Laboratory results. Timeliness as a quality attribute and strategy.

Although timeliness of results reporting has not been a major focus in clinical laboratories, there is increasing pressure from clinicians to report results rapidly. Even though there are only sparse data, timeliness in reporting of laboratory results undoubtedly affects clinician and patient satisfaction as well as length of hospital stay. Improving turnaround time (TAT) is a complex task involving education, equipment acquisition, and planning. All the steps from test ordering to results reporting should be monitored and steps taken to improve the processes. Various strategies to improve TAT at each step in the testing process are discussed.

Physician satisfaction and emergency department laboratory test turnaround time.

OBJECTIVES: To determine the length of time for the components of the emergency department (ED) turnaround time (TAT) study in 1998 and to ascertain physician satisfaction concerning laboratory services to the ED. METHODS: Using forms supplied by the College of American Pathologists Q-Probes program, participants conducted a self-directed study of ED TAT over a 4-week period. Data requested included various times of day associated with the ordering, specimen collection, laboratory receipt, and result-reporting stages of stat ED TATs for potassium and hemoglobin. Additionally, practice-related questions associated with the laboratory were asked. Participating laboratories also provided a physician satisfaction survey for up to 4 physicians who were users of ED services. Results of both the TAT study and the physician satisfaction survey were returned by mail. Participants were drawn from the 952 hospital laboratories enrolled in the 1998 College of American Pathologists Q-Probes study on ED TAT. The main outcome measures included the components of the ED TAT process, factors associated with decreases in ED TAT, and the results of the physician satisfaction survey. RESULTS: Six hundred ninety hospital laboratories (72.4% response rate) returned data on up to 18 230 hemoglobin and 18 259 potassium specimens. Half of these laboratories responded that 90% of potassium tests were ordered and reported in 69 minutes or less, whereas the TAT for 90% of hemoglobin results was 55 minutes or less. Comparison of the components of TAT for both potassium and hemoglobin with similar studies done in 1990 and 1993 showed no change. Factors found to statistically contribute to faster TATs for both tests were laboratory control of specimen handling and rapid transport time. When whole blood specimens were used for potassium determination, TAT improved. Emergency department physicians chose the study-defined lower satisfaction categories of Often, Sometimes, Rarely, and Never for the questions concerning the laboratory being sensitive to stat testing needs (39.1%) and meeting physician needs (47.6%). Many of the physicians surveyed believed that laboratory TAT caused delayed ED treatment more than 50% of the time (42.9%) and increased ED length of stay more than 50% of the time (61.4%) when compared with other specialty users of the ED. CONCLUSIONS: Laboratory ED TATs have remained unchanged for almost a decade. Emergency department physicians are not satisfied with laboratory services. Although it appears that one issue may relate to the other, the interaction between the laboratory and the ED is quite complex and has been evolving for at least 30 years. Improvement in interoperability between the departments is essential for operational efficiency and patient care. Effective communication channels need to be established to achieve these goals.

Interinstitutional variation in glycohemoglobin monitoring and glycemic control of diabetic patients.

OBJECTIVES: To compare how frequently institutions monitor glycohemoglobin in diabetic patients, the level of glycemic control achieved and to identify institutional factors associated with higher rates of monitoring and lower glycohemoglobin levels. METHODS: A total of 212 institutions retrospectively abstracted laboratory and outpatient records of up to 30 diabetic patients who had initial glycohemoglobin monitoring performed in their laboratories. Data from a cohort of 5586 diabetic patients and 17 365 assays were analyzed. RESULTS: Overall, 31.3% of patients underwent glycohemoglobin monitoring at least quarterly, the frequency recommended by the American Diabetes Association (ADA) to stabilize patients at target hemoglobin A(1c) (HbA(1c)) levels. A total of 64.9% of patients were monitored at least semiannually, the ADA recommendation for patients with stable diabetes in glycemic control (final HbA(1c) level <7%). When we compared the top and bottom deciles of the 212 institutions, there was more than an eightfold difference in the proportion of patients monitored at least quarterly and more than a twofold difference in the proportion of patients monitored at least semiannually. Glycemic control was assessed by examining the value of the last glycohemoglobin determination on record after at least 8 months of management. For all 5586 diabetic patients, the median value of the last HbA(1c) assay was 7.4%. Comparing the top and bottom deciles, there was almost a fourfold difference among institutions in the proportion of diabetic patients in glycemic control. The use of reminders to order glycohemoglobin monitoring was associated with higher rates of semiannual monitoring (P <.05) and tighter glycemic control (P <.05). In addition, patients who were monitored more frequently experienced glycohemoglobin reductions of greater magnitude (P <.001). The presence of diabetes clinics and the use of rapid methods for testing glycohemoglobin were not associated with monitoring frequency or glycohemoglobin levels. CONCLUSIONS: There is wide interinstitutional variation in the frequency with which diabetic patients are monitored and the level of glycemic control achieved. The use of prompting systems to remind providers to order glycohemoglobin monitoring was associated with more frequent monitoring and superior glycemic control.

