Special Feature

Whither Waiting: Turnaround Times of

Laboratory Tests
for Emergency Room Patients
Thomas S. McConnell, MD, and Cheryl Writtenberry-Loy

Turnaround times of laboratory tests for emergency room (ER) patients, both the ER and the clinical labora-
from specimen collection to result reporting, were analyzed and compared. tory of a medium-sized southwestern
Intervals of process times by laboratory test equipment were assessed, as university hospital collected data for
well as ER patient waiting times. The average turnaround time for all tests 49 consecutive weekday shifts during
was 57 minutes, compared with the average time a patient spent in the ER the spring of 1980 (Tables I and II).
of 195 minutes. The shortest average turnaround was ten minutes for sep-
Demographic data of the hospital in
arate (discrete) analysis of blood gases, while the longest was 86 minutes
for serum electrolytes, glucose, and urea nitrogen performed on a sequential which the study was conducted are:
analyzer. Discrete analyzers, a laboratory computer system, individual test (1) 271-bed general and acute care
ordering, adequate communication of clinical data and physician needs to teaching hospital with 14,400 annual
the laboratory, input from emergency personnel to laboratory personnel, admissions, 79,500 patient days, av-
and a "STAT lab" are mechanisms that could shorten waiting and turn- erage occupancy of 82% and average
around times. stay of 6.0 days; (2) 120,000 annual
clinic visits and 52,000 ER visits; and
(3) 480,000 unweighted annual test
procedures with a College of Ameri-
can P a t h o l o g i s t s (CAP) work load
times, this study sought to determine
W aiting for laboratory test results
often frustrates both physicians
and patients 1 2 and probably adds to
the actual turnaround intervals of the
commonest laboratory procedures or-
weighting of approximately 12 mil-
lion units. Laboratory tests from the
ER constitute 8.9% of the total pro-
the overutilization of the clinical lab- dered by emergency room physicians
cedures performed in the laboratory
o r a t o r y . A l t h o u g h some d a t a a r e in comparison to the time patients
with 91% of those ordered with high
available on the usefulness and turn- spend in the emergency room.
priority (STAT or "as soon as possi-
around times of STAT tests, 3 5 infor- Methods ble").
mation regarding actual intervals
between patients' entering and leav- A laboratory technologist familiar The laboratory is situated one floor
ing the emergency room (ER), speci- with the procedures and systems in immediately above the ER, with hand
men collection, and turnaround times
for laboratory procedures was not
found in a literature search.
In preparation for establishing a Table 1: ER-Laboratory Time Study (49 Shifts, 0900-1730 hrs, Mon-Fri,
STAT laboratory in our institution, March 25 to June 2, 1980)
and to develop a baseline a g a i n s t Patients who had laboratory work 348
which to compare later turnaround Patients with no admit or discharge time documented 85
Patients with obvious ' 'times" errors in data recording 10
Patients studied with documented data point times (N) 253
Total minutes in ER 49,408
Average minutes in ER per patient 195
From the Pathology Service, Univ of New Mexico Hos- (range) (8-680)
pital, Albuquerque, NM 87106.

644 LABORATORY MEDICINE VOL. 14, NO. 10, OCTOBER 1983

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 Table II: ER-Laboratory Time Study, with Specific Emphasis on Event Nodal Point Intervals (49 shifts, 0900-1730 hrs , Mon-Fri, March 25 to June 2, 1980)

Time between
Time between Time between Time between Time between test results Time between
patients' ER specimen specimen Time between test's lab in ER and time test results
log-in and collection collection test's lab clock-out and physician reach ER and
specimen and laboratory and ER clock-in and time results sees ER patients'
collection clock-in patients' log-out lab clock-out reach ER results log-out time
Data Points (N) 153 227 140 501 386 159 128*
Total Minutes 11,968 2,956 16,628 28,536 1,257 392 13,410
Average Minutes 78 13 119 57 3 2.5 105
Range Minutes 0t-275 1-104 0-580 4-271 1-39 1-49 0-608
"185 patients had data n this category, but 55 of these left before results were received and their data were discarded.
tZero minutes results from the log entries having the same times.

