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Do you think that reducing lab test delays is next to impossible or requires a major investment in capital? That’s not the case, according to Judy Horton, RN, MSN, CS, manager II of the ED at Harris Methodist Fort Worth (TX) Hospital, where delays in X-ray readings were reduced by 60% and pharmacy delays were cut by 71%. "Once you start analyzing the cause of a problem, often you find it’s something in the process which is fairly simple and easy to fix," says Horton.
At first, ED staff assumed that additional resources were needed in order to reduce delays, says Ralph Baine, RN, manager I of the ED. "That was our perception in the beginning," he says. "But we realized that in many cases, we could reduce delays significantly without spending any capital dollars at all, other than meeting time."
Here are the interventions that effectively reduced delays at Harris Methodist’s ED:
• A bell system is used in the hospital pharmacy. Previously, it took an average of 45 minutes to fill workman’s comp prescriptions in the ED. "We send our prescriptions over by pneumatic tube system. The prescription would sit in the tube, and the pharmacists weren’t aware it was there," says Horton.
The solution required no investment in capital, only a simple process change that cost nothing, says Horton. "A system was developed with a bell that rings when the ED prescription arrives, which decreased the delay to 13 minutes," she explains. The bell system is linked to the lights in the room so they blink when an ED tube arrives, in case no one hears the bell, she adds. "A colored bag is used for ED prescriptions so they stand out from any other tubes that are in the system," says Horton.
• Areas of focus were identified. The effort began by collecting data for turnraound times for radiology, the laboratory, and pharmacy, says Horton. "That validated the problem," she explains. In each area, data were analyzed with the use of flow charts, so that specific goals could be identified, says Horton. "For radiology, it was getting the films read and the answer back in the most efficient way. For pharmacy, it was getting the medication; for lab, it was getting the blood and results," she says. Wherever delays or stops in the process were identified, staff had to come up with solutions to eliminate them, says Horton.
• The six most common lab tests were identified. Overall, average lab turnaround times were decreased by 39%, from 33 minutes to 20 minutes, for the ED’s six most common tests: complete blood count, Chem 7, arterial blood gas, pregnancy, cardiac panels, and urinalysis. "The laboratory made these ED tests a priority and reduced turnaround time to 20 minutes," Horton reports.
The six tests were made a priority by including the lab in ED meetings to determine how delayed tests affected the length of an ED visit, says Baine. "A test on an admitted patient that takes an hour may not change the length of stay as much as an ED patient who is waiting for the result to go home," he explains.
• The location of the X-ray room was changed, and technicians were made aware of the workload. The X-ray room was moved from the back of the ED to the center of the department, which decreased transport times, says Horton. "All three nursing areas now surround these centralized X-rays," she notes.
Another problem was making technicians aware of the workload in the ED, says Baine. "The three nursing stations kept their X-ray cards’ or orders at their individual desks," he says. "Technicians had to walk around to the three areas to find out how many were ordered at a given time."
A corkboard was placed right outside the X-ray room, and the X-ray cards are placed on one of three sections corresponding to the nursing area of the patient, he explains. Now, X-ray can see at a glance all the films ordered in the ED, Baine says. This allows them to be on call for extra staff when needed, instead of just plugging along at one pace not knowing that five X-rays were just ordered," he explains.
These changes had a significant impact on turnaround times related to X-ray, says Horton. "It took 75 minutes from the ordering of the film to actually taking the film, and now takes only 18 minutes," she reports.
• The radiology software was changed. The software on the dictation system was changed to give the ED films priority, says Baine. "Previously, as our films went into the reading stack, if they had 10 films to read, then we were number 11," he notes. Now, the ED film dictation jumps to the top of the transcriptionist’s screen, and automatically prints out at the ED nurse’s station.
It also was determined that double work was being done, since both the ED clerks and the file room personnel were entering or verifying entered orders, says Baine. "It was changed so that we do not look the films up. Instead, we send them straight to the file room, and they do all the ordering," he explains. "This saved work and time on our part."
Tip: Don’t use average times to track delays
Do you use average times to track delays in your ED? If so, you may want to rethink this practice, argues Baine. When the ED set about to reduce ancillary test turnaround times, average times were reported for ancillary test delays, he says. "But we quickly realized that wasn’t a very accurate way of reporting. If you are aiming for an average of 30 minutes, a test with an hour delay would cancel that out."
Similarly, overall average test results of one hour can be cancelled out by an average during a slow time of 15 minutes, says Baine. He recommends using the 90% percentile instead. "That way, you focus on the 10% that matters," he says. For example, instead of focusing on 6,000 complete blood counts (CBCs), you can work on the 600 CBCs that were over 30 minutes, he explains. "You can identify the problems that made those tests take longer," he adds.
For more information on reducing ancillary test delays, contact:
• Judy Horton, RN, MSN, CS, Emergency Department, Harris Methodist Fort Worth Hospital, 1301 Pennsylvania Ave., Fort Worth, TX 76104. Telephone: (817) 882-3339. Fax: (817) 882-3344. E-mail: email@example.com.
• Ralph Baine, RN, Emergency Department, Harris Methodist Fort Worth Hospital, 1301 Pennsylvania Ave., Fort Worth, TX 76104. Telephone: (817) 882-3385. Fax: (817) 882-3344. E-mail: firstname.lastname@example.org.