CEO SUMMARY: Steadily increasing numbers of patients at Massachusetts General Hospital exceeded the capacity of its emergency department. Challenged to help with the situation, lab administrators created a point-of-care testing kiosk within the emergency department (ED). This unique lab project proved to be a home run. Length of stay in the ED was reduced and the admissions rate was lowered by a significant amount, more than covering the added cost of point-of-care testing. It’s another demonstration that added-value lab services can change the cost/quality paradigm for the better.
AFTER YEARS OF RELENTLESS pressure to slash costs, a growing number of hospital administrators are now challenging their laboratories to develop and implement new value-added testing services.
This shift is an important development. It gives laboratory administrators an unprecedented opportunity to become the catalyst for significant and far-reaching clinical changes within a hospital or integrated health network (IHN).
At Massachusetts General Hospital, in Boston, Massachusetts, ever-growing numbers of patients were exceeding the capacity of the emergency department to accommodate them. Lab administrators decided that the laboratory could play a key role in improving this situation by expanding point-of-care testing (POCT).
“In a nutshell, our emergency department was seeing a larger volume of patients than it was capable of accommodating,” stated Kent Lewandrowski, M.D., Associated Director of Clinical Laboratories at Mass General Hospital. “The need to divert patients arriving at overcrowded emergency rooms is a widespread problem among many hospitals in the Northeast and the Boston Globe was publishing stories about this situation.
“Emergency departments were full either because they did not have enough capacity to see the patients or beds were not available if they needed to be admitted,” explained Dr. Lewandrowski. “Patients were being diverted to other hospitals, many of which had similar issues.
“The emergency department is the gateway to our hospital,” he added. “A significant percentage of our admissions come through that door. So, if our emergency department is bogged down attempting to deal with ever-growing numbers of patients, this has many consequences for the rest of the hospital and the quality of care. For these reasons, any suggestions on how to improve the situation within our emergency department at Mass General got plenty of attention from administration.”
Boost Value Of Lab Testing
For Dr. Lewandrowski, this was an opportunity to boost the value of lab testing services. “Through most of the 1990s, we were in a commodity mode, where reducing the unit cost of laboratory tests was almost a fanatical obsession,” he stated. “But every lab eventually reaches the point where marginal gains from progressive cost reductions get smaller and smaller.
“We realized the laboratory is only about 4% of the hospital’s operating budget; yet it plays an essential role in almost all clinical activities,” noted Dr. Lewandrowski. “So we viewed the challenges in the emergency department as an opportunity for our lab to move beyond ‘commodity’ services and develop new ways to provide added-value for our doctors, nurses and patients.”
To accomplish this, lab administrators at Mass General recognized that the differential in cost-per-test of point-of-care and main lab testing was not the issue. “Obviously, core labs with high volumes have economies of scale and the unit cost tends to be low,” observed Dr. Lewandrowski. “In contrast, POC tests are done one at a time, yielding few economies of scale. So, what is POCT’s big advantage? Speed—reduced time to result.
Lab Info is Time-Sensitive
“Laboratory information has value which decays with time,” he noted. “What’s today’s value of my sodium when I had an appendectomy at the age of 12 years old? It’s almost nothing. Whereas, if I am an acute presentation in the emergency department, the value of that same test is relatively high.
“For our laboratory to support the emergency department, we felt the highest value we could offer would be to provide extremely fast turnaround time on selected test results,” said Dr. Lewandrowski. “One of our primary goals was to affect length of stay. If we could successfully reduce length of stay, then this benefit would far outweigh the additional costs associated with POC testing versus the core lab.”
In the spring of 2000, Mass General developed a task force to address the issues of emergency department “divert.” This task force included physicians, nurses, laboratory, radiology, and other functional areas. “The laboratory seemed the easiest place from which to start,” said Dr. Lewandrowski. “It has a defined test menu to support specific clinical applications, along with associated turnaround times (TAT).
Defined The Mission
“So we defined our mission,” he continued. “It was to eliminate the laboratory as a contributor to emergency department divert and to decrease emergency department length of stay. If we could succeed in this mission, then other departments, such as radiology and inpatient units, could come along and do their part.