delivery by an ER technician being times (PT,PTT) were performed using minutes. The interval between the
the usual mode of specimen transport. one of three BioQuest e Fibrosystems. time the laboratory result arrived in
ER technicians, physicians, or nurses Amylase and ethanol (ETOH) proce- the ER and the time the patient was
ordinarily collect the specimens (ex- dures were performed on a DuPont f logged-out was the second longest,
cept when a blood crossmatch is or- aca II. Urinalysis (UA) and platelet a v e r a g i n g 105 m i n u t e s . (Fifty-five
dered; then a blood bank technologist counts were done manually. patients left the ER before their lab-
draws the specimen). Laboratory re- oratory results were received; these
sults are communicated by telephone,
Results were excluded from the study). The
pneumatic tube, or human messen- Three hundred forty-eight patients third longest interval was the time
ger. Times were obtained from ER who were logged into the ER during between patient log-in to the ER and
manual logs, ER encounter sheets, the 8V2 hour daytime shifts between the time of specimen collection, an
laboratory requisitions as clocked in March 25 and J u n e 2, 1980 (49 days) average of 78 minutes.
by ER personnel, laboratory results and who had one or more laboratory The average turnaround time for all
as clocked out by laboratory person- tests performed were studied. Of these, laboratory procedures studied was 57
nel, and personal observation. Also 254 patients had both log-in, log-out m i n u t e s , w h i l e t h e i n t e r v a l from
analyzed were times between clock-in and most, but not all, of the inter- specimen collection to laboratory clock-
and clock-out of the ten tests most fre- mediate times documented; most of in time averaged only 13 minutes. It
q u e n t l y ordered by ER physicians these patients had multiple tests or- took an average of three minutes for
(Table III). dered. Patients for whom at least one the results to reach the ER after lab-
test was ordered were in the ER an oratory clock-out time and only 2V2
Those tests for which a laboratory average of 195 minutes. minutes for the ER physician to see
instrument fed analog data directly
Seven time intervals were studied the results.
into the central processing unit of the
(Table II). The interval between spec- Average turnaround times for the
computer ("on-line") were analyzed
imen collection and patient log out was most frequently ordered tests a r e
w i t h t h e c o m p u t e r w o r k i n g both
the longest, with an average of 119 shown in Table III. They ranged from
properly ("up") and improperly
("down"). The laboratory computer
system in operation at the time of this
study was a Microform" System 2000,
a n d o n - l i n e e q u i p m e n t w a s two Table III: ER-Laboratory Time Study, Times Between Laboratory Clock-In and Clock-Out
by Type of Procedure for the Ten Most Frequent Tests in the Study
Technicon" SMA-6/60s and one Coul-
(49 Shifts, 0900-1730 hrs, Mon-Fri, March 25 to June 2, 1980)
ter 0 Model Ssr.
N Total (min) Average (min) Range
Serum electrolytes (sodium, potas- CBC, computer up 68 2,325 34 14-79
sium, chloride, and C0 2 ), urea nitro- CBC, computer down 20 1,002 50 21-86
gen, and glucose were performed on CBC, total 88 3,327 38 14-86
the SMA-6. Complete blood counts SMA 6, computer up 73 5,878 73 23-150
SMA 6, computer down 17 1,839 108 34-178
(CBC) w e r e d o n e on t h e C o u l t e r
SMA 6, total 90 7,717 86 23-178
counter (the tests performed included CBC plus diff, computer up 93 4,791 52 18-128
hematocrit, hemoglobin, erythrocyte CBC plus diff, computer down 11 754 69 13-122
count, leukocyte count, and the eryth- CBC plus diff, total 104 5,545 53 13-128
rocyte indices with leukocyte differ- Blood gas 41 415 10 4-21
entials being performed manually). UA 41 2,880 70 18-252
Platelet count 6 371 62 24-128
Blood gases were analyzed by one of PTorPTT 43 2,811 65 36-256
two I n s t r u m e n t a t i o n L a b o r a t o r y 1 Amylase 18 1,148 64 34-135
model 813 discrete analyzers. Pro- ETOH 26 1,483 57 20-116
thrombin and partial thromboplastin Totals 457 25,697 56 4-256