Postanalytical quality improvement: a College of American Pathologists Q-Probes study of elevated calcium results in 525 institutions.

OBJECTIVE: To evaluate elevated patient calcium results as a postanalytic quality indicator of physician practices. DESIGN: Participants prospectively identified hypercalcemic patient results for 4 months or until they found 320 hypercalcemic results, and then, after at least 3 days, reviewed the medical records of these patients. Hypercalcemia was defined as a calcium value that exceeded the upper limit of each laboratory's reference range by 0.12 mmol/L or more. Participants, as well a subset of their physicians who did not acknowledge or respond to elevated results in the medical record, answered a questionnaire about their practices. PARTICIPANTS: Five hundred twenty-five laboratories enrolled in the College of American Pathologists Q-Probes program. MAIN OUTCOME MEASURES: The presence of hyercalcemic results in patients' medical records and physicians' acknowledgement and response to those elevated results. RESULTS: More than 5500 hypercalcemic results were identified, of which 53.2% represented a new finding. About 3.5% of results were not charted in the patients' records, and 23.1% of patient records did not contain clinician documentation of the abnormal result. Follow-up laboratory tests were not ordered for 13.8% of the elevated values. For 570 of the 808 results for which there was neither clinician documentation nor designated follow-up laboratory tests ordered, patients' physicians received written notification of the elevated calcium results along with a questionnaire. Responses were received from 386 physicians (68%). One hundred physicians indicated they did not order the specific calcium measurement, and of these 100, 85 responded it was part of a panel. The 286 physicians who ordered the test stated the results ultimately led to further testing (69%), a change of management (56%), or a new diagnosis (25%). CONCLUSIONS: We found that a high percentage of abnormal results (3.5%) were not documented in the patients' medical records, the diagnosis of hypercalcemia frequently was new (53.2%), and a high percentage of physicians did not respond to elevated calcium results by writing a note (23.1%) or ordering another test (13.8%). Opportunities for quality improvement at these postanalytical steps are far greater than at the analytical step. Laboratorians must help physicians identify and respond to clinically important laboratory results.

Employee competence and performance-based assessment: A college of American pathologists Q-probes study of larboratory personnel in 522 institutions.

OBJECTIVE: To survey employee competence assessment practices in departments of pathology and laboratory medicine and provide suggestions for improvement. DESIGN: A 3-part study consisting of a questionnaire about current competence assessment practices, an evaluation of compliance with stated competence assessment practices using personnel records of 30 employees, and a written appraisal of competence of 5 specimen-processing staff members per institution. SETTING: A total of 522 institutions participating in the College of American Pathologists 1996 Q-Probes program. MAIN OUTCOME MEASURES: Institutional competence assessment practices, compliance of each institution with their own practices, and determination of competence of specimen-processing personnel. RESULTS: Of the participating institutions, 89.8% had a written competence plan and 98.1% reported reviewing employee competence at least yearly. General competence was reviewed by direct observations (87.5%), review of test or quality control results (77.4%), review of instrument preventive maintenance (60.0%), written testing (52.2%), and/or other methods (20.8%). In 8.6% of institutions, employees who failed competence assessment were not allowed to continue their usual work. On review of records of 14 029 employees for adherence to the laboratory's general competence plan, adherence was 89.7% for direct observations, 85.8% for review of quality control and test results, 78.0% for review of instrument records, and 74.0% for written testing. Employee failure rate ranged from 0.9% to 6.4%, depending on the competence evaluated. Adherence to an institution's plan was 90.4% for new employees, 93.1% for computer skills, 95.8% for laboratory safety, and 92.1% for continuing education. When a written competence assessment was given to 2853 specimen-processing staff members, 90.0% responded satisfactorily. CONCLUSIONS: Opportunities for improvement in employee competence assessment are numerous, and we provide several specific suggestions.

