Answering your questions

Do you have a formula for Productivity and Information? We are being told to make do with less staff. Most bigger labs are staffed 24/7; we are not. I have three full-time certificate techs (including myself), one full-time lab aide, and one part-time lab aide. We are a small lab; our hours are 7 a.m. to 5:30 p.m., Mon through Fri, and 5:30 p.m. to 6 a.m., Mon through Fri. On weekends, someone is on call from 7 a.m., Sat, to 6 a.m., Mon. The three techs share the on-call hours. We average around 500 hours of call hours/month, and we get call-out on an average of 70 to 80 hours/month. On the productivity sheet I receive, there is nothing about call hours waiting by a phone and getting $1/hr, and it puts call-back hours in overtime. I understand there is a national formula. Do you have any information on this formula?

I am not aware of any formula that can be universally applied in measuring a lab’s productivity. There are many variables to be considered with each lab that make it difficult to establish such a formula. In today’s technology-rich market there are many vendors selling instruments that differ in test menus, methodology, specimen preparation requirements, specimen capacity, specimen throughput, and needed technical skills. In addition, there may be other factors that can impact laboratory efficiency, such as clinician demands of the lab, pathologist requirements, result reporting capabilities, budget constraints, age of equipment, and regulatory issues (CLIA regs, licensure).

Historically, there have been products such as CAP’s Work Load Recording System (WLRS), which was introduced in 1969. It was based on actual time measurements of specific tests performed on specific instruments (work load unit = one minute). As new technology came along and the number of companies making clinical equipment increased, the ability to keep up with these changes became an overburdening process, and the program was terminated in 1992.

However, labs that wanted to address productivity issues often purchased and participated in benchmarking programs that compare your lab to other “labs like yours.” This comparative information is calculated from self-reported data collected by each lab. These data may include billable inpatient tests/FTE, billable outpatient tests/FTE, billable tests/worked hour, and/or billable tests/paid hour. Collating the data from a number of laboratories allows for the calculation of averages and standard deviations.

The ability to reasonably compare these metrics, though, is highly dependent on collecting enough information from laboratories as similar to yours in function as possible. That can be a limiting factor if your laboratory is more eclectic than others. While these programs can be expensive and sometimes a bit misleading, as some unique features of your lab may not be addressed in the data collection process, the metrics provided through these programs do offer some point of reference and can be useful long-term by comparing your own statistics from quarter to quarter and year to year. Benchmarking is a moving target, with metrics that change with technology and other factors. It is useful, but not all encompassing, in measuring productivity.

However, the bigger question here is one of providing adequate laboratory staffing to ensure quality patient care. A complete analysis of the situation could generate the kind of information that would help define this situation and could be useful to support hiring needs.

Questions to consider: What are the test volumes for M-F day shift, compared to night shift, compared to weekends? Are there big disparities among the shifts (for example, are more tests/FTE performed at night than on other shifts)? Are there tests performed on off-hours that could or should have been completed during the day shift? What tests are ordered that require staff to be recalled? Who is responsible for blood draws, nursing or the lab? Is there a problem at the nursing unit level whereby orders are not processed in a timely fashion? Can point-of-care testing be implemented on the floor (performed by nurses?) that would eliminate some tests being sent to the lab, especially at off-hours? Is there a triage system, i.e., a pathologist involved in authorizing the recall? Can staffing be staggered by one or two hours to better cover the different shifts? Can an increased workload over the past two-three years be demonstrated (# billed tests/FTE)? Can you show that length-of-stay (LOS) is increased or other patient services delayed because of untimely lab results? Do you have any documentation regarding staff burn-out (complaints from the staff, staff turnover, increased absenteeism)? An honest and complete evaluation of the current laboratory staff is also important to ensure that maximum efficiency already exists. With appropriate supporting documentation in hand, one can then approach administration with a request for additional help.¹

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Reference

1.  Kurec AS. Staffing and scheduling of laboratory personnel. In: Management in Laboratory Medicine. 3rd ed. Lippincott: Philadelphia, PA. 1998.