LABORATORY MEDICINE VOL. 14, NO. 10, OCTOBER 1983 645

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 ten minutes for arterial or venous
blood gas analysis to 38 minutes for
a CBC, 70 minutes for urinalysis, and
86 minutes for the combination of
serum electrolytes, glucose, and urea
nitrogen.
Computer up and down times relate
to hematologic and chemical proce-
dures performed on equipment on-line
to the computer. All average inter-
vals documented were shorter when
the computer was up than when it was
down.
The CBC with or without leukocyte
differential was the most frequently
performed test (236 of 655 or 36%),
the SMA-6 (counted as a panel test)
was second (132 of 655 or 20%), and
urinalysis was third (78 of 655 or 12%).
Discussion
This study includes data derived
only from the weekday shift. Week-
end, evening, or night shift data might
well show different results, due to the
putative change in type and numbers
of ER patients, and because most non-
priority laboratory work is not per-
formed in off-hours. T h i s clinical
laboratory does not have a STAT sec-
tion, but accommodates rapid turn-
a r o u n d p r o c e d u r e s in i t s r e g u l a r
sections.
The observer was unable to collect
all time intervals for each patient in
the study period. This explains why
the number of data points differ from
one interval to another.
By considering patient events to-
gether with specimen or test events
(Table II), we have mixed the interval
data. Although patient, specimen, and
result events are linked in time, they
are not necessarily dependent on each
other except at specimen collection
time. If a patient had multiple tests
ordered, the blood specimens for these
were all collected at one time. Re-
sults, however, were reported individ-
ually as they became available.
Many of the 55 patients who left
the ER before the results were re-
ceived signed out against medical ad-
vice. Others got tired of waiting and
were allowed to leave. ("We'll call you
if the tests are abnormal" is a com-
mon ER maneuver.) In discussion with
ER physicians and nurses after the
study was completed, it appeared t h a t
the wide variety of patient problems
and dispositions commonly caused in-
consistent intervals. Some patients left
6 4 6 LABORATORY MEDICINE VOL. 14, NO. 10, OCTOBER 1983
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the ER quickly because they were ad-
mitted or transferred, others lingered
for observation or therapeutic pur-
poses, and still others were dis-
charged shortly after specimen
collection. Some came to the ER only
for blood drawing. Actual numbers in
these categories were not recorded, but
we believe that the heterogeneity of
patient problems accounted in large
measure for the interval variations.
The short turnaround time for blood
pH, P 0 2 , and P C 0 2 (ten minutes av-
erage, never more than 21 minutes)
was possible because the procedure
was performed on a dedicated single-
purpose discrete analyzer u s i n g a
noncentrifuged discrete sample by
laboratory technologists who were in-
structed to give top priority to the
analysis of blood gases. The Techni-
con SMA 6/60 is a non-STAT sequen-
tial multiple analyzer. Even if top
priority status was assigned to anal-
yses performed on this instrument,
average turnaround times as short as
ten minutes could never be achieved
because of sample centrifugation time
and the nondiscrete manner in which
specimens, controls, blanks and stan-
dards are manipulated. The DuPont
aca is an example of an automatic
multitest discrete analyzer; thus, if
intralaboratory priority equivalent to
t h a t assigned to blood gases were also
assigned to serum amylase, for ex-
ample, the turnaround time could av-
e r a g e s i g n i f i c a n t l y less t h a n 64
minutes. Similarly, the seven tests
performed on the Coulter Ssr could be
completed within an average of ten
minutes. Because the laboratory com-
puter is effective in "bookkeeping"
details, results from the CBC and
SMA-6 are derived in a significantly
shorter time when the system is up
than when it is not functioning.
The performance of a leukocyte dif-
ferential count (which also includes
an evaluation of erythrocyte, leuko-
cyte, and platelet morphology and
qualitative assessment of the particle
numbers on the stained slide) adds a
significant time increment to the per-
formance of the CBC regardless of the
computer's status. Performing a leu-
kocyte differential count in conjunc-
tion w i t h t h e CBC m a y also a d d
significant waiting time for the ER
