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Laboratory Turnaround Time
Laboratory Turnaround Time
discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/5460692
Article in The Clinical biochemist. Reviews / Australian Association of Clinical Biochemists · November 2007
Source: PubMed
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Review Article
Abstract
Turnaround time (TAT) is one of the most noticeable signs of laboratory service and is often used as a key performance indicator
of laboratory performance. This review summarises the literature regarding laboratory TAT, focusing on the different definitions,
measures, expectations, published data, associations with clinical outcomes and approaches to improve TAT. It aims to provide
a consolidated source of benchmarking data useful to the laboratory in setting TAT goals and to encourage introduction of TAT
monitoring for continuous quality improvement. A 90% completion time (sample registration to result reporting) of <60 minutes
for common laboratory tests is suggested as an initial goal for acceptable TAT.
TAT” is sometimes used to describe the interval between physicians choosing when the physician gets the results as
when a test is requested to the time a treatment decision is the end point and 50% when the ED gets the results. Similar
made.13-15 Although the laboratory can and perhaps should results were seen earlier in the 1990 CAP Q-Probes survey
be involved in all these steps, many laboratories restrict their with test ordering or phlebotomy the preferred start point
definition of TAT to intra-laboratory activities, arguing that and laboratory reporting or physician receipt the preferred
other factors are outside their direct control and that timing endpoint for the majority of physicians.21
data for extra-laboratory activities are not readily available.16
Such an approach will necessarily underestimate TAT since Use of different measures to describe TAT also complicates
non-analytical delays may be responsible for up to 96% of comparisons. It is important to examine a frequency histogram
total TAT.17,18 In the ED, delay in review of results by clinicians of data before deciding on appropriate descriptive measures.
is the greatest component of perceived TAT.16 In the case of TAT, the overall process is composed of multiple
sequential steps, each with a minimum or fastest time possible.
Intra-laboratory TAT can also vary in its definition with For example, if a centrifuge is set to 10 minutes spinning time,
possible start points of sample receipt time, registration time, centrifugation can take no less than 10 minutes and may take
or analytical sampling time and end points of analytical longer if there are delays (e.g. balance problems). This means
completion time, result verification time, result transfer to that Gaussian distributions for each of the individual steps
electronic medical record time and report printing time. or for the total TAT are not expected. It is thus inappropriate
to use means and standard deviations as descriptors of TAT
Another classification of time periods separates the steps into distributions.
the pre-analytical (order to preparation), analytical (analysis)
and post-analytical (reporting to action) phases.19,20 These A non-Gaussian distribution with a positive skew (or tail to
divisions have often been used when classifying errors and the right) is seen for TAT distributions, meaning that median
delays and are sometimes used for description of TAT. and tail size are the preferred measures.22 Tail size can be
quantified as the percentage exceeding a defined time (outlier
There are differences between clinicians and laboratories in rate) or as the time corresponding to a defined percentile of
their definitions of TAT. In the 1998 CAP Q-Probes program, the distribution (e.g. 90th). This last measure is increasingly
41% of laboratories defined ED TAT as time of receipt in common in the literature and is referred to as the 90%
the laboratory until time of report, 27% as ordering of test to completion time. Valenstein and Emancipator studied the
result reporting and 18% as specimen collection to reporting.8 performance of four measures of laboratory TAT: the mean,
However over 40% of physicians defined ED TAT as starting median, 90th percentile, and outlier rate.22 For tests with long
at physician request and only 9% at laboratory receipt TATs, the most important quality of a TAT measure is high
(Table 1). There was better agreement between laboratories reproducibility, so that improvement in reporting speed can be
and physicians in the choice of endpoint with over 40% of distinguished from random variation resulting from sampling.
Start Time
Lab Receipt 9 13 8 4 5 7
When Drawn 15 13 22 14 14 18
On ED Order 28 40 16 18 19 16
Physician Request 45 33 51 63 58 57
Physician Realisation 2 1 4 1 3 2
End Time
Physician acts on results 0 0 0 1 1 3
When charted 5 3 3 7 6 7
ED gets results 50 67 26 33 32 29
Physician gets results 44 26 72 22 62 57
The mean was found to be the most reproducible of the four there is little agreement among clinicians on what constitutes
measures, followed by the median. The mean achieved acceptable TAT.19 Service to the ED is a particular source of
acceptable precision with sample sizes of 100-500 tests. For dissatisfaction with 87% of institutions reporting complaints.21
tests with normally rapid TATs, the most important quality Expectations have increased despite technological
of a measure is high sensitivity and specificity for detecting innovations (e.g. analytical, pneumatic tubes, computers) in
whether TAT has dropped below standards. The outlier rate the laboratory.28 This may reflect greater attention to reducing
was found to be the best measure of TAT in this setting but patient LOS in the ED and wards and greater clinician
required sample sizes of at least 500 tests to achieve acceptable familiarity with the analytical speed of POCT devices such as
accuracy. blood gas analysers.
