As clinical laboratorians, we are all familiar with the pressure to provide test results quickly, and in many institutions some of the greatest need for rapid turnaround times comes from the emergency department (ED). Although the competing demands placed on busy labs and equally busy EDs can easily lead to conflict, partnering together on well-structured studies and pilot programs provides objective data to drive best practices that work for both areas.
Distinct Points of View; common mission
EDs are unique environments: In comparison to other clinical areas they generally have more diverse patient populations presenting with a wider range of conditions, as well as unpredictable demand for their services that can vary in a single day from oversaturation to near emptiness. Throughput is both a quality metric and a constant problem for many EDs, and the focus on optimizing efficiency is so intense that projects decreasing ED length of stay by even less than 10 minutes have been published.
EDs also are set up to take care of patients’ immediate needs and move them on to their next proper destination, like being hospitalized or discharged home. Given all these pressures, it’s quite understandable that EDs emphasize speedy over definitive test results.
This mindset can be difficult for clinical laboratory professionals to understand or accept given their interest in validation, quality control, traceability, standardization/harmonization, and other ingredients for robust and definitive results. Lab-driven initiatives that only measure in-lab waste, or replace faster technologies for slower but more accurate ones, can be met with disinterest or outright rejection if they do not account for the concerns and needs of ED staff.
Despite these differing perspectives, both groups have at heart a single goal: providing excellent patient care. Keeping that common mission at the center of their discussions and recognizing the interests and goals of both sides can lead to extremely successful collaborations that benefit both labs and EDs.
Using Data to Bridge the Divide
Laboratorians are no strangers to the idea of using data to guide processes and make decisions. However, the challenge in quality improvement is often less an issue of Do we have data? than of Can we get the right data? Changes affecting more than one area need input from all parties involved, including their perceptions about the quality gap and which metrics matter the most to them. For a project to succeed, data must reconcile these factors.
Like many institutions, we have experienced a never-ending rise in ED visits for the last several years, which underscores the need for efficient laboratory support. To respond to this need, our lab and ED have collaborated on several projects of various sizes, including evaluating who should collect blood for lab tests (phlebotomy or nursing), how much blood is needed for add-on testing, and whether various point-of-care tests improve time to diagnosis and ED throughput.
Each project began with an assessment of the quality gap and a discussion of which endpoint(s) both groups were looking for. These inputs provided the framework for determining what data would be required to address each party’s key concerns.
For example, a pilot study of point-of-care cardiac troponin testing evaluated not only the length of stay for chest pain patients—the initial impetus for the project—but also which laboratory values were considered when ruling out myocardial infarction. Although the latter endpoint was rather time-consuming to extract, it weighed heavily in our decision-making about whether to implement the new test.
Similarly, looking beyond mere numbers helps in re-examining long-standing practices. When various concerns led to a discussion about the rainbow draw of extra blood in different tube types and colors at our institution, both lab and ED staff were hesitant to curtail this extra blood collection because of the strongly perceived need for add-on tests.
To examine this issue further, we surveyed ED staff regarding their opinions about rainbow draws, including how many patients avoided additional collections and how often add-ons were ordered. When we compared the survey responses against add-on test and tube utilization data, we found a striking discrepancy between the subjective perceptions of a highly efficient, patient-centered practice and the objective degree of waste observed. This drove a compromise solution that balanced the concerns of both the laboratory and the ED, to the benefit of patient care.
The pressure to optimize efficiency and improve support for intense clinical practices including the ED is likely to continue growing in the coming years. In my experience, one way to work toward that optimization is by adopting data-driven approaches to process improvement, with an eye toward the needs of both groups, and with the patient always at the center of the discussion.
Christine Snozek, PhD, DABCC, FADLM, is a chemist at Mayo Clinic in Scottsdale, Arizona. Email: Snozek.Christine[at]mayo.edu