College of American Pathologists
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cap today

It’s a small world: Making the most of modest means

March 2004
Karen Southwick

When a laboratory instrument breaks down at Marian Medical Center, on the central coast of California, staff members roll up their sleeves to fix it because the nearest repair facility is three to four hours away, which means at least a day’s turnaround.

"We have to be very good at repairing instruments ourselves and doing on-site and preventive maintenance," says Nancy Felton, laboratory manager at Marian, a 167-bed hospital in Santa Maria, Calif., about equidistant from San Francisco and Los Angeles.

Consequently, reliability and user-friendly maintenance and repair are key criteria in the hospital’s purchase of new or replacement instruments. "We want to be able to deal with most problems ourselves," Felton says.

Marian Medical Center and other small hospitals (under 200 beds) share similar lab-management problems: When considering new tests, these labs must justify not only the cost of the equipment, but also the space and training resources they will consume. Turnaround time and volume are also important factors.

At the same time, small hospitals must compete vigorously to attract and retain physicians. And, since these hospitals are often the sole providers in their areas, they emphasize high-quality, wide-ranging patient care. "Being small is no excuse for being less than excellent," says Edward Ewing, DO, laboratory medical director for Waynesboro Hospital, a 62-bed facility in central Pennsylvania.

Testing, testing

In deciding whether to add a new test to the laboratory menu, the lab must first consider how vital the test is for patient care and how quick the turnaround time is. How often the test will be used at the hospital also comes into play for non-stat tests.

Profiled below are five acute-care hospitals that offer emergency room services, surgery, intensive care, maternity care, and other typical services. That means if the emergency room, surgery, or another department requires a new stat test, these laboratories will find a way to provide it.

"Our formula is probably not much different than everyone else’s," says Peter C. Cote, MD, director of pathology and laboratory services at Ephrata Community Hospital, a 133-bed hospital in southeastern Pennsylvania.

"The first questions we ask: Is there a clinical demand for rapid turnaround, and do we need this test to provide the scope of care at our hospital?" Dr. Cote says. If the answers are yes, "then we bring in that test regardless of cost."

South Florida Baptist Hospital, a 147-bed hospital in a semi-rural area between Tampa and Orlando, has a similar formula. "Our general rule of thumb is that if someone needs the results today, we do it here," says laboratory manager Karen Noyce.

At Ephrata, if the lab determines that a four- to eight-hour turnaround is not necessary for a test, then it assesses whether the test can be done more effectively at an affiliated hospital or a reference lab, says Dr. Cote.

A new test that all the hospitals have added is B-type natriuretic peptide, or BNP, for cardiology. Although offering BNP meant acquiring a separate instrument, "it’s important to be able to do this test quickly for patients coming in with heart failure," Dr. Cote notes. His hospital also does D-dimers and other coagulation tests.

At Marian Medical Center, "over 40 percent of our work is stat," says Felton, and about a quarter of the tests are run in the ER. In addition to BNP, the hospital has added fetal fibronectin.

Another stat procedure all the hospitals offer is rapid HIV when a hospital staff member is accidentally exposed to the virus. "We will do stat HIV testing on the person whose blood or fluid exposes an employee," says John Belders, laboratory director for Campbell Health System, which runs the 98-bed Campbell Memorial Hospital, Weatherford, Tex.

For labs in small hospitals, a common test menu consists of routine chemistry, cardiology, hematology, and urinalysis. Most do coagulation and some microbiology. These labs generally send out complex microbiology, molecular testing, virology, and toxicology, either to a sister hospital in their health system or to a national reference laboratory. They tend to do most of their anatomic pathology in-house and are split on cytology. Some send out all Pap smears and human papillomavirus testing. Others, like Ephrata, do conventional Pap tests in-house and send out liquid cytology Pap tests.

"We send our specimen vials for ThinPrep to our CPAL [Central Pennsylvania Alliance Laboratory] central lab in York just to have the smears made on an instrument that does the same for other CPAL members," Dr. Cote clarifies. "The slides come back to Ephrata for staining, screening, and sign-out." The HPV Hybrid Capture II test is performed off those vials for Ephrata and other members of CPAL.