Use of outlier rates has been recently promoted but use of dual Unhappiness with TAT remains a problem today. A 2006
measures is useful in providing information on the norm (the report of a CAP Q-Probes study of nursing satisfaction
median) as well as the exception (the tail size).23,24 This allows with hospital clinical laboratory services in 162 hospitals
a more balanced appreciation of TAT and avoids excessive showed most satisfaction with result accuracy, phlebotomy
attention to a single parameter. An alternative single measure courtesy toward patients and nursing staff, and notification
is the use of the mean as this will be sensitive to outliers as of abnormal results.29 Respondents were least satisfied with
well as the bulk of the population.7 urgent test TAT, laboratory management responsiveness and
accessibility, phlebotomy responsiveness to service requests,
Another approach is the use of failure time analysis to study and routine test TAT. The most important aspect of laboratory
TAT such as Kaplan-Meier survival curve plotting, log-rank service reported by nursing personnel was urgent test TAT.
tests and Cox proportional hazards model.25 The Kaplan-Meier
Published data on TAT expectations are generally scanty.
approach treats active samples like living patients. At sample
Clinician and laboratory staff expectations of ED TAT for
registration, the sample TAT clock is set to 0. Upon sample
haemoglobin, potassium, glucose and pO2 measurements were
completion, its status is analogous to a patient who has died
surveyed as part of the 1990 CAP Q-Probes survey of 2763
(TAT clock is set to 1) and the time lapse from registration
clinicians and 722 institutions.21 The distribution of expected
is its “survival” time. This methodology allows different
TAT (phlebotomy to result reporting) is shown in Table 2. As
distributions (e.g. urgent vs. routine samples) to be compared
can be seen, laboratory staff set less timely goals for all four
using the log-rank test and can help identify variables that
analytes than the clinicians. Of the different physician groups
affect TAT using the Cox model, but is of limited use in
surveyed, generally surgeons had the fastest TAT expectations.
routine TAT monitoring.
Based on past CAP Q-Probes data, Steindel and Novis have
suggested that reasonable component TATs are 15 minutes
Unfortunately the variety of different approaches in the for order to collection and collection to receipt times and 30
literature creates difficulties when searching for benchmarking minutes for receipt to verification time for urgent samples
or state-of-art data. Inspection of journal abstracts is from the ED or intensive care unit (ICU).24
sometimes insufficient to allow clear identification of how
TAT was measured and study of the original text does not The CAP Q-Probes study on biochemical markers of
always clarify the details. The descriptions in external myocardial injury TAT from 2004 collected data from 159
quality assurance programs of TAT (e.g. CAP Q-Probes, Q- hospitals regarding the expectations of order to report TATs.30
Tracks) often provide the clearest and most easily understood The median (and inter-quartile range) physician expectation
procedures. Howanitz, who has published widely on the CAP of 90% completion TAT was 37.5 (31-45) minutes. These
survey results, has suggested that TAT be defined from the times were shorter than those estimates from laboratory staff
time the test is ordered to the time that results are available to (median 60 minutes) and actual performance (median 91
the caregiver and that TAT goals be expressed as a percentage [74-105] minutes). The laboratories’ 60 minute expectations
of all results completed within the time interval (e.g. 90% may have been shaped by the National Academy of Clinical
or 95% of results completed within the time interval).26,27 Biochemistry’s goal of a TAT (collection to reporting) of 1
However laboratories without electronic order entry systems hour or less.31,32
may have difficulty collecting accurate ordering times and
may find intra-laboratory TAT a more feasible option at One author from a diagnostic product vendor stated that
present. despite a standard TAT for acute care laboratory testing in
tertiary care institutions of typically less than 15 minutes for
Expectations of Turnaround Time blood gas or electrolyte values, from a clinical perspective
Over 80% of laboratories receive complaints about TAT, yet the desirable TAT is closer to 5 minutes.33 It was argued that
Table 2. ED TAT in minutes (phelebotomy to result reporting) expectations of clinicians and laboratory staff for ED.21
Hb
Clinicians (%) 15 34 32 2 6 12 1
Laboratorians (%) 2 8 18 4 9 54 8
K
Clinicians (%) 6 28 38 4 12 12 2
Laboratorians (%) 0 6 16 5 8 58 10
Glucose
Clinicians (%) 12 30 36 4 8 12 2
Laboratorians (%) 0 6 14 5 10 56 10
pO2
Clinicians (%) 57 34 8 1 1 1 0
Laboratorians (%) 22 35 18 4 2 18 4
meeting this requirement necessitates the use of POCT and Table 3. Percentiles of 90th percentile completion times
that this approach would become the future standard of care. (minutes) for K and Hb TAT from CAP Q-Probes studies.8
in 2002 for FBCs, thyroid tests and basic metabolic panels.37 Table 4. Percentiles of institutional median and 90th percentile
A test was considered to have completed within one day if the completion times (minutes) for troponin and CKMB order to
result were available to clinicians by 0700h on the first non- report TATs from CAP Q-Probes.30 Reprinted with permission
holiday weekday after the date of specimen collection. This from the Archives of Pathology & Laboratory Medicine.
criterion was met by 98.8% of institutions for basic metabolic Copyright 2004. College of American Pathologists.
panel measurement, 99.5% for FBC and 88.8% for thyroid
tests. For the 65 institutions who had previously participated in
a similar study in 1997, the percentages meeting the criterion n 10th 25th 50th 75th 90th
rose from 91.3% to 98.2% (metabolic panel), 95.9% to 99.6%
Troponin
(FBC) and 63.7% to 90.0% (thyroid tests).
