Labs and Physicians Need to Talk About TAT
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.