For nonurgent tests, "we have to look at how to do them in the most cost-effective way," Dr. Cote says. Staff members need to ask: What kind of volume is expected? Can the test be done on an existing instrument? Does it require hiring new staff or investing heavily in training? What are ongoing operational costs?

"Generally," says Belders, of Campbell Memorial, "I am not going to bring in a test that I won’t run very often because that’s not cost-effective." Hepatitis C testing is one example. "It would cost me several thousand dollars to get the equipment and $15 to $20 per test to do it because volume is low," Belders notes. "I can send it out for $5, and no one is going to live or die because it takes an extra day."

He also sends out esoteric tests, such as cancer antigens and molecular work, to a reference lab about 30 miles away. But because the send-out tests are generally low-volume, Belders estimates his lab does "90 to 95 percent of all the work that’s ordered here."

Says Marian’s Felton, "If it’s not needed stat and we don’t have the volume to maintain our quality level, we send it out." That includes such procedures as electrophoresis, gas chromatography, and flow cytometry. Still, she estimates that 98 percent of Marian’s laboratory work is performed in-house.

Hospitals in cold climates must also consider the delays that can occur because of inclement weather when deciding which tests should be sent out, says Ray Minnick, laboratory manager at Waynesboro Hospital. "Every time you put a sample on the road, you run the risk of it not getting there in the required time frame."

Clinicians’ needs drive some testing decisions, and because it’s difficult to attract physicians, particularly specialists, to rural or semi-rural hospitals, the labs work hard to give them what they want.

For example, Waynesboro recently added two gastroenterologists to its staff. This led the hospital to add tissue transglutaminase, or TTG, levels and more iron evaluations, such as transferrins. "We’re able to do that with our new chemistry analyzers from Bayer, which are multifunction," Minnick says.

At the urging of its ER physicians, Waynesboro is taking another step: initiating a protocol for crash testing under which doctors can draw blood on a patient without waiting for a phlebotomist. The sample is handed to the lab and given priority treatment.

Advantages of affiliations

Most of the small hospitals interviewed by CAP TODAY touted the benefits of being affiliated with systems in which larger hospitals with higher volumes can handle some of the more complex tests. Small hospitals also are able to get better deals on supplies and equipment by buying in bulk through their systems.

As part of the Central Pennsylvania Alliance Laboratory, which includes six hospital systems, Ephrata has "the advantage of being able to combine the test volumes from our six institutions to provide our menu of some 130 tests at considerable cost savings to our members," Dr. Cote says. The members "pay for the tests at cost as if this [core] lab was an extension of our own hospital laboratory," he adds.

CPAL’s jointly owned core laboratory, which is centrally located in York, Pa., performs a variety of tests, including immunochemistry, molecular diagnostics (including nucleic acid testing), electrophoresis, chromatography, and atomic absorption spectrophotometry.

All six hospital systems do outreach. "We have multiple drawing sites and a courier that runs between the offices," Dr. Cote says. The priority for tests: "Whatever can be done here at Ephrata is done here. The next choice is CPAL’s lab, then a reference lab."

Ephrata performs about 1 million billable tests a year, Dr. Cote adds, and sends out another 60,000. "We are at a constantly evolving balance between our reference lab, the lab in York, and our own lab," he says. As instrumentation improves, "more and more tests can readily be done in our own small lab."

Waynesboro Hospital is affiliated with Summit Health, which is also part of CPAL. "We represent the smallest institution," says Dr. Ewing. "The largest institution has 10 times our workload." Waynesboro’s chemistry tests account for about three percent of CPAL’s total.

To make decisions about purchasing instruments, CPAL has organized affinity groups that specialize in areas such as chemistry or microbiology. "Our equipment purchasing decisions are heavily impacted by decisions that the affinity groups make," Dr. Ewing says.

For the most part, this is an advantage because it brings together more expertise and purchasing power. The flip side is that CPAL may select a laboratory instrument that’s not necessarily suited to smaller members.