Median 158 74.5 67 57.8 50 45
The 1998 CAP Q-Probes study of ED TAT definitions 90 Percentile
th
158 129 108 93 76 66.5
previously described also examined potassium and CKMB
haemoglobin TAT performance.8 The distribution of 90% Median 112 82 69.5 58.0 48.3 40
completion times of the 693 responding laboratories is shown 90th Percentile 112 131 112 91.5 73.0 61
in Table 3. Half of the laboratories responded that 90% of
potassium tests were ordered and reported in 69 minutes or
less, whereas the TAT for 90% of haemoglobin results was 55 The TAT for routine early morning blood collections was
minutes or less. monitored in a CAP Q-Probes study of 657 institutions.40
Delivery time was from sample collection to laboratory
In a 1996 CAP Q-Probes study, Steindel and Novis examined receipt and analytical time from sample receipt to test
order to verification times for urgent samples from the ED completion or verification. The median (and inter-quartile
or ICU.24 Using a 70 minute TAT to define outliers, the % of ranges) distributions for institutional median TATs were:
outliers was 10.0% for ED and 14.7% for ICU. Major areas in delivery time 25 (17-35) minutes; analytical time 42 (32-55)
which delays occurred were test ordering, 29.9%; analytical minutes; total TAT 73 (58-92) minutes. ICUs had a faster
phase, 28.2%; collection of the specimen, 27.4%; post- TAT (medians: delivery 22; analytical 38; total 67 minutes)
analytic phase, 1.9%; and undetermined, 12.5%. Personnel than non-ICUs (medians: delivery 30 minutes, analytical 43
problems (primarily staff shortages) were a major cause of minutes; total 80 minutes). For all collections, the median
delays and occurred in the test ordering (37.8%), collection TATs for haemoglobin were delivery time 25, analytical
(51.4%) and analytical (33.7%) phases. Problems relating to time 34 and total TAT 67 minutes while for potassium the
test performance accounted for only 10.9% of the delays. The medians were delivery time 28, analytical time 47 and total
low percentage of errors involving test performance is well TAT 82 minutes. Factors shown to correlate with shorter total
documented elsewhere in the literature.38,39 TATs were rural locations, a lower sample collection to staff
ratio, intensive care unit specimens, plasma for potassium
The 2004 CAP Q-Probes study on biochemical markers of measurements, the practice of delivering each specimen as it
myocardial injury TAT examined order to report TATs for is collected, pneumatic tube delivery system, direct delivery
CKMB and/or troponin measurement for patients presenting route, and continuous versus batch testing.
to the ED with symptoms of acute myocardial infarction.30
The distribution of institutional 90% completion TAT (order Critical or notifiable values have faster communication
to report) is shown in Table 4. Shorter troponin TATs were requirements than other results. Ricos et al. have published a
associated with performing cardiac marker studies in EDs useful summary of extra-laboratory quality indicators that can
or other peripheral laboratories and having cardiac marker be used as specifications for benchmarking.41 They suggested
specimens collected by laboratory rather than by non- a mean of 6 minutes to communicate critical results on
laboratory personnel. inpatients and 14 minutes on outpatients. They also suggested
11% as an acceptable fraction of laboratory reports delivered
A 1989 Q-Probes study of cerebrospinal fluid cell count, outside of the time goal specified by the clinician.
protein, glucose and Gram stain testing TAT of more than 400
laboratories found median intra-laboratory (accessioning to A CAP Q-Probes survey in 1997 examined the timeliness of
reporting) goals of 60 minutes with 30 and 45 minutes being critical value reporting.42 The details of the median institutional
the next most common goals.7 Actual median actual TATs TATs from this survey of 671 institutions are shown in Table 5.
were: cell count 32 minutes, glucose 34 minutes, protein 37 Verification time was defined as time between test completion
minutes and Gram stain 45 minutes. to result ready for reporting. Notification time was defined as
Table 5. Critical values: percentiles of median TATs Table 6. Mean (and standard deviations) of urgent K, Hb,
(minutes) for individual institutions.42 Prothrombin Time and Troponin intra-laboratory TAT from
the Study Group for the Standardization and Promotion of
TAT Interval n 10th 50th 90th Turnaround Time Control.44
Prothrombin Time
Verification 630 17 3 <1 Cycle Analyte n Mean TAT Time % Tests
Notification 602 13 3 <1 in min (min) to completed
(SD) complete within 60
Total 631 28 10 1
90% of mins (SD)
K
tests (SD)
Verification 640 14 4 <1
Notification 607 8 2 <1
1998 K 24 47.0 (14.0) 79 (30.0) 78.1 (15.2)
Total 643 22 8 1
I Hb 23 35.5 (14.0) 67.4 (29.6) 85.1 (12.4)
Blood Cultures
PT 22 49.5 (16.8) 85.7 (33.4) 75.2 (18.2)
Verification 584 193 40 2 1998 K 30 45.3 (14.0) 77.3 (31.2) 80.6 (14.6)
Notification 561 24 5 <1 II Hb 28 34.3 (16.9) 64.4 (34.7) 85.8 (12.9)
Total 592 234 55 15 PT 26 44.3 (11.6) 74.4 (26.7) 80.9 (15.1)
1999 K 32 44.5 (13.9) 73.7 (25.7) 81.7 (20.1)
I Hb 30 30.6 (11.7) 55.6 (25.3) 90.3 (10.3)
the time from result being ready for reporting until PT 27 42.9 (9.8) 72.7 (29.3) 85.0 (12.9)
notification of health care provider. Total TAT was time from
1999 K 28 40.7 (12.8) 66.1 (21.2) 85.9 (14.6)
test completion to notification of provider. Factors associated
II Hb 28 30.5 (16.7) 54.3 (30.4) 89.3 (13.2)
with longer TATs included larger institutions and teaching
PT 24 41.3 (14.0) 63.9 (24.5) 85.9 (16.9)
hospitals, outpatients, institutions that require verification
2000 K 33 44.1 (15.1) 72.4 (31.3) 83.1 (16.3)
of results before reporting, reporting to physicians (vs other
Hb 32 33.6 (16.7) 61.5 (30.3) 86.6 (15.3)
health care providers) and use of continuous monitoring
PT 29 41.4 (14.0) 63.9 (24.5) 85.9 (16.9)
systems for blood cultures.