The autopsy as a performance measurement tool--diagnostic discrepancies and unresolved clinical questions: a College of American Pathologists Q-Probes study of 2479 autopsies from 248 institutions.

OBJECTIVE: To develop a multi-institutional reference database for quality improvement purposes using the autopsy to define clinical diagnostic discrepancies and resolve clinical questions. DESIGN: Using the College of American Pathologists Q-Probes format, institutions prospectively assessed a maximum of 15 consecutive autopsies each, excluding forensic cases and stillborn infants, conducted over a 6-month period. They documented answers to clinical questions provided at autopsy and classified unexpected disease diagnoses according to a standardized system. SETTING AND PARTICIPANTS: Hospital-based autopsies performed at 248 institutions participating in the 1993 College of American Pathologists Q-Probes Quality Improvement Program. MAIN OUTCOME MEASURES: Percentages of clinical questions resolved by the autopsy and percentage of autopsies with unexpected findings of graded clinical impact. RESULTS: In the aggregate database of 6427 questions from 2479 autopsies, overall 93.0% were answered by the autopsy. The 3 most common question categories were (1) identify pathology to account for clinical signs or symptoms (28.0%); (2) establish the cause of death (21.0%); and (3) confirm a clinical diagnosis (19.0%). At least one major unexpected disease finding that contributed to the patient's death was discovered in 39.7% of the total number of autopsies. There were no differences in the percentages of autopsies with these major unexpected findings when the data were stratified by institutional demographics or decedent characteristics. CONCLUSION: This multi-institutional study underscores the clinical relevance of postmortem examination in current medical practice by consistently providing answers to unresolved clinical questions and frequently revealing major unexpected findings that contributed to the patient's death. It is our strong belief that this postmortem-derived clinicopathologic information is a key indicator of effectiveness of care. Integration of this information into institutional quality improvement programs will improve system processes and clinician performance.

Blood culture contamination: a College of American Pathologists Q-Probes study involving 640 institutions and 497134 specimens from adult patients.

OBJECTIVE: To examine clinical and laboratory practices associated with contamination of blood culture specimens from adults. DESIGN AND SETTING: A College of American Pathologists Q-Probes quality improvement study involving prospective evaluation of adult blood culture contamination rates in 640 institutions. MAIN OUTCOME MEASURE: Proportion of contaminated blood cultures. RESULTS: A total of 497134 blood cultures were studied. The median adult inpatient blood culture contamination rate was 2.5% (central 80th percentile=0.9%-5.4%) by laboratory assessment. There was no significant difference in contamination rates between inpatient and outpatient cultures (P=.273). The median contamination rate by clinical assessment (2.1%) was significantly lower (P=.005), primarily because of a lower proportion of cultures with coagulase-negative Staphylococcus that were interpreted as contaminants when only one of multiple specimens was positive. Specimen collection variables associated with significantly lower contamination rates included use of a dedicated phlebotomy service (P=.039), use of tincture of iodine for skin disinfection (P=.036), and application of an antiseptic to the top of the collection device before inoculation (P=.018). Teaching institutions and high numbers of occupied beds were demographic factors associated with higher contamination rates for inpatients but not for outpatients. Culture parameters associated with higher contamination rates included microbial growth from a single specimen, isolation of certain microbial species (eg, coagulase-negative Staphylococcus), and longer time to detect growth in culture. Contamination rates were not significantly affected by the type of blood culture method used, specimen volume, or use of a double-needle collection procedure. CONCLUSIONS: There is wide variation in blood culture contamination rates among institutions. Three specimen collection factors and three culture variables were identified as having a significant effect on blood culture contamination.

Changes in emergency department turnaround time performance from 1990 to 1993. A comparison of two College of American Pathologists Q-probes studies.