“Our next two steps were relatively simple. First, we established a limited test menu based on interviews with the emergency department (ED) physicians and nurses,” noted Dr. Lewandrowski. “Second, we looked at the workflow processes in the ED which involved ordering lab tests and responding to the test results.
Complex Source Of Delays
“Here is where we learned a surprising lesson. I had assumed that the lab was probably responsible for most delays in TAT,” he observed. “However, it proved to be more complicated than that.
“Our process flow studies revealed that five discrete activities affected turnaround times: 1) it averaged 40 minutes between the time an ED patient was registered and a test was ordered; 2) it was an additional 20 minutes between order and collection of specimen; 3) transport to the lab averaged 30 minutes; 4) the core lab generally delivered results in about 60 minutes; and 5) we discovered that it averaged about 60 minutes for physicians to review the results once they were available,” Dr. Lewandrowski said.
Caveats in POCT Testing Programs
EXPERIENCE HAS GENERATED important lessons about point-of-care testing (POCT) at Massachusetts General Hospital (MGH). Kent Lewandrowski, M.D., Associate Director of Laboratories at Mass General offers these five caveats:
1. Sufficient Test Volume: It’s important to generate enough tests to properly utilize the labor dedicated to POCT. MGH’s lab is looking to expand the POCT menu as one way to increase test volume.
2. Select the Right Technology: Space is an issue. The kiosk doesn’t have room for supplies, reagents, and other items. Some good test technology is unusable because it requires too much space within the kiosk.
3. Vendor Support: Many POCT vendors lack the experience to offer sophisticated support for POCT applications, plus MGH is using POCT differently than in most other hospital settings.
4. Complicated to Match POCT Results With Main Lab Results: Different test technologies used in the POCT kiosk and main lab generate numbers which are often different, such as cut-off points. To avoid confusion with the medical staff, POCT results which are negative are reported simply as negative. In some cases, a positive POCT test result, such as a cardiac screen, is reflexed to the main lab so the patient’s test record has consistent numbers.
5. Team Approach is Mandatory: POCT requires input from the lab, physicians, nurses, and administration. A project manager is essential.
Need To Revise Work Flow
“These facts framed our challenge. We estimated that 25% of patients seen in the emergency department would receive one of those target tests we had identified earlier,” he noted. “For our POCT kiosk to serve this substantial number of patients, we would need cooperation to revise certain work processes in the ED. To minimize such changes, we decided to concentrate on specific clinical areas where a change in laboratory testing technology could generate positive changes in patient outcomes, with further positive impact on the problem of ED divert.
“To achieve this goal in specific clinical areas, we quickly realized that only a limited number of diagnostic technologies would reduce the turnaround time of our targeted tests,” recalled Dr. Lewandrowski. “After boiling it all down, we were left with point-of-care or nothing. Further, we also knew that, even if we reduced the lab turnaround time to zero, existing ED work processes still accounted for an average of 154 minutes of total TAT.
“Obviously this mission could not be achieved by the lab alone,” he added. “Given the many dysfunctions of the current system, I felt we really needed a radical solution if we were to succeed.”
Prototype POCT Program
The decision was made to implement the emergency department POCT kiosk on a demonstration basis. The project was scheduled to last at least four months. “Funding for this demonstration project came, in part, from several vendors,” he added. “In particular, Abbott Laboratories was very supportive of our efforts, even though it did not involve Abbott test kits. We budgeted for a higher number, but only spent about $40,000 during the demonstration phase.”
To ensure that it was professionally handled, a dedicated POCT lab team of five was created. “Our objective was to speedily implement this concept and at the same time maintain a high quality of test results and operate in full compliance with all regulations,” observed Dr. Lewandrowski. “Our POCT staff would concentrate full-time on implementing this project and did not have duties in the main lab.
Measure Five Outcomes
“We decided to measure four outcomes: 1)length of stay in the emergency department; 2) turnaround time of tests; 3)physician satisfaction with turnaround time; and 4) accuracy,” he added. “We carefully collected data before and after this POC testing project.”