2001 K 32 46.1 (14.2) 73.0 (25.7) 80.2 (18.7)
Hb 32 34.4 (13.5) 59.2 (22.2) 87.5 (13.0)
Between 1998 and 2002, the Study Group for the
PT 32 45.5 (12.4) 72.6 (25.3) 80.8 (17.3)
Standardization and Promotion of Turnaround Time
Control under the auspices of Comitato Italiano per la
Standardizzazione dei Metodi Ematologici e di Laboratorio,
Società Italiana di Biochimica Clinica and Società Italiana outliers (%) were: FBC 0.9, 2.5, 4.8; urinalysis: 1.1, 3.6, 8.2;
Medicina di Laboratorio ran an external quality program metabolic panels: 2.4, 8.3, 17.3 and troponin 0.8, 5, 8.1.
assessing urgent test intra-laboratory TAT for potassium,
haemoglobin, troponin or CKMB and prothrombin time A recent summary of ED TATs posted on the Association of
measurements.43,44 Participants recorded the time when the Clinical Biochemists general chemistry e-mail list summarised
specimen reached the laboratory and the time when the result is 12 replies from laboratories regarding their TATs.45 Ten of
reported. Laboratories collected data for urgent determinations the responses were from the UK, one from Canada and one
for seven consecutive days. The results are shown in Table 6 from Australia. In terms of goals, five labs aimed for TAT
(troponin data were only available for 2002). There is little within 60 minutes (for 90-95% of samples), one laboratory
evidence of improvement over the five years of the program, 45 minutes (90%) and one laboratory 55 minutes (% not
either in TAT means or outlier rates. stated). One regional audit of six labs was reported with an
average TAT of 31–70 minutes and a 95th percentile TAT of
A 2005 study examined mean TAT (received to verified) 76-109 minutes. The poster’s laboratory had an average TAT
and percentage outliers (>30 minutes: FBC, >40 minutes: for urea and electrolytes of 30 minutes and a 95th percentile
chemistry measurements, >60 minutes: troponin I, >30 of 72 minutes. Many of the respondents mentioned delays
minutes: urinalysis) in 11 community hospitals.23 The best/ in receiving samples and it was felt that a within-laboratory
average/worst values for mean TAT (minutes) were: FBC 6, TAT of 40 minutes was achievable as an average but not as
10, 12; urinalysis: 8, 10, 13; metabolic panels: 13, 25, 29 and a 95% percentile without compromising quality because
troponin 28, 37, 41. The best/average/worst values for TAT of sample dilutions, quality assurance failures, “problem
samples” and clashes with peak workloads such as when requested (80% no investigations vs. 42% with laboratory tests
samples from general practices arrive. Solutions suggested and 57% with radiology tests).8 However the importance of
by the respondents to improve TAT included use of profiles laboratory test delays in contributing to prolonged LOS is less
to reduce sample registration time, not delaying reporting of certain. Saunders et al. described a computerised model of ED
results until sample dilutions are completed and the use of operations, showing that the time taken to see the initial care
heparinised plasma samples. giver is the key factor in LOS and that testing (laboratory or
radiology) only has a potential impact when the stay exceeds
Phlebotomy time was measured by Leung et al. in a private 1 hour.60 Delays in ED TAT are most commonly pre-analytical
hospital setting.46 1867 phlebotomy requests were included and post-analytical. Steindel and Howanitz describe a study of
in the study. Average time (and standard deviation) for the ED TAT in hospitals in Washington DC which found that the
procedure was 10.4 (2.4) minutes. The success rate at first most common reasons for test delays were linked to sample
phlebotomy attempt was 97%. collecting and transport, the practice of interrupting routine
testing for urgent analyses, and communicating results to
Audit of blood collecting practices in a paediatric hospital clinicians.8 These same reasons were also seen in later studies
showed that the time spent collecting blood was 11.0 minutes in 1990-1993 and 1999.10,24
per single request.47 The analytical time for urgent blood
gases was approximately six minutes with a total TAT of 16 The value of POCT in ED has been examined both in theory
minutes. and in practice. A hypothetical approach was taken in a study
examining central laboratory testing against (blinded) POCT
Turnaround Time and Clinical Outcomes in the ED.55 Mean TAT was reduced from 59 minutes with
Faster TAT is universally seen as desirable. Statements such central laboratory testing (sample collection to result entry
as “the more timely and rapidly testing is performed the more into mainframe computer) to eight minutes with POCT
efficient and effective will be the treatment” and “it is almost (sample collection to results shown on the POC device
axiomatic that providing a more rapid result saves time and display). Mean therapeutic TAT (using the central laboratory)
therefore money” are common in the literature.47-49 However was 85 minutes (sample collection to physician review of
faster TAT does not necessarily improve patient outcome. results). Physicians estimated that POCT would have resulted
Steindel et al. examined the timeliness of early morning routine in earlier therapeutic action for 19% of patients and based on
clinical laboratory tests for inpatients in 653 institutions this estimate, the authors said “the ability to minimise TAT
and found little evidence that longer routine test turnaround with use of a POCT device … can result in quicker decisions
times affect patient length of stay.27 Shortening the TAT of regarding patient admission and discharge, earlier and more
microbiological procedures was associated with an improved appropriate diagnosis, fewer tests and shortened length of
clinical outcome in two studies performed in the USA but not stay”. Decision analysis modelling has suggested that blood
in Europe.50-52 The hope of prompt medical decision making gas analysis by POCT in postoperative coronary artery bypass
guided by quick convenient testing has led many hospitals graft patients has an expected positive economic outcome
to consider decentralised testing (by POCT or satellite and may be associated with decreased incidence of adverse
laboratories) despite little evidence of decreased LOS or cost clinical events or earlier detection of such events.61
savings.53,54 POCT has been suggested for analytes that have
a required reporting TAT of <30 minutes.15 Proponents argue However real life studies have not necessarily borne out such
that total cost should theoretically decrease if TAT is faster predictions. The maxim “faster is better” is not always true
through use of decentralised testing as episodes of care will and non-laboratory limiting factors need to be considered.62
be shorter and transport costs reduced. However, on a direct Parvin et al. examined the use of POCT during a five week
charging basis, decentralised testing is more expensive.12,55,56 experimental period in which ED personnel used a POCT
POCT glucose measurement, for example, is 3-4 times the device to perform Na, K, Cl, glucose and urea testing.63 No
cost of central laboratory measurement.12,55-58 These increased decrease in ED LOS was observed in the tested patients during
costs reflect duplication of staff and equipment.17,59 the experimental period. Median LOS during the experimental
period was 209 minutes vs. 201 minutes in the control periods.
