Richard A. Savage, MD
Q. Is there a benchmark or community standard for the percentage of stat tests relative to total workload? Our overseas military hospital would probably be most comparable to a small community hospital.
Editor’s Note: This question was referred to the CAP Practice Management Committee. Following are committee members' responses.
A. Our laboratory performs 1.9 million billable tests
per year. Our stat testing, which we feel is higher than the norm, is
22 percent of the total. Because our institution is a trauma center and
has a large, busy emergency department, our percentage of stat tests is
likely higher than usual.
A. The ratio of stat testing to total testing varies
depending on the nature of the clinical services provided by the hospital,
the laboratory testing menu, and the scope of point-of-care testing performed.
For a large hospital laboratory such as ours, stat testing may range from
as low as 25 percent to more than 50 percent of total testing volume.
Changing physician ordering practices and improving turnaround times for routine testing can reduce stat ordering. We have reduced stat orders by about 10 percent by introducing automation and autoverification for the majority of high-volume tests. In fact, we no longer treat stat specimens differently from routine specimens if they are destined for the automated line. Turnaround times are now more predictable and shorter for many tests so physicians are decreasing the number of stat orders.
Outside the central laboratory we have experienced growth in point-of-care testing, and the POC tests are usually those that physicians had tended to order as stat. Consequently, growth in POC testing is reducing the number of stat orders received in the central laboratory.
A. I am not aware of any benchmarking. Our tertiary
care hospital has had a problem with too many stat orders, creating added
costs and inefficiencies.
In 2003, our stat orders were 37 percent, and, in 2005, those orders dropped to 24 percent. The reduction can most likely be attributed to a newly defined stat order list and point-of-care testing. First, the hospital medical executive committee verified and developed a stat order list. Any tests not specified on the stat list can no longer be ordered as a stat test. Second, the hospital has increasingly used more point-of-care testing.
Other initiatives to address the issue of too many stat orders, though likely not as effective, included re-educating doctors regarding ordering options (stat, timed, on the chart by 5:00 AM) and focusing on providing prompt results within the requested time frame.
A. A simple comparison probably cannot be made since
institutions can differ significantly. For example, we have one of the
busiest emergency departments and trauma units in our urban area, with
about 70,000 visits per year, as well as the largest (60+ beds) neonatal
intensive care unit in the state, which generate a lot of stats, so our
percentage of stats logically would be higher.
This is a parameter of operation all laboratories probably should be monitoring. Another way of looking at it is by internal comparison. If the percentage of stats is trending up, then it may be due to a change in patient population or deterioration in the turnaround time of regular testing or a change in practice of staff ordering tests. If the rate seems unreasonably high, then general TAT may not be meeting the needs of the medical staff and would necessitate a closer look at sources of requests to see if selected adjustments in operations could generate a larger reduction in the percentage of stats.
I asked our director if he is aware of any published benchmark data. This is his answer: We have looked at our number of stat orders but not as a percentage of total orders. I have not seen a standard published in the literature. The numbers at our institution are probably in the 30 percent range, but that is an estimate and should be verified with real data. The problem is that users think they must request stat to get the result within a few hours, and therefore the number of stat tests that are truly needed is much smaller than what is generated.
A. Stats vary according to the institutional services
and, as such, are a barometer of those services, rather than a target
to be achieved. I am unaware of any published general benchmarks, although
specific articles appear occasionally regarding turnaround time, which
may have data regarding stats embedded in them, such as for troponin measurements
(Novis DA, Jones BA, Dale JC, et al. Arch
Pathol Lab Med. 2004;128: 158-164).
I believe staff should review the CAP Laboratory Accreditation Program standards regarding TAT and ensure that the needs of the medical staff are being met. If there is a perception that too many stats are being ordered (although that is not implied in the question), the medical director should perhaps review lab TAT in general or with respect to particular tests to ascertain if process improvement is needed. Alternatively, if there are individual abusers among the medical staff who regularly order stats inappropriately, then it is the medical director’ responsibility to attempt to change these ordering patterns and, thereby, assure appropriate laboratory use and resource consumption.
A. Our institution does about 1.2 million tests per
year, and our stat percentage is between five percent and 10 percent.
We are probably on the low end. We have no teaching staff, and most of
the stats come from the emergency department.