OBJECTIVE: To compare the results of a 1990 College of American Pathologists Q-Probes Emergency Department (ED) turnaround time (TAT) study with a similar study done in 1993 and to identify factors associated with TAT improvement. DESIGN: Participants gathered data over a 4-week period on the various times of day associated with the ordering, specimen-collection, laboratory-receipt, and result-reporting stages of stat tests for potassium and hemoglobin levels, using a mail-in questionnaire that also included practice parameter questions. PARTICIPANTS: Laboratories enrolled in the 1990 College of American Pathologists Q-Probes study on ED TAT and laboratories enrolled in the 1993 program ED TAT study. MAIN OUTCOME MEASURES: Components associated with shorter ED TAT and, for those participating in both the 1990 and 1993 studies, comparison with previous results. RESULTS: Six hundred fifteen hospital laboratories returned data on up to 43,521 hemoglobin and 41,989 potassium specimens. Half of these laboratories collected and reported 90% of their ED potassium results in 53 minutes or less, compared to 61 minutes or less in 1990, and reduced the corresponding median collection-to-reporting TAT for 90% of hemoglobin results from 46 minutes or less to 39 minutes or less. The fastest 10% of laboratories showed interlaboratory median order-to-report TATs of 36 and 50 minutes for potassium and hemoglobin tests, respectively. Comparisons of TATs from 277 laboratories with 1990 and 1993 data were possible. Components found to contribute statistically to improvement of ED TAT between 1990 and 1993 were laboratory control of specimen handling, rapid transport time, and monitoring. Active monitoring was particularly important when the laboratory did not control the specimen-handling process. CONCLUSIONS: Laboratories improved their control of ED TAT from 1990 to 1993 and reduced the number of TAT events exceeding 70 minutes. Internally set TAT goals, however, were not met most of the time.

The College of American Pathologists, 1946-1996. Quality Assurance Service.

Since its creation in 1970, the College of American Pathologists Quality Assurance Service Committee has provided important and highly respected interlaboratory programs for daily quality control. In 1988, this committee extended its domain by announcing Q-Probes, a unique benchmarking program for laboratory quality assurance. Because of the success and rapid growth of this program during the next 2 years, the Quality Assurance Service Committee expanded into two committees, namely, QAS-QC and QAS-QA, with expertise concentrated, respectively, in quality control and quality assurance. These committees have compiled a history of significant scientific and educational contributions to members, the international laboratory community, other physicians, and patients. New directions for both committees are now underway so that their contributions can continue in the rapidly changing field of pathology and laboratory medicine.

Timeliness of urinalysis: a College of American Pathologists Q-probes study of 346 small hospitals.

OBJECTIVE: To explore preanalytic handling of urinalysis specimens. DESIGN: The study was a College of American Pathologists Q-Probes study consisting of two parts. The first part was a questionnaire about participants' urinalysis practices. The second part required collection of information from four specific urinalysis specimens per shift on 30 consecutive days or from 200 urine specimens, whichever occurred first. SETTING: Three hundred forty-six small hospitals enrolled in the Small Hospital Q-Probes program. MAIN OUTCOME MEASURES: Compliance with guidelines requiring nonrefrigeration and specimen measurement within 2 hours of collection, and identification of practices associated with better performance. RESULTS: Almost 50,000 urinalysis specimens were analyzed. About 68% of the specimens were measured without prior refrigeration, 2.3% were refrigerated before, 17.9% were refrigerated after, and 4.5% were refrigerated before and after arrival in the laboratory. Aggregate analysis indicated that 11.2% of never-refrigerated specimens exceeded the recommended 2-hour time standard before analysis. For inpatients and outpatients, respectively, 64% and 77% of laboratories were able to meet the 2-hour goal 90% of the time. Improved performance was associated statistically with ordering urinalysis stat, an enforced policy of specimen rejection for delayed transport of inpatient specimens, and the listing of a collection time for outpatient specimens. CONCLUSIONS: A large number of urinalysis specimens exceeded current quality guidelines for handling. Laboratories must monitor and improve preanalytic handling of urinalysis specimens.

Clinical laboratory quality control: a costly process now out of control.