The relationship between laboratory TAT and patient LOS in Stratifying patients by presenting condition (chest pain, trauma,
the ED is unclear, but it is now generally accepted that POCT is etc.), discharge/admit status, or presence/absence of other
not a panacea for LOS problems in the ED.13 Use of laboratory central laboratory tests did not reveal a decrease in patient LOS
tests is associated with longer LOS. Heckerling described a for any patient subgroup during the experimental period. The
higher percentage of patients discharged from the ED within reason POCT did not improve LOS was that laboratory TAT
two hours if no laboratory or radiology investigations were was not the rate-limiting factor for discharge.
Kendall et al. used a randomised controlled design in which 43 minutes faster for Na, K, and Cl, and 44 minutes faster
samples were randomly allocated to POCT or testing by the for urea and glucose than from the central laboratory but
hospital’s central laboratory.64 Changes in management in physicians reported that had the bedside results been available,
which timing was considered to be critical occurred in 7% of a different or an earlier therapeutic approach would have
patients in the POCT arm of the trial. Decisions were made resulted in only 9.5% of the cases. The decision to release or
74 minutes earlier when POCT was used for haematological admit the patient was based on one or more of the laboratory
tests as compared to central laboratory testing, 86 minutes values for 10.7% of patients sampled. In no case in this series
earlier for biochemical tests, and 21 minutes earlier for blood did a physician report that final ED clinical outcome would
gas analysis. However there were no differences between the have been affected.
groups in the amount of time spent in the department, LOS in
hospital, admission rates, or mortality. The literature on turnaround time and patient outcome is
inconclusive at best. With few exceptions, there is little evidence
van Heyningen et al. described their experience in placing a of the benefit of faster TAT on LOS or patient care despite the
whole blood electrolyte analyser in the ED for a trial period. intuition that faster results must be better. Certainly more studies
TAT (sample collection to result availability) using POCT are needed but there will always be difficulty generalising findings
(median five minutes) was faster than a porter system to given the unique work processes in each healthcare setting.
carry samples to the central laboratory, with results returned However the existing literature already reliably demonstrates the
electronically (median 58 minutes) or a pneumatic tube importance of factors other than laboratory TAT in determining
rapid transport system (median 49 minutes).65 However total patient outcomes and the need to consider work processes
patient waiting time (medians: 219 minutes with POCT; 212 together with TAT to achieve improvements.
minutes with the porter system; 258 minutes with the rapid
transport system) did not change. Other factors, such as Methods to Improve Turnaround Time
reduced bed availability on the wards and delays associated Between 1993 and 1998, the mean 90% completion time
with other investigations (such as radiology, enzymes, drug (collection to reporting) for potassium and haemoglobin in the
assays, and blood cell counts) had a greater impact on patient CAP Q-Probes program improved minimally from 60 and 45
disposition. The importance of factors other than test TAT in minutes to 57 and 44 minutes respectively, demonstrating the
influencing outcomes was further demonstrated by Nichols difficulty in improving TAT service.26,27 The CAP programs
et al., who studied the ability of POCT to decrease inpatient help identify factors associated with faster performance and
and outpatient waiting times for cardiovascular procedures.66 provide suggestions for service improvement.
