has great pricing and a great shelf life. And if you order by the end of this month I can get you an evaluation kit at half price. I just need to know your volumes for a two year contract.”
Maybe this is a good deal, maybe not. Here are a few questions to ask:
- Is this kit on our Group Purchasing Contract? Always good to know, if your hospital has a GPO.
- Would you mind sending me a package insert to review? Salespeople usually aren’t lab people. A package insert will reveal a wealth of information.
- Do you have any literature to support your claims? Data-based decisions are always best.
- Are you the sole distributor of this product? Freight costs between distributors or direct shipment costs can add up, so this is a good detail to consider.
- Are controls included in the kit? Controls and calibration verification materials can be expensive, adding cost.
I’ve heard the “new and improved” pitch a thousand times. It is what all good salespeople do, and it’s a great way to get word out about new products. But a laboratory doesn’t have to evaluate every kit, try every new method, or believe every deal. We’re always in the driver seat.
NEXT: Please and Thank You