Lab Turnaround Time Study Sets Alarm Bells Ringing

In any fast paced pathology laboratory, turnaround time (TAT) of results is extremely important. As laboratory pathologists, we may imagine our clinical colleagues sitting anxiously in front of their computers waiting for our reports. But actually this often isn’t the case. Sometimes they don’t access our results for days. And in a few cases, they aren’t accessed at all.

Why is TAT important?

As pathologists, we’re consistently expected to work efficiently – so too are clinicians – and various models are used to assess our performance in this regard. But total TAT (defined here as the time from the clinician requesting a test to receiving and interpreting the results) is very rarely studied. Last year at our clinic we established a maximum TAT for our outpatient day hospitals. But even if my laboratory meets these standards and validates results within this timeframe, the information still needs to be accessed by the clinician in order to be of any value to the patient. I know how efficient my lab is, but I was curious about my clinician colleagues. Could I find out when my results were consulted? This motivated my investigation into post analytical TAT, in other words, how long it takes for a clinician to access patient test results, once they left my lab at the University of Valencia Hospital Clinic in Spain (1). Some of the results were surprising – and alarming.

In many of today’s labs, the majority of results from pathologists are “in the cloud”, so not only do we no longer print hard copies, but we can see when our results are accessed by clinicians. For two months we collected two specific times concerning each request: the time the results were made available on the intranet, and the time the results were first accessed by a clinician. We also established that the latest time for consulting results on the day in process (the time limit) would be 3pm.

Based on the advice of clinicians, we established a maximum TAT of two hours for processing requests from our day hospitals. This means that from receiving samples in the laboratory to reporting basic biochemistry results on our intranet, no more than two hours should elapse.

Good news, bad news

Let’s start with the positive results from our study, which included 945 requests; the vast majority (73 percent) of clinicians accessed our results the day they became available, which is the ideal scenario. However, one-fifth were not accessed for between one and eight days (despite the results being available). Surprisingly, 27 percent of the tests we carried out were consulted late or not at all (see Chart). It’s a shockingly high number, which implies that the initial requests were perhaps less crucial than the clinicians initially thought. Were these results just unimportant from the start or had there been a failure to follow up? After discussing this with them it seemed that they were largely made because of oncological protocols attached to treatments and “just in case” scenarios.

Finally, a small number of cases were consulted before the complete results were available. This was our fault because our laboratory failed to provide the results within the two-hour timeframe, but I was pleased to note that after this initial enquiry by the clinician, full results were made available fairly quickly (between 13 minutes to an hour after the clinician initially accessed them), so the waiting time for results in these cases was not too long.

Our study turned up some interesting findings about what happens to our results once they’ve left the lab. But using TAT as a measure of efficiency is not always straightforward.

No measurement, no improvement

“If you cannot measure it, you cannot improve it”. Lord Kelvin’s quote perfectly illustrates the dilemma we are currently facing in our pathology labs: how can we possibly improve TAT if we cannot measure it accurately? Currently, there is no system in place to do so; there are huge variations in lab workflows and there is no standardized method for measuring TAT. For example, TAT for our lab would usually only include the intra-laboratory tests or “pure analytical phase” part of the work, but why? Most laboratory errors occur before and after lab testing (2), and these two phases may also be responsible for up to 96 percent of total TAT (3,4).

The majority of laboratory information systems (LIS) do not measure total TAT (the time from initial clinician request through to their consultation of the results) or even the individual TATs for the pre and post analytical phases in the testing process. In effect, our laboratory is operating blind. How do we know exactly how much time has lapsed since the sample was obtained to when it arrives in our laboratory? How do we define the time the sample is in the laboratory? Before or after centrifugation? And which machine or device is recording the time? And how?

As pathologists, we must be able to prioritize our work. If all requests are equally urgent, then in reality, none of them are deemed urgent. So clinicians must make us aware of those requests that are high priority.

But to be truly effective as a laboratory, we must agree with the rest of the clinical services (such as clinicians and phlebotomists) a total TAT for the requests we receive. We must also define what we mean by those TATs – what specific stages in the process do they include?

Once TATs are agreed and defined we must continue to measure the degree of compliance with them.

What needs to change?

The information from our study demonstrates the value of measuring TATs. In this case it has also served to highlight a serious issue: the volume of requests that are not consulted.

As pathologists, we must always aim to improve our TATs by lowering our delivery non-performance rate (found to be four percent in this particular study). But, improvement has to come from both sides. Communication with clinicians is essential – our colleagues must be aware of when our reports will be available in order to encourage them to consult results earlier.

LIS could play an important role. We would recommend that LIS developers implement a software function, which allows us to measure TAT both during the time the specimen is in our laboratory, but also before it arrives and after it leaves, giving us important information on the pre and post analytical stages. This would result in much closer collaboration and transparency between various groups within the healthcare system. As an example, the phlebotomist could record the initial venipuncture step and collection of the sample, our laboratory could then record arrival and analysis of the sample, the time we validate it and make it accessible to the clinician. Finally, the time the clinician accesses the result could be recorded, giving us a full and clear picture of the sample’s journey from the moment it was taken. Ideally, all of these times would be monitored by software, using a completely computerized physician order entry system.

Pathologists, clinicians and patients would all see benefits if our processes are optimized. In our case, these results have led us to implement several improvement measures. Importantly, we have encouraged clinicians to consider which of their requests are really in need of prioritizing, and which are not. We’ve also urged them to consult available results earlier since we have demonstrated that our lab meets its TAT targets 96 percent of the time.

Think outside of your lab

The most important thing we have learned from our study is that improving TAT is no longer just a “laboratory problem”. The time it takes to obtain a sample, the length of its journey to your laboratory, the hour at which the clinician consults your report – all of these things have an impact on your efficiency and your workflow. To focus simply on speed within the laboratory does not provide the full picture and will not optimize delivery of a test result from initial request. The fact is, no matter how capable your laboratory is, a failure to communicate and establish standards with other clinical services will result in inefficient practices. To tackle the challenge presented, a new method has to be created, established and controlled by both laboratories, clinicians, and other health professionals working in close collaboration.

If we have no information on TATs at all phases of the testing process, we can’t detect inefficiencies and potential drawbacks, making it very difficult to introduce strategies to improve. If my laboratory is analyzing samples it receives at lightning speed but the samples arrive very slowly or doctors consult my results very late, then what am I actually achieving?

Total TAT is a crucial, bottom-line measurement of the efficiency of all the services involved in testing a patient and one which deserves much more scrutiny as we strive to continually streamline and improve our services.