They found that moving testing from a central laboratory to
the medical unit did not improve waiting time until significant An example is the CAP Q-Tracks monitor of outlier rates for
changes in workflow were made. ED urgent potassium and routine inpatient morning blood
results over two years from 291 hospitals.70 Outliers were
Other studies have demonstrated advantages of POCT in the defined as those tests whose TAT exceeded the institution’s
ED but generally suffer methodological shortcomings. For agreed TAT from sample receipt by the laboratory until result
example, Singer et al. examined the effect of cardiac troponin I release to the physician (for ED potassium) and collection to
POCT on ED LOS in chest pain patients. This was a before reporting (for inpatient morning blood results).71 The median
and after design with two weeks of central laboratory testing ED urgent potassium outlier rate dropped from 11.2% to 7.1%
of troponin followed by two weeks in which nurses performed over 8 quarters and the median morning rounds test reporting
POCT for troponin I. ED LOS reduced from 7.1 to 5.2 hours outlier rate similarly dropped from 9.9% to 7.8% over the
with POCT availability.67 However this was not a randomised same time period. Factors suggested by superior (top 25%)
trial and was limited to admitted patients. Caragher et al. participants in the urgent ED potassium survey that may have
examined the effect of cardiac biomarker POCT in the ED on contributed to their performance were: electronic test order
sample collection to result reporting TAT and saw a reduction entry, automatic printing of specimen labels and assignment of
in mean TAT from 87 to 39 minutes.68 Unfortunately no clear accession number at time of sample acquisition, use of different
data on LOS were reported. coloured labels for urgent specimens, use of three minute
urgent centrifuge, use of plasma rather than serum specimen,
Test results affect the decision to admit or discharge patients use of whole blood rather than plasma or serum specimens,
in the ED in a minority of cases. Sands et al. examined the specimens transported to the laboratory by pneumatic tube
use of bedside Na, K, Cl, urea, glucose, and/or haematocrit systems, training of laboratory staff to expedite handling of
measurement in the ED against routine testing in the central urgent samples, utilisation of urgent laboratory located in the
laboratory.69 The results from bedside testing were available ED. Factors suggested by superior (top 25%) participants in
the morning round result survey that may have contributed Pneumatic tube systems can speed up TAT without reducing
to their performance were: initiation of phlebotomy rounds sample quality. Fernandes et al. examined the effect of a
earlier in morning, revision of work schedules to co-ordinate pneumatic tube system on ED test TAT (order to report) and
available manpower with workload needs, addition of sample haemolysis rates.75 Use of the pneumatic tube system
personnel to process specimens and expedite transport of reduced mean haemoglobin TAT from 43 to 33 minutes and
specimens to the laboratory, transportation of specimens to mean potassium TAT from 72 to 64 minutes with no significant
the laboratory in batches such that testing can begin on the difference in haemolysis rate (6% with a pneumatic tube
first batch of specimens while phlebotomists return to the system and 10% with a human courier). Individual studies
wards to collect a second batch, a new category of specimens have demonstrated improved TAT with savings in transport
(e.g. “Urgent 2”) to expedite processing of morning samples, staff costs. However such systems can under-perform due
regular review of pending logs, use of plasma or whole blood to poor design (which is often based on mail transport) or
for chemistry testing, printing of results in patient care area insufficient canisters.16,76 The 1990 CAP Q-Probes study on
immediately following result verification, transportation of ED TAT showed the few laboratories using pneumatic tube
specimens to the laboratory by pneumatic tube. transport systems had slower TATs and later studies showed
a higher uptake rate but below average TAT independent of
In 1995, Steindel reviewed the results of previous CAP Q- their tube system design classification.8,10,77 It was conjectured
Probes on timeliness of laboratory results and noted some that such delays reflected problems with staff not sending or
common elements to their findings.72 Some observations, retrieving specimens promptly and underlined the need to
such as that computer systems yielded slower TATs, refer to consider all aspects of workflow rather than just physical
1990-1993 data and may now be outdated. Others however installation in planning a transport system.
may still be relevant. TATs distributions were the same for
laboratories that monitored TAT and those that did not, Introduction of instrumentation can also improve TAT. Berry
suggesting laboratories were not using the data collected examined the effect on TAT (order to result) of introduction of
for quality improvement activities. Urgent laboratories, automated urinalysis.78 Use of the automated system showed
located either in the ED or elsewhere, did not yield clinically a 30% increase in availability of reports at 30 minutes, 9%
significant decreases in TAT, with differences in the order of improvement at 45 minutes, and 3.2% improvement at 60
minutes. Urgent laboratories had the slowest 10% of samples, minutes. The urinalysis staff also handled haematology duties.
suggesting inadequate staffing or equipment for peak With use of the automated system, a 44% improvement in
workloads.73 Transportation time was a major factor in TAT FBCs was noted in the 30 minute TAT, 22% improvement at
and could be reduced by moving analysis closer to the point 45 minutes, and 8% improvement at 60 minutes. Laboratory
of collection or providing faster transport (e.g. pneumatic staff were able to complete urinalysis testing more quickly
tube systems).74 Sample collection done by laboratory staff and therefore attend to FBCs sooner, resulting in improved
resulted in faster TAT than when collected by others. Sample TAT for both tests. Holland et al. saw no change in received to
preparation delayed TAT- whole blood or plasma analysis was verified ED potassium TAT means with the introduction of total
faster than serum testing.8,10 laboratory automation but noted a reduction in outlier (defined
as >40 minutes) percentage from 18% to 5%.79
In 1999, Steindel and Novis examined TAT outliers (defined
as urgent tests with order to verification TAT >70 minutes).24 Use of satellite laboratories in the ED can improve TAT
They felt that a system to monitor outlier TATs was easy to and reduce patient LOS. Lewandrowski et al. described an
establish. Each laboratory should determine the distribution of average reduction of 51.5 minutes in test TAT, an ED patient
outlier TATs in its own institution and set an outlier criterion LOS reduction of 41 minutes and an increase in physician
at the TAT seen when a sufficient volume of outlier specimens satisfaction.80 Similar results were seen by Leman et al. who
(recommendation 10%) is observed. When investigating outliers, noted a TAT (dispatch of sample to result availability) reduction
the cause for all specimens exceeding the outlier criterion should of 47.2 minutes for FBC, 66.1 minutes for d-dimer testing, and
be established. If delays are in the pre-analytical phase, one 41.3 minutes for chemistry testing.81 Decisions to discharge
should study the collection and transport processes used. They patients were significantly faster but no change was seen
felt that the laboratory should manage these activities as lack of with decisions to admit patients. There was a trend for earlier
laboratory control of the pre-analytical phase was a common laboratory results modifying intravenous drug or fluids orders.