That happened with Waynesboro, but Dr. Ewing says he’s pleased that CPAL permits members to "opt out" of purchasing decisions and buy a different brand of instrument.

Waynesboro recently did just that when it decided to consolidate its general chemistry and immunoassay on a single analyzer from Bayer. CPAL had selected a different instrument with a bigger footprint and higher throughput. "We didn’t need the volume," Dr. Ewing says. "We needed a smaller machine that can do a broader range of tests."

South Florida Baptist is part of a regional nine-hospital consortium, BayCare Health System, that includes a large 800-bed hospital where it can send esoteric tests, such as molecular biology. "Typically we buy as a group," Noyce says. "We haven’t had any huge disagreements."

She notes that one of the primary suppliers, Beckman Coulter, has different models based on volume, and South Florida Baptist can select the model that best meets its needs. She adds that larger instruments often require less maintenance, which can be very important to small labs.

Instrumentation issues

In making equipment choices, space becomes a central issue for labs in small hospitals. Other factors are range of menu, ease of use, and staff, resource, and maintenance requirements.

When Waynesboro chose a different machine than CPAL selected, "it was not only [for] the smaller footprint," says Dr. Ewing. "Maintenance was less. And our techs only need to know how to run one instrument now for many different kinds of tests. It reduces the stress on personnel." The new instrument allowed Waynesboro to increase its workload without adding space or personnel.

At Campbell Memorial, most current purchases are replacements, Belders says. The lab recently bought a small Stratus bench analyzer from Dade Behring that can run two chemistry tests. It is smaller and more cost-effective than the machine it replaced, he says.

"We always have to determine, first of all, whether the equipment is even feasible for our lab and our space," he says. "We can’t just get something because the physicians want it or because it will look pretty in the lab."

In considering a new or replacement instrument, Marian does a financial analysis of the products that vendors offer under their contract with Catholic Healthcare West, the system to which Marian belongs. This includes doing a literature search and obtaining physician input. "We especially look for reliability, small footprint, and a wide test menu," Felton says, although, she adds, "most instruments now are very similar on pricing and quality."

Once the laboratory administration narrows the options based on financial considerations, "I will allow my staff to decide which instrument they would prefer," she says. "That way, I get buy-in from the clinical techs who have to run the instrument."

Marian just purchased a backup hematology analyzer "because we needed more capacity and it’s automated," Felton says. Without a backup, "if our primary hematology analyzer went down, we were back to manual differentials."

Noyce, of South Florida Baptist, says quality is the first consideration. Then she looks at ease of use, flexibility, and training requirements.

POC decisions

Point-of-care testing is generally limited to glucose meters used by nurses who are trained and supervised for that purpose by the lab. For everything else, "at a small hospital you’re generally within 100 feet of the lab, and specimens can be easily delivered," says Waynesboro’s Dr. Ewing.

With limited staff, "it makes life a whole lot simpler to retain central lab testing," he adds. "You don’t have to deal with issues like quality control and getting results into our [lab] computer."

Furthermore, says Dr. Cote, POC is usually "considerably more expensive" than running a test in the core lab. "Sometimes people want to do POC because it’s there. But it’s usually not quite as accurate as a main lab." The only POC testing at Ephrata, he says, is "a couple of dozen glucose meters—the test is done by nurses trained by the labs."

Though "there are demands to do things close by in the ER and neonatal units," so far the laboratory has been able to meet the needs, Dr. Cote says. "We have a band of phlebotomists who can go where they’re needed." In a small hospital, it’s harder to cost-justify POC testing than it is in a large hospital, he adds.

Ephrata, however, is considering putting in a neonatal ICU, and Dr. Cote believes POC testing would be justified there because the instruments must be sized for that use and because there’s a need for speed.

Marian does POC glucose testing and some surgery-related tests, including activated clotting times and blood gases. It also does dip urinalyses for pregnancy in the obstetrics unit.

"It’s decided based on patient needs," says Felton. For all the POC tests, "the lab retains 100 percent of the responsibility for oversight and quality assurance."

Karen Southwick is a writer in San Francisco.