We studied laboratory internal quality control (QC) processes using the College of American Pathologists Q-Probes program. Over 500 institutions participated, providing practices based on approximately 710,000 cholesterol, 880,000 calcium, 400,000 digoxin, and 1,180,000 hemoglobin QC results. The costs of QC included participant median control samples rates comprising 9.1, 9.4, 37.0, and 6.8% for the four analytes respectively, repeat patient test rates of 0.36% for hemoglobin to 0.65% for digoxin, and median delays in reporting results when QC exceptions occurred of 15.8 min for calcium to 24.7 min for hemoglobin. Quality control practices were complex and highly variable among participants and frequently differed from internal laboratory protocols and from long-established quality guidelines. We conclude that QC is costly, and laboratorians frequently do not follow established QC practices, in part because they are complex. To improve compliance, we believe QC practices must be simplified.

Chemistry specimen acceptability: a College of American Pathologists Q-Probes study of 453 laboratories.

OBJECTIVE: To determine the frequency and reasons for rejection of chemistry specimens. DESIGN AND SETTING: College of American Pathologists Q-Probes laboratory quality improvement study prospectively recording rejected chemistry specimens in 453 laboratories. MAIN OUTCOME MEASURE: Percentage of submitted specimens rejected for testing. RESULTS: Of 10,709,701 chemistry specimens submitted to the participating laboratories during the data collection period, 37,208 (0.35%) were rejected prior to testing. The institutional 10th, 50th (median), and 90th percentiles were 1.35%, 0.31%, and 0.06%, respectively. The most frequent reason for rejection was hemolysis, which occurred five times more frequently than the second most cited reason, insufficient specimen quantity to perform the test. When examined with their respective frequency of use, a higher percentage of rejected specimens were collected in microcollection tubes than in other containers. When compared with the respective frequency with which they collect specimens, laboratory personnel submitted significantly fewer rejected specimens than other in-hospital personnel groups and slightly more than out-of-hospital nonlaboratory personnel. The poorest performance was demonstrated by other in-hospital nonlaboratory personnel. Serum and plasma oxalate/fluoride specimens exhibited significantly lower rejection rates when compared with the other specimen types. Relative rejection rates were higher for nongel tubes and lower for syringes when compared with gel tubes. CONCLUSION: Specimen rejection should be monitored on a regular basis. Institution-specific factors that are associated with rejection should be identified and targeted for improvement efforts. Action thresholds should be set sufficiently low to assure that continuous improvement is effected.

Reasons for proficiency testing failures in clinical chemistry and blood gas analysis: a College of American Pathologists Q-Probes study in 665 laboratories.

OBJECTIVE: To determine the reasons for proficiency testing (PT) failures from 41 chemistry and blood gas analytes using data collected to benchmark performance. DESIGN: Self-administered survey requesting number of challenges by analyte encompassing nine PT events. When the challenge resulted in a self-defined failure, further information was requested concerning the magnitude of the failure (as a standard deviation index) and categorization of the type of failure into six major groups (Methodologic, Technical, Clerical, Survey, Unexplained, or Other) and then into subgroups. PARTICIPANTS: Laboratories enrolled in the 1992 College of American Pathologists Q-Probes program. MAIN OUTCOME MEASURES: Rate of PT failures and reasons for failure. RESULTS: Proficiency testing data from 670,489 challenges performed in 665 laboratories revealed 9268 (1.4%) unacceptable results. Failure types were distributed as follows: Methodologic, 33.5%; Technical, 17.4%; Clerical, 11.1%; Survey, 7.8%; Unexplained, 25.7%; and Other, 7.4%. CONCLUSIONS: Individual analyte PT failure is a common event in the participating laboratories, but failures in successive or alternate events are rare. Analysis of the reasons for failed events indicates that most identified reasons occurred in either the Methodologic or Technical categories (50.9%). Analysis of the failure types suggested investigation pathways based on the magnitude of the failure that could reduce the 25.7% rate of unexplained failures.

Quality assurance of autopsy face sheet reporting, final autopsy report turnaround time, and autopsy rates: a College of American Pathologists Q-Probes study of 10003 autopsies from 418 institutions.