cause of delay. Such suggestions, although laudable, may not
be feasible for many laboratories in terms of data availability, Winkelman and Wybenga examined TAT for blood gas
resources and time needed to routinely investigate the TAT of analyses performed at a central laboratory and at a satellite
10% of all urgent samples. laboratory and found a mean TAT of 6 minutes for the central
laboratory (pneumatic tube system, broadcasting results to improved patient outcomes was uncertain and a potentially
computer terminals at the originating site) and 4.5 minutes limiting factor was clinicians’ capacity to make use of faster
in the satellite laboratory.82 The difference was attributed to test results.
savings in transit time in the pneumatic tube and accessioning
time in the central laboratory. The total cost per reportable Ostbye et al. examined the introduction of a module for
result was substantially higher for the satellite laboratory than laboratory test order entry and reporting in a hospital setting
for the central laboratory. and noted a reduction in order to result availability time
from 270-350 minutes to 90-180 minutes (average reduction
Other studies have shown similar results but such improvements 3 hours).90 The details of the time savings, whether pre-
are not guaranteed.8,10,83,84 A 1996 CAP Q-Probes study analytical or post-analytical, were unfortunately not described
showed testing in a urgent laboratory to be a significant factor in the paper.
in contributing to TAT outliers in ED and ICU samples.24 It
was hypothesised that urgent laboratories are not well suited Persoon et al. used lean production principles to reduce the
to cope with high volumes of samples, resulting in sample pre-analytical processing time (accessioning to delivery to
queuing.10 Thorough review of the timeliness of laboratory analyser) from 29 to 19 minutes and allowed the laboratory
results, the factors causing delays and possible solutions is to meet its goal of a TAT (start and end points not specified)
suggested before considering setting up a urgent laboratory.8 of less than one hour for 80% of results for 11 consecutive
months.91
There is some evidence that use of computerised clinician
order entry (CCOE) systems can reduce both intra-laboratory Multifactorial analysis shows TAT to be affected by a variety
and total TAT.85 However problems with capturing accurate of factors that can be placed in two categories.8 The first are
specimen requesting and collection times exist even with uncontrollable institutional factors, such as institution type,
CCOE systems, complicating assessment of therapeutic bed size, location, which are probably surrogate markers for
TAT.86 Mekhjian et al. examined the effect of CCOE in two staffing levels, governance, case mix and geography. The
ICUs, one with and one without the technology.87 The average second are controllable process factors, which should be the
laboratory result reporting TAT (receipt to reporting) in the focus of quality improvement activities. These include the
surgical ICU (with CCOE) of 23 minutes was faster than in the nature of the phlebotomy staff, extent of computerisation and
medical ICU (without CCOE) with a mean laboratory TAT of method of specimen transport.10
31 minutes. This reduction presumably reflects time saved by
elimination of specimen registration. How comparable these The different approaches that can be taken are best summarised
two units were is not clear – the workload from the surgical by Howanitz in his paper on errors in laboratory medicine and
ICU of 1142 requests a month was almost double that from practical lessons to improve patient safety.26 He lists more than
the medical unit (683 requests a month) and test mix was not 20 published suggestions for improving TAT (see Table 7).
described in the paper. In terms of therapeutic TAT, reducing pre-analytical delay
through faster sample transport and delivery is probably the
Thompson et al. examined the effect of CCOE on timeliness most important single improvement. Within the laboratory,
of urgent laboratory and imaging tests in an ICU in a tertiary initial steps could be to review sample centrifugation time
teaching hospital.88 Median time from ordering to obtaining and speed requirements, review choice of quality control rules
laboratory specimens decreased from 77 to 22 minutes, to minimise false rejection rates, and implement automatic
median time from ordering to laboratory result being reported dilution and rerun functions on analysers.4 Other key laboratory
decreased from 148 to 74 minutes, and median time from processes to consider are the use of plasma or whole blood
ordering to imaging completed decreased from 97 to 30 samples, primary tube sampling, consolidation of analytical
minutes. platforms, interfacing instruments and autoverification of
results. Process mapping to identify rate-limiting steps within
Westbrook et al. used a controlled before and after study of the the laboratory is useful and simple improvements should be
effect of implementation of a CCOE system.89 TAT (receipt to considered before more complex ones such as total laboratory
availability of result) reduced for both prioritised (average 4.5 automation and computerised clinician order entry are
minutes) and non-prioritised tests (15.6 minutes), both within contemplated.
(12.8 minutes) and outside (17.8 minutes) business hours. This
reduction reflected the elimination of sample requisition by Summary
laboratory staff upon specimen receipt. However the authors Despite technical, transport and information technology
felt that the extent to which improvements can translate into improvements in recent decades, TAT continues to be a
Table 7. Suggestions to improve TAT.26 Reprinted with permission from the Archives of Pathology & Laboratory Medicine.
Copyright 2005. College of American Pathologists.
