La tempestività come qualità e strategia. L’esperienza di Pordenone

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Riassunto

Premesse.

La tempestività della risposta, misurata come turnaround time (TAT), è un attributo essenziale della qualità del laboratorio clinico. Lo scopo del lavoro è descrivere l’esperienza di Pordenone per il miglioramento del TAT degli esami urgenti provenienti dal Dipartimento di Emergenza (DE).

Metodi.

Con uno strumento informatico dedicato (ATNA) del LIS sono stati misurati il TAT totale (richiesta-risposta visualizzata) e i TAT pre-analitico (richiesta—consegna campione in laboratorio), analitico (ricevimento campione—verifica dei risultati) e post-analitico (disponibilità risultati in LIS—visualizzazione in DE) di 5000 pazienti consecutivi del DE, determinando media, mediana (M) e tempo di completamento del 90% degli esami richiesti (90° pc) di 4 esami pivot: emoglobina (Hb), glucosio (Gl), potassio (K) e troponina (cTn). Le cause dei ritardi sono state studiate con root cause analysis (RCA) e con analisi causa-effetto secondo Ishikawa su 245 outlier (90° pc\(\,>60~\mbox{min}\)) in un audit tra Laboratorio (2 medici, 7 TSLB) e DE (14 medici, 32 infermiere) che ha, altresì, individuato gli interventi necessari per raggiungere l’obiettivo di TAT\(\,<60~\mbox{min}\). Il miglioramento del TAT è stato monitorato dopo ogni singola implementazione delle azioni correttive stabilite, utilizzando come esame pivot cTn, in quanto rappresentativa della peggiore performance di TAT.

Risultati.

Nelle misure iniziali M era 15 min per Hb, 36 per Gl e K, 44 per cTn e il 90° pc 43, 70, 67 e 79 min, rispettivamente. M di TAT pre-analitico era 27 min, di TAT analitico 13 min (primo risultato) e 38 min (ultimo risultato del profilo d’urgenza) e di TAT post-analitico 48 min. RCA (20 passaggi esaminati) e diagramma causa-effetto identificarono 3 determinanti principali dei ritardi: in ordine di importanza, il trasporto del campione dal DE al Laboratorio, le abitudini di visualizzazione dei risultati in DE e il cambio turno mattutino dei tecnici di laboratorio (TSLB). Conseguentemente le azioni correttive suggerite furono, in ordine di implementazione: revisione modalità del cambio turno mattutino dei TSLB, modifica delle regole di visualizzazione in DE, acquisizione di un sistema di trasporto meccanico. Il miglioramento del TAT di cTn fu: dopo revisioni organizzative, M stabile (44 min) e 90° pc 5 min (da 79 a 74); dopo introduzione posta pneumatica, M 3 min (da 44 a 41 min) e 90° pc 5 min (da 74 a 69 min); dopo revisione software gestionale M 4 min (da 41 a 37 min) e 90° pc 13 min (da 69 a 56 min). Il miglioramento totale è stato di 7 min per M ma di ben 29 min (36,7%) per 90° pc, con una diminuzione degli outlier di cTn da 19% a 5% e il 95% degli esami completati entro il TAT stabilito di 60 min.

Conclusioni.

Il miglioramento del TAT degli esami urgenti fino al raggiungimento dell’obiettivo di 60 min è possibile con l’utilizzo di metodi di miglioramento continuo combinati come RCA e audit. Le azioni correttive devono essere molteplici e interconnesse perché le ragioni dei ritardi sono multifattoriali. Il lavoro all’interfaccia clinica-laboratorio è fondamentale sia per il risultato pratico sia per stabilire un clima di collaborazione sistematica. La convinzione che la tempestività non sia solo un obiettivo ma una strategia del Laboratorio è essenziale per il raggiungimento dei risultati.

Parole chiave

TAT Audit Analisi delle cause radice Posta pneumatica POCT Automazione Sistemi informatici Medicina di Laboratorio 

Timeliness as quality and strategy. The Pordenone experience

Summary

Background.

The timeliness, measured as turnaround time (TAT), is an essential attribute of quality for the clinical laboratory. The present work describes the Pordenone experience on the improvement of the TAT of stat tests from Emergency Department (ED).

Methods.

Total TAT (order-to-report), pre-analytical TAT (order-to-receipt), analytical TAT (receipt-to-result), and post-analytical TAT (LIS result-to-viewed report) of 5000 consecutive ED patients were determined as average, median (M) and time of completion of 90% of requested tests (90° pc) of 4 pivot tests: hemoglobin (Hb), glucose (Gl), potassium (K), and troponin (cTn). An audit between laboratory (2 physicians and 7 technologists) and ED (14 physicians and 32 nurses) examined the reasons of delay by a root cause analysis (RCA) according to Ishikawa on 245 outliers and identified the needed interventions. A systematic monitoring of TATs, after each implementation of suggested actions, was conducted measuring M and 90° pc of cTn stat, as test with the worst TAT performance.

Results.

Base M was 15 min for Hb, 36 for Gl and K, and 44 for cTn while 90° pc was 43, 70, 67, and 79 min, respectively. Pre-analytical TAT M was 27 min; analytical TAT 13 min (first result) and 38 (last result of biochemical profile); post-analytical TAT 48 min. By RCA (20 steps), the audit identified as main determinants of TAT delay, in order of importance, specimens transportation from ED to Laboratory, rules for viewing results in ED, technologists’ shift change in the morning, and pointed out the needed interventions (in order of implementation: organizational modifications; mechanical transportation of specimens). The improvement was systematically measured as cTn TATs after the suggested actions: after organizational intervention, M stable and 90° pc 5 min (from 79 to 74 min); after pneumatic tube implementation, M 3 min (from 44 to 41 min) and 90° pc 5 min (from 74 to 69 min); after reviewing of informatics rules of LIS, M 4 min (from 41 to 37 min) and 90° pc 13 min (from 69 to 56 min). The total improvement of TAT was 7 min for M and 29 min (36.7%) for 90° pc, with a decrease of outlier of cTn from 19 to 5% and 95% of tests completed in 60 min.

Conclusions.

The goal of stat tests in 60 min is reached by continuous improvement methods as RCA and audit. The improvement interventions should be multiple and interconnected because the reasons of delay are multifactorial. The clinic-laboratory interface work is essential, both for the practical results and for a positive and systematic climate of collaboration. The Laboratory should be convicted that timeliness is an attribute of quality and a strategy.

Keywords

Turnaround time TAT Audit Root cause analysis Pneumatic tube POCT Automation Information technology Laboratory Medicine 

Notes

Conflitti di interesse

Nessuno.

Studi condotti su esseri umani e animali

Per l’esecuzione dello studio non è stato ritenuto necessario richiedere il consenso informato in quanto le valutazioni di Laboratorio sono state condotte su dati anonimi. Il presente studio non ha comportato l’utilizzo di animali da esperimento.

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Copyright information

© Società Italiana di Patologia Clinica e Medicina di Laboratorio 2018

Authors and Affiliations

  1. 1.Laboratorio AnalisiOspedale di Pordenone, AAS5PordenoneItalia
  2. 2.Dipartimento di EmergenzaOspedale di Pordenone, AAS5PordenoneItalia

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