patient, and the application of results
may not be appropriate for ER pa-
t i e n t s who h a v e normal leukocyte
counts. We suggest t h a t orders be
written, "leukocyte differential if leu-
kocyte count abnormal."
In this and most other hospital lab-
oratories, discrete, priority analyses
are performed with more urgency than
batched groups of tests. The ER phy-
sician can save more of the patient's
time by ordering separate tests that
are needed for immediate care rather
than panels or groups of tests that may
be performed in batch modes on one
instrument. The question of cost ef-
fectiveness for such a practice is a dif-
ferent matter, and was not addressed
by this study.
Almost one half of the hematologic
and chemical procedures for the en-
tire hospital are ordered "as soon as
possible" (ASAP) or "STAT" during
weekday shifts. The laboratory con-
siders all work from the ER STAT or
with ASAP priority unless otherwise
noted. A competing urgent work load
from other areas in the hospital, the
clinics, physicians' offices, etc, creates
g r e a t problems in p r i o r i t i z i n g t h e
performance of STAT or ASAP tests.
Usually, little clinical information is
available to help laboratory person-
nel in effectively making this priori-
tization.
On the basis of this study, the fol-
lowing six conclusions a n d recom-
mendations emerge:
(1) Turnaround intervals for cer-
tain laboratory tests and ER
procedures are established.
These vary in relation to sev-
eral parameters and systems,
some of which are functions of
laboratory and ER policies and
resources.
(2) A significant amount of patient
t i m e is c o n s u m e d by e v e n t s
other than those that relate to
laboratory testing. Such activ-
ities as radiologic, cardi-
ographic, clinician consultation,
and patient observation proce-
dures should also be analyzed
for appropriateness of time uti-
lization.
(3) For high p r i o r i t y l a b o r a t o r y
testing, discrete analyses can
be performed and results re-
ported more quickly t h a n tests
performed in p a n e l s , groups,
and batches. In this context, ER
physicians should order only
what they need for the imme-
diate care of the patient so that
 the discrete analyzers can be
used to greatest advantage.
(4) General testing priorities should
be assigned within the labora-
tory after receiving input from
the physicians and others con-
cerned with emergency, inten-
sive, and urgent care. Adequate
clinical information on requests
and communication from the ER
physician are essential to set-
ting individual testing priori-
ties.
(5) The administrative necessity of
a more efficient means to per-
form nonpriority procedures in
batches on scheduled runs in
hospital laboratories where
there are significant amounts
of both routine and priority work
loads may require the estab-
lishment of a STAT section. In
this manner, multiple sequen-
tial analyzers and other non-
priority instruments and
systems can be used for routine
work while discrete analyzers
and high priority systems are
utilized for specific, urgent tests.
(6) An on-line laboratory computer
system such as the Microform
System 2000, when functioning
properly, can significantly de-
crease t u r n a r o u n d t i m e s for
certain laboratory tests.
References
1. Dove HG, Gifford R, Schneider KC: The trips of
slips: time delays in laboratory and x-ray data
for outpatients in a teaching hospital. JAMA 1980;
243:537-539.
2. Foster JD, Louria DB: Study of patient waiting
times in a moderate-sized teaching hospital. J Med
Soc NJ 1979;76:568-583.
3. Barnett RN, Mclver DD, Gorton WL: The medi-
cal usefulness of STAT tests. Am J Clin Pathol
1978;69:520-524.
4. Murphy JM, Penberthy LA, Fraser CG: Clinical
view of turnaround times for STAT tests. Am J
Clin Pathol 1979;72:884.
5. Burrows S, Schiffman R, Roberts B, et al: Con-
ducting a medical audit of STAT laboratory or-
ders. Pathologist 1980;34:517-519.
Suppliers
a. Microform, Mountain View, CA.
b. Technicon, Tarrytown, NY.
c. Coulter Electronics, Hialeah, FL.
d. Instrumentation Laboratory, Inc, Lexington, MA.
e. BioQuest, Cockeysville, MD.
f. E. I. DuPont, Wilmington, DE.

ERRATUM
Legends reversed. In the article "Staining With Basic Fuchsin" by Charles J. Churukian,
HT, HTL(ASCP), and Eric A. Schenk, MD, (Laboratory Medicine 1983;14:431-434), the
information in legends 4 and 5 has been reversed. Gram-negative bacteria are shown in Fig
4 and acid-fast bacteria are shown in Fig 5.

LABORATORY MEDICINE VOL. 14, NO. 10, OCTOBER 1983 647

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