Dr. Lewandrowski also realized the importance of getting favorable attention to the POC test project. “We hooked people’s interest around the hospital by calling this new concept a ‘point-of-care testing kiosk.’ Hospital staff quickly became intrigued with what we were proposing to do.”
During a recent tour of Massachusetts General Hospital, THE DARK REPORT saw the point-of-care kiosk, located in the ED. It is a small room, approximately ten feet deep and six feet wide. A countertop with sink runs along one wall. Several POCT instruments, with tiny footprints, are lined up on the counter. At any one time, two individuals man the POCT kiosk. This arrangement insures that one individual is always available to perform a test even if the other staffer is circulating within the ED in support of POC testing activities.
“Our POCT kiosk is small and cozy,” noted Dr. Lewandrowski. “There’s not much room for equipment, given the limited space and target turnaround times we have to meet. So we had to select ‘fast and small’ technology. Whenever possible, we chose single-use, disposal types of test technologies. In our experience, many products are good and work according to the manufacturer’s specifications.”
Identifying Source of Costs
The good news is that the POCT kiosk demonstration project delivered tangible results. “The net effect was that length of stay for ED patients who received POCT testing was reduced by an average of 45 minutes,” explained Dr. Lewandrowski. “Equally significant, the measurement of physician satisfaction doubled, on a ranking of one-to-five, to 4.5. Test accuracy was rated as equal to the main lab.
“Some areas produced particularly impressive results,” he continued. “For example, POC testing for cardiac patients sliced 70 minutes from their ED visit for those patients who were discharged and 37 minutes off the ED visit for those who were admitted.
“Without adjusting for acuity, we also saw the rate of discharge for patients with chest pain go from 13.3% before the POCT kiosk to 31.9% after the POCT kiosk,” he said. “However, con- firming this result would require us to evaluate patient acuity, which we have not yet done.”
Declining Divert Rate
“Most significantly, about this time the divert rate in the emergency department began to decline,” he added. “Even as the lab was making a contribution with the POCT kiosk, other areas like radiology were streamlining their procedures and emergency department physicians were implementing work flow improvements. Taken collectively, all these efforts reduced the divert rate by 27% as of this month and it has stayed down.”
Administration judged the POCT kiosk to be a success and now funds it full-time. “This is a classic example of quality improvement,” noted Dr. Lewandrowski. “The POCT’s testing costs are higher than if these same tests were done in the main lab. But, POC testing is contributing to improved quality of patient care in the ED while also contributing to a lower overall cost-per- encounter. The added value of POCT is much greater than its additional cost.”
Hospital administrators recently decided to make the point-of-care testing kiosk an ongoing service within the emergency department. This presents Dr. Lewandrowski with a new challenge. “To support a permanent POCT kiosk, we now have to develop formal guidelines for maintaining ongoing competence, accreditation, and quality. That’s not so sexy and exciting as a pilot project and requires hours of arduous work to develop the procedures and documentation necessary to run this as an ongoing laboratory function.”
Added-Value By The Lab
Emergency department divert provided laboratorians at Massachusetts General Hospital (MGH) with an opportunity to increase the value of the laboratory to both clinical and operational activities within the hospital. This is a good demonstration of how progressive hospital laboratories are moving beyond simply reporting an accurate test result in a timely fashion.
Specifically, the problem needing resolution within the emergency department at Mass General required a sophisticated management response by the hospital’s laboratory. The calculation of cost-versus-benefit went beyond a simple cost-per-lab-test assessment and involved measuring performance variables that included ED patient length of stay, ED patient admittance/discharge rates, physician satisfaction, and the overall cost of the patient’s ED encounter.
The POCT kiosk represents the emerging paradigm in hospital laboratory organization and management. Increasingly, multi-hospital integrated health networks want the clinical laboratory to become part of a comprehensive solution to a system-wide effort to improve clinical care pathways.
Laboratory administrators and pathologists will need to adapt to this shift in management expectations. Laboratory testing is gaining increased importance in the success of integrated health networks. This means increased clout for lab administrators and pathologists. It also requires additional management skills and a willingness to support the full “episode of care.”