—Anthony Kurec, MS, H(ASCP)DLM
Clinical Associate Professor, Emeritus
SUNY Upstate Medical University 

In our environment we have patients keeping OB Clinic appointments who are then being sent, “fasting,” to the lab with requests for a three-hour glucose tolerance test. Some of these patients arrive at 9 a.m. or 10 a.m., and I believe that they are no longer truly fasting because, even though they’ve not eaten, they’ve become physically active and their bodies have begun to mobilize glycogen stores, etc. Do you have definitive information about this? 

There does not appear to be much in the literature about this issue.There is one reference found, an excerpt in Tietz, Fifth Edition, page 1432.

The table, “Factors that influence the glucose tolerance test,” addresses that activity and time of day are two factors influencing this testing. They state that the testing should begin between 7 a.m. and 9 a.m. and the patient should remain seated during the test without smoking cigarettes.

There was a study published in  2010¹ which looked at a slightly different but related issue involving subjects fasting overnight and doing prolonged moderate-intensity exercise. The data showed no change in plasma glucose levels (determined by a YSI instrument) during the exercise period (90 minutes). It remained very stable at ~100 mg/dL (~5.5 mmol/L) ±4% (n=15 subjects).

There does not seem to be specific definitive information directly related to the question as posed.

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Reference

1.  Merry TL, Wadley GD, Stathis CG, et al. N-Acetylcysteine infusion does not affect glucose disposal during prolonged moderate-intensity exercise in humans. J Physiol. 2010;588(9):1623-1634.

—Judy Hundley, MT(ASCP)
Supervisor, Chemistry Core Lab
University of Virginia Health System

We have two blood gas analyzers with lytes/glucose/coox (analyzing fewer than 100 samples/month) on the same department doing twice-a-year parallel studies. Is a third/fourth instrument from another department needed for other studies? Is correlating three samples a week for these studies till you get to the six-months interval required by Federal /JCHO,CLIA/CAP guidelines?

Federal regulations require that any laboratory or health system that offers the same test in different locations must assure that the results of testing in all locations agree within clinically relevant limits. To assure compliance with this regulation, at least six patient samples should be analyzed twice a year in duplicate per instrument. A minimum of five of the six samples must agree within a specified acceptable percent variance or absolute difference, or a corrective action must be taken and documented (recalibration, service call, etc.). If a corrective action occurs, it should be immediately followed with six additional patient comparisons agreeing within the established acceptable limits for the parameter.

The semi-annual comparisons should be performed using a reference analyzer. Semi-annual comparisons are performed between the reference method for the laboratory or health system (analyzer in the main lab) and the point-of-care device where applicable. Acceptability criteria are based on CLIA’88 guidelines, clinical impact, and instrument performance.

Percent differences are calculated as POCT instrument/reference instrument. Absolute differences are calculated as reference instrument minus POCT instrument. All results should be reviewed by the director of the laboratory or designee.

—Denise Eavers, MPH, MT(ASCP)
Manager, Point of Care Testing
University of Virginia Health System

Is there any evidence that using a fan to dry peripheral blood smears has a positive or negative effect on the appearance of morphology? Is it a safety violation to use a fan to dry peripheral blood smears?

This question is still open to interpretation. Small fans are used within a closed system such as instrumentation that incorporates this technology. If labs do not have this technology and decide to use a fan, they have to take precautions to minimize potential creation of aerosols.

Generally, blood smears should be dried as quickly as possible to avoid drying artifact. In some laboratories a small fan is used to facilitate drying.¹ However, fans can cause aerosols, which should be avoided in the lab.

Our lab uses an instrument that automatically prepares and stains 95% of our smears. That instrument incorporates small internal fans at both ends of the process.

When we make the smears by hand, we let them air dry and then stain. In researching this question, the main finding was that areas with high humidity could employ a fan.

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Reference

1.  Hematology: Clinical Principles and Applications; Elsevier; 2007.

—Barbara Strain, MA, SM(ASCP)
Director of Value Management
and
Donna L. Canterbury, MT(ASCP)SH
Hematology Supervisor—
Core Laboratory
University of Virginia Health System

MLOs “Tips from the clinical experts” column provides practical, up-to-date solutions to readers’ technical and clinical issues from experts in various fields. Readers may send questions to [email protected].