OBJECTIVE: To develop a multi-institutional reference database of autopsy practice and performance for quality improvement purposes. DESIGN: In 1990, participants in the Q-Probes quality improvement program of the College of American Pathologists (CAP) each retrospectively evaluated the 25 most recently completed consecutive autopsy reports and determined the number of deaths and autopsies that occurred in their institutions during 1989. SETTING: Hospital-based autopsies excluding forensic cases and stillborn infants. PARTICIPANTS: Four hundred ten institutions in the United States and eight institutions in Canada. MAIN OUTCOME MEASURES: Completeness of face sheet information contained in final autopsy reports, turnaround time for completion of final reports, and institutional autopsy rates. RESULTS: In the aggregate database of 10003 autopsies, the following six data items (from a total of 21) were present in 95% to 100% of the final autopsy reports in at least 85% of the participating institutions: institution where autopsy was performed, patient's name, patient's sex, autopsy number, autopsy date, and prosecter's name. The turnaround times for the final autopsy reports were as follows: 30 days or less in 47.6% of the cases, 31 to 60 days in 28.8%, and more than 60 days in 23.7%. A higher median percentage of autopsy final reports were completed in 30 days or less in institutions with the following characteristics: nonteaching (P < .004), no pathology residency program (P < .002), and rural location (P < .027). A lower number of autopsies performed in 1989 was associated with a higher median percentage of final reports completed in 30 days or less (P < .007). The aggregate autopsy rate for all participating institutions was 12.4%, and the median rate was 8.3%. Median autopsy rates for teaching institutions and institutions with pathology residency training programs were 15% and 19%, respectively. CONCLUSIONS: This multi-institutional study identified a core group of face sheet data items that were consistently present on final autopsy reports. However, the majority of the face sheet data items examined were inconsistently recorded. Approximately 75% of final autopsy report turnaround times were within the standard established by the Joint Commission on Accreditation of Healthcare Organizations. Nearly two thirds of the institutions reported autopsy rates for 1989 of 0% to 10%.

Blood culture quality improvement: a College of American Pathologists Q-Probes study involving 909 institutions and 289 572 blood culture sets.

OBJECTIVE: To evaluate solitary blood culture (SBC) collections as a preanalytic quality indicator of blood culture practice. DESIGN AND SETTING: Two College of American Pathologists Q-Probes laboratory quality improvement studies involving prospective evaluation of the proportion of and reasons for SBC collections in 909 institutions. OUTCOME: Reduction in the proportion of SBCs. RESULTS: Of 289572 blood culture sets studied, the median proportion of SBCs per institution was 10.1% and 12.1% among adult inpatients, 25.4% and 33.3% among adult outpatients, and 89.0% and 100% among pediatric/infant patients in the first and second (follow-up) studies, respectively. The two most common reasons for not performing a second culture in adults were (1) test not indicated and (2) physician believed one was sufficient. When compared with inpatient cultures, a significantly higher proportion of outpatient SBCs were classified as not indicated (P < .0001). Among 198 institutions participating in both studies, a significant decline in SBC rates was observed in the subgroup (n = 50) that continued to monitor SBCs (P = .004). CONCLUSIONS: Interinstitutional evaluation of solitary blood cultures provides a benchmark for quality assessment and an opportunity for performance improvement in blood culture specimen collections.

Adapting mobile robotic technology to intralaboratory specimen transport.

OBJECTIVE: To evaluate and implement two identical inexpensive robotic vehicles for transport of patient specimens within our clinical laboratory. DESIGN: We accepted delivery of the first two robotic vehicles produced by a local vendor and studied the vehicles for 13 months. The first 4 months of familiarization and customization were followed by 9 months of routine use. SETTING: Within the specimen-processing, hematology, and chemistry sections of a large academic medical center's clinical laboratory, one floor below ground. INTERVENTION: The vehicles replaced 1.5 individuals who transported specimens. OUTCOME MEASURES: The number of kilometers the vehicles traveled and the number of routes begun, completed, not completed, and with unknown status. In addition, we assessed the types of problems that occurred, employee satisfaction, and financial payback. RESULTS: When used on all shifts for 13 months, the vehicles traveled an average of over 2000 routes and 212 km per month. At any one time, at least one vehicle was operational. Of the 17 problems that occurred, the most frequent were navigational problems caused by obstacles, such as personnel, in the vehicle's right-of-way. For 6 of the last 9 months, navigational, mechanical, and electronic problems together occurred no more than two or three times per week. Financial payback for the vehicles occurred in less than one year. CONCLUSIONS: By the end of the study, the robotic vehicles completed 99.4% of their routes. Specimen-processing and transport personnel reported the vehicles made their jobs easier and improved timeliness of specimen delivery. We anticipate our potential savings over 5 years to be approximately $200,000 (US).