Test selection and order Test request - Standardised nomenclature for easy look up
entry - Customised screens for rapid ordering
- Enable providers to order electronically
Specimen collection and Appropriate information and - Ensure accuracy of admission, discharge and transfer data updates
delivery handling - Consider patient location tracking
- Automate lookup of information on volume, container, and special
precautions for handling specimens
Phlebotomy - Scrutinise phlebotomy practices
Specimen labelling - Use barcodes
Specimen delivery - Consider pneumatic tube, robots, dumbwaiter or conveyor belt-
type system
Specimen type - Review use of plasma and serum separator tubes and whole blood
For each step - Monitor and improve TAT (mean, median, percentage meeting
criteria and/or outliers)
- Evaluate specimen flow to maximise efficiency
- Track and eliminate errors
cause of customer dissatisfaction with the laboratory service. control. Observations such that 45% of the results for urgent
Laboratory staff can feel frustrated when the effects of laboratory tests requested by the ED were never accessed
improvements in intra-laboratory TAT are diluted by pre- or were accessed too late do little to encourage efforts by
analytical and post-analytical factors seemingly outside their the laboratory to provide a faster service.92 Clinician TAT
expectations that are unrealistic or infeasible are also a source the areas served by the laboratory but should probably
of friction. In 1993, Howanitz reported that the fastest intra- be restricted to no more than four. A variety of different
laboratory TAT technically possible for serum glucose was 24 tests, priorities and locations should be chosen to cover
minutes, which was too slow for one third of physicians.21 the range of work provided by the laboratory.
2. Clear definition of TAT in terms of start points and
This review of the literature illustrates the difficulty in end points. Despite the attraction of assessing both
recommending any universal evidence-based goals for intra-laboratory and extra-laboratory TAT, such data
laboratory TAT for two reasons. Firstly, the wide range of work are often not available and the laboratory must use the
practices (clinical and laboratory) and timing data availability data that can be gathered easily, reliably and on an on-
hinders common agreement on TAT definitions. There has going basis. With increasing availability of electronic
been progress in this area in recent years, with more explicit timestamp data of clinician requesting and result
descriptions of TAT data in the literature and increasing reviewing times, a closer approximation to therapeutic
availability of timing data through laboratory computerisation TAT becomes possible. Intra-laboratory TAT may be the
and electronic medical record development. Secondly, there easiest to define, using start points of specimen receipt
is little indication that decreased TAT improves patient care (or registration) and end points of result availability to
or hospital LOS.4 There is a need for well-designed studies of requester (or hardcopy printing). However laboratories
the effect of laboratory TAT on patient outcomes. However the should ensure that the choice of timing points is relevant
outlook in this area is less optimistic. It is difficult to design in their local context and that practices such as sample
and perform studies in stable operating environments that registration prior to sample collection (as is possible in
can separate the effect of the laboratory service from other an outpatient setting) or the addition of a test request to
confounding variables and that can produce generalisable an existing sample requisition do not result in misleading
results applicable to other sites. time interval calculations. TAT histograms should be
studied carefully to identify any unexpected patterns or
Given this lack of evidence, should one dismiss TAT as an the presence of anomalous data points.
important quality measure? Howanitz and Howanitz argued 3. Clear definition of measures to be measured. Medians,
that if laboratory results provide essential data for patient 90% (or 95%) completion times and outlier rates are
management, it follows that more timely results will improve preferred over Gaussian-based mean and standard
patient care and that, despite the lack of evidence, it is deviation measures. Despite their attraction, 90%
reasonable to assume that timeliness of laboratory results completion times are often not routinely calculated by
affects physician efficiency and hospital LOS.4 They felt laboratory information systems and may require offline
that all common laboratory tests should ideally be reported analysis of extracted raw data. Outlier rates may be easy
as fast as possible by methods yielding high quality results, to obtain on an ongoing basis and can also be a source
suggesting 60 minutes or less from sample registration to of cases for further investigation on a regular schedule
reporting under optimal conditions. (e.g. root cause analysis of delay for the slowest 20
troponin samples every month). Similarly median
Evidence-based medicine proponents may be unconvinced
values are less commonly available than mean values –
by such reasoning. A pragmatic approach which recognises
the laboratory should work with the available measures
the importance of TAT to clinicians is to set TAT goals
while appreciating any inherent shortcomings.
locally, informed by both the published literature and by local
4. Clear definitions of acceptable and unacceptable
expectations. Providers and users should decide on standards
performance based on clinical evidence, benchmarking
that meet the clinical needs and can be accomplished by the
data and local expectations. These goals should be
providers.30,93 This method offers the advantages of a local
negotiated with users. A sample registration to result
TAT definition that matches available timing data and an
reporting 90% completion time of <60 minutes for
opportunity for dialogue with laboratory users to examine and
common laboratory tests is a good starting point for
moderate their expectations.
discussion.4
Several basic steps are required to assess TAT on an ongoing 5. Establishment of a system for long term monitoring of
basis. An achievable and modest approach is preferable to performance using available data.
one with unrealistic data collection plans and over-optimistic 6. Regular review (e.g. monthly) of performance measures
looking for unacceptable performance and trends.
goals.
7. Regular review of performance goals whenever systems,
1. Choice of appropriate analytes for monitoring. These workflow or equipment change and on an annual basis.
should be chosen to reflect different service needs of 8. Consider supplementation of internal TAT monitoring
with enrolment in external programs such as CAP Q- 11. Lundberg GD. Acting on significant laboratory results.
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