CEO SUMMARY: Throughout the United States, hospital laboratories are working to meet ever-increasing lab testing demands by emergency department physicians. In response, many labs debate the benefits of a point-of-care testing (POCT) solution versus operating a rapid response lab in or next to the emergency department. Baylor chose the latter, and reports that it was a win-win for all stakeholders.
EMERGENCY DEPARTMENTS are demanding more from the laboratories that serve them. Among these needs are an expanded menu of tests and faster turnaround times for laboratory results.
Across the country, hospital laboratories are responding with three primary strategies. One is to provide an expanded menu of POC (point-of-care) tests in the emergency department (ED). Two is to establish a rapid response laboratory in or near the ED. Three is to use pneumatic tube systems and other methods to get ED specimens into the core laboratory to support faster turnaround times.
One laboratory which was an early-adopter of the rapid response lab approach is Baylor University Medical Center, located in Dallas, Texas. In 1999, it was one of the first hospitals in the nation to build a rapid response laboratory in the emergency department. THE DARK REPORT recently conducted a site visit to Baylor for a first-hand look at this solution and its impact.
“There was a need to address overcrowding in the emergency department,” stated Michael Nicar, Ph.D., Director of Baylor’s core laboratory. “With 1,000 beds and 80,000 ED patients per year, the core lab was struggling to fully meet the needs of the ED physicians. As it turns out, the catalyst for implementing the rapid response lab located in the ED here at Baylor was one of the ED physicians.
“On the whole, our rapid response lab solution has worked well for the ED, for the laboratory division, and for the hospital itself,” noted Nicar. “What surprised us, however, were a number of positive outcomes which had not been anticipated.”
“Before the STAT laboratory, our ED was dependent upon a pneumatic tube system,” recalled Pamela Bollinger, M.T., Manager of both the ED rapid response lab and the hematology laboratory. “Baylor is a huge facility. Any failure of the pneumatic tube system was a huge problem. The system became especially strained when pharmacy also wanted to hook into it. One solution, at the time, was to establish a tube system ‘user group.’
“This was a workaround for the shortcomings of the pneumatic tube system,” she added. “It turned out the effective response to the problem was locating a rapid response lab within the emergency department. That alleviated the problem.”
As the laboratory and ED crafted a solution, funding was not an issue. “Administration judged the STAT lab for the ED as a new cost center. It was incorporated into the pathology department’s budget,” Bollinger said.
Next was staffing. “Prior to the rapid response lab, we had two phlebotomists serving the ED,” explained Bollinger. “To service the ED, we replaced the phlebotomists with a total of six MTs. We established our space requirements and re-engineered the work flow process. As an example, ED specimens going to the core lab were identified by colored labels.
“Obviously, operation of the rapid response laboratory required a new level of cooperation and interaction across several departments,” she said. “Interaction increased between lab personnel and the ER physicians and nurses, as well as with the admissions department. This is not typically the case for core lab personnel.”
The big win for the rapid response laboratory is the reduction in test turnaround times. “We’ve realized reductions of 50% or more in the turnaround times of the most-used tests,” Nicar commented. “Currently, we average about 22 minutes on CBCs and 30-35 minutes on chemistry and troponin tests.
“With faster test results, our ED physicians are able to treat patients with greater accuracy and speed,” he continued. “Since launch of the STAT lab, physician satisfaction with lab testing services has definitely gone up.
“Another cost-saving strategy we initiated was to start sending a.m.-admit patient testing to the STAT lab via pneumatic tube,” noted Nicar. “This strategy allowed us to shut down what we called the “a.m. admit lab” during this time. Because it is a slower time in the ED, we now tube specimens to the rapid response lab because it has the capacity to handle these additional tests.”
“Our STAT lab has contributed to improved ED cardiac and stroke care,” said Nicar. “We do troponins in the ED STAT Lab. We also now do BNP in- house, in the core lab. In the last month, Baylor initiated new stroke protocols in the ED. To support this, we provide troponin, CBC, chemistry, and coagulation tests. Coag specimens are directed straight to the coag STAT lab and bypass the serum room.”
Baylor’s laboratory team points to a number of unexpected and useful outcomes resulting from the operation of its rapid response laboratory in the emergency department. “The rapid response lab increases ‘face time’ between lab personnel and ED physicians and nurses,” stated Patricia Williams, M.T., Education Coordinator for the pathology department. “Ordinarily, these clinicians don’t interact with MTs working in the core lab. So our entire laboratory division benefits from this higher level of professional interaction.”
Reduction In Labeling Errors
“In fact, one striking example is how interpersonal relationships helped us reduce errors in labeling and fostered greater cooperation between lab and ED personnel,” explained Williams. “There were instances when ED nurses did not get the labels just right. Our lab personnel helped the ED nurses—who are involved in the diagnostic and treatment process—understand how specimen labeling errors extend lab test turnaround times. It was an ‘aha’ moment when they realized how a labeling error would delay the time required for the lab to produce and deliver the information they need to assess the patient.
“Another bonus outcome from our ED rapid response lab was a major gain in the core laboratory,” added Bollinger. “Because core lab personnel are no longer interrupted by STAT testing requests, we’ve seen a significant gain in productivity in our core lab. That is the type of positive impact which is often overlooked in these types of arrangements.”
Lab Test Correlation
Correlating the tests between the core laboratory and the rapid response lab took effort at Baylor. “We use the same instrumentation and methodologies in both labs,” said Nicar. “This is essential to cut down on time-consuming correlation problems. Physicians appreciate the consistency in the lab results. Consistent instrumentation also makes it easier for core lab personnel to cover the STAT lab when necessary.
“Overall, we judge our ED rapid response lab to be a successful solution,” Nicar declared. “One key lesson to share is that staffing it with the right people is essential. Their close interaction with ED physicians and nurses makes that essential”
Would Baylor do anything differently, based on its experience? “We would allocate more space for the STAT lab,” answered Nicar. “In fact, Baylor is adding a new ED building which incorporates a rapid response laboratory. This new lab will have bio-terrorism testing capabilities because it is part of the front-line services of our emergency department.”
POCT or STAT Lab? How Baylor Chose One
BACK IN 1999, Baylor University Medical Center’s decision to opt for a rapid response laboratory within the emergency department (ED) followed an already-established precedent within Baylor.
“At that time, we already had a satellite laboratory alongside the surgery suites,” stated Pamela Bollinger, M.T., Manager of Baylor’s ED rapid response lab. “For both the laboratory and physician staff, this meant the concept of a rapid response laboratory next to a clinical service was not breaking new ground. That concept was already accepted and working successfully elsewhere in our hospital.
“That made it easier to plan our rapid response laboratory to be located within the emergency department,” she continued. “Also, we believed that a rapid response laboratory solution would make it easier to select instruments and test methodologies that would correlate with test results produced in the core laboratory. That was particularly true six years ago, because point-of-care technologies were not as advanced as they are today.
An upcoming issue of THE DARK REPORT will cover how Baylor developed the test menu and selected instruments and test methodologies to use in their ED STAT laboratory. This analysis will also cover the issues and solutions adopted by the Baylor laboratory to get rapid response lab test results into the LIS.
Four Positive Outcomes From Baylor’s ED Rapid Response Lab
1➔ 50% reduction in TAT
2➔ Improved interdepartmental cooperation and physician satisfaction
3➔ Greater efficiencies in core lab
4➔ Overall cost savings