Timeliness of automated routine laboratory tests: a College of American Pathologists Q-Probes study of 653 institutions.

Benchmarks for timeliness of early morning routine clinical laboratory tests were developed from over 17,000 urea nitrogen and 16,000 white blood cell count measurements made for inpatients in 653 institutions participating in the College of American Pathologists Q-Probes program. Urea nitrogen and white blood cell counts were considered surrogates for routine chemistry and hematology tests. Laboratories at the 50th percentile reported median urea nitrogen and white blood cell counts by 09.04 and 08.51 h, respectively, whereas those at the 10th percentile reported these median measurements by 11.30 and 11.18 h, respectively. Results were available sooner in non-teaching than teaching institutions, and in smaller rather than larger institutions, with the degree of computerization affecting test availability. Timeliness also was affected by instrument type and mode of operation, but was unaffected by the percentage of stat testing. Based on modeling by regression analysis, there was little evidence that longer routine test turnaround times affect patient length of stay.

Bedside glucose monitoring. Comparison of performance as studied by the College of American Pathologists Q-Probes program.

OBJECTIVE: To measure changes in practice characteristics and accuracy of bedside glucose monitoring between studies performed in 1991 and 1994. DESIGN: Participants in a 1991 and a 1994 bedside glucose monitoring study of the College of American Pathologists Q-Probes program were compared using data collected by a questionnaire for 15 quality variables and data from paired specimens for accuracy. Accuracy goals of bedside testing were those defined by the American Diabetes Association as within 10% of the laboratory value. Accuracy was estimated using a daily paired comparison of patient specimens for 30 days, one bedside glucose instrument, and individuals who commonly performed these measurements. SETTING: Institutions subscribing to the College of American Pathologists' voluntary quality improvement program, Q-Probes. PARTICIPANTS: In 1991 and 1994, 605 and 544 institutions collected data about performance characteristics, whereas 171 and 242 institutions participated in the accuracy components, respectively. MAIN OUTCOME MEASURE: Changes in accuracy between 1991 and 1994. RESULTS: When compared, improvement occurred for 12 of 15 quality variables. However, no significant changes were found for the percentage of values within stated accuracy goals. CONCLUSIONS: Although the process of bedside glucose testing improved between the 1991 and 1994 studies, the testing accuracy remained unchanged.

Bedside glucose monitoring quality control practices. A College of American Pathologists Q-Probes study of program quality control documentation, program characteristics, and accuracy performance in 544 institutions.

OBJECTIVE: To investigate the adequacy of bedside glucose monitoring (BGM) quality control documentation and monitoring, characterize program structure and organization, and identify characteristics associated with the ability to produce accurate results. DESIGN AND SETTING: College of American Pathologists Q-Probes laboratory quality improvement study in 544 institutions. MAIN OUTCOME MEASURES: Percent compliance with quality control (QC) documentation, appropriate corrective action, and frequency of inappropriate patient testing, and the percentage of BGM results within +/-10% and +/-15% of a corresponding clinical laboratory glucose result. RESULTS: Five hundred forty-four institutions reviewed a total of 19543 individual QC paper documents from 2543 separate BGM instruments. Ninety percent of QC determinations that should have been performed and noted on these documents were recorded; of those performed, 2.8% of QC results were outside of the acceptable range. Thirty-two percent of the out-of-range QC results had no record of corrective action. There were 527 reported instances of one or more patients being tested when there was no record of corrective action for out-of-range QC results. There were 20665 undocumented potential QC events, with 2053 instances of one or more patients being tested when there was no documentation. Two hundred forty-two institutions submitted 6653 paired BGM and clinical laboratory results for comparison. Approximately 56% of BGM results were within +/-10%, and 74% were within +/-15% of the corresponding clinical laboratory result. Factors associated with better accuracy performance are discussed. CONCLUSIONS: There is a need for improving compliance with QC documentation, improving appropriate corrective action follow-through, decreasing the frequency of inappropriate patient testing, and improving BGM accuracy performance. We provide recommendations for improvement.