Journal:Comprehensive improvements in the emergency laboratory test process based on information technology

Full article title	Comprehensive improvements in the emergency laboratory test process based on information technology
Journal	BMC Medical Informatics and Decision Making
Author(s)	Zhang, Liang; Liu, Zhen Hua; Lv, Yin Jiang; Fu, Shui; Luo, Zhang Mei; Guo, Mei Li
Author affiliation(s)	Zhejiang University School of Medicine, People’s Hospital of Cangnan Zhejiang
Primary contact	guomeili2000 at 163 dot com
Year published	2023
Volume and issue	23
Article #	292
DOI	10.1186/s12911-023-02387-x
Distribution license	Creative Commons Attribution 4.0 International
Website	https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-023-02387-x
Download	https://bmcmedinformdecismak.biomedcentral.com/counter/pdf/10.1186/s12911-023-02387-x.pdf (PDF)

Abstract

Objective: To explore the application effects of information technology (IT) on emergency laboratory testing procedures.

Methods: In this study, IT-based optimization of the emergency laboratory testing process was implemented between October and December 2021. Emergency laboratory test reports from January to September 2021 were placed into the pre-optimized group, while those from January to September 2022 were categorized into the post-optimized group. Additionally, the emergency laboratory test report time, emergency laboratory test report time limit coincidence rate, error rate, and employee and patient satisfaction levels in individual months and across the whole period were described. Moreover, changes in the above indicators before and after the implementation of IT-based optimization were explored, and the application effects of IT-based optimization were also evaluated.

Results: The emergency laboratory test report times after the implementation of IT-based optimization were shorter than those before IT-based optimization (P < 0.05). The total number of laboratory test items before and after information optimization amounted to 222,139 and 259,651, respectively. Also, IT-based optimization led to an increase in the emergency laboratory test report time limit coincidence rate from 98.77% to 99.03% (P < 0.05), while the emergency laboratory test report error rate fell from 0.77‱ to 0.15‱ (P < 0.05). Additionally, IT-based optimization resulted in increases in both employee satisfaction, from 80.65% to 93.55% (N = 31, P > 0.05), and patient satisfaction, from 93.06% to 98.44% (P < 0.05).

Conclusion: The automation and IT-based optimization of the emergency laboratory testing process significantly reduces the emergency laboratory test report time and error rate. Additionally, IT-driven optimization enhances the alignment of emergency laboratory test report deadlines and enhances the overall quality and safety of emergency laboratory testing.

Keywords: emergency laboratory test, information technology, process optimization, satisfaction, turnaround time

Introduction

With the progress of medical reforms in China, there is now an increasing demand for high-quality healthcare services. Stricter requirements regarding the quality and efficiency of laboratory tests have also been proposed in clinical practice. On that basis, to further improve the quality and speed of laboratory test reports, clinicians are exploring methods to satisfy the demands of clinical applications and patients for the accurate and timely processing of laboratory tests. In China, most patients with acute onset, severe symptoms, or complex conditions are initially admitted to the emergency department, which increases the aggregation of patients with acute and critical conditions. [1] In contrast to conventional patients, patients in the emergency department often simultaneously require emergency rescue and disease diagnosis. Therefore, the emergency department must provide the ideal allocation of limited resources in the shortest possible time. Additionally, there are more stringent requirements for emergency laboratory test results, since delayed or inaccurate test results may affect the clinical diagnosis and lead to delayed or even inappropriate treatment. [2, 3]

Emergency laboratory tests are a vital component of emergency medical treatment. A comprehensive array of emergency laboratory test items and accurate and timely test reports provide adequate support for emergency patients to receive effective care within the optimal rescue window. [4, 5] Moreover, the rapid evaluation of patients can be achieved within the emergency department in case of sudden onset of disease, trauma, or public health emergencies. Meanwhile, the emergency department should cooperate with various hospital departments to make clinical decisions swiftly, thereby saving the lives of patients and avoiding further aggravation of disease. As the front line of emergency diagnosis and treatment, emergency laboratory tests play a crucial role in the treatment of patients with acute, severe, and critical conditions. Moreover, emergency laboratory test results exert a significant impact on making timely and accurate clinical decisions. [6] Therefore, reducing emergency laboratory test report times is essential for enhancing emergency treatment capability.

According to the accreditation criteria for ISO 15189 Medical laboratories: Requirements for quality and competence [7], turnaround time (TAT) is defined as “the duration between two designated points in the process before, during, and after laboratory tests.” TAT is employed to reflect the working efficiency of laboratories and is the preferred indicator for evaluating laboratory service quality. The laboratory test report time refers to the laboratory TAT, namely the duration (in minutes) from the time when the laboratory receives the specimen to the time when the report is sent. As a result, TAT has become an important controllable quality indicator for laboratory testing. There are specific regulations and requirements regarding this indicator in China's 2011 Detailed Implementation Rules for the Accreditation Standards of Tertiary General Hospitals (三级综合医院评审标准实施细则). Additionally, TAT was included as one of the 15 quality indicators issued by the National Centre for Clinical Laboratories in 2015, and it has been verified as an important quality indicator in laboratory tests. As specified in ISO 15189 Medical laboratories: Requirements for quality and competence [8], laboratory quality management includes the management of test result authenticity and reliability and also covers the management of various factors that may affect test results. The laboratory test report time is a key factor that affects the diagnosis and treatment of patients. In numerous clinical laboratories worldwide, the laboratory test report time is regarded as an important observation indicator for continuous quality improvement, while limitations in the emergency laboratory test report time have been highlighted. [9,10,11]

The application range of laboratory information technology has become an important symbol of scientific laboratory quality management. By applying information management technology to analyze and monitor the time nodes of key links in laboratory tests, the main test line, namely the “laboratory test report,” can be more effectively managed. Although IT has been applied to laboratory management and has achieved favorable results [12,13,14], transformation and optimization based on this technology are performed differently according to the procedures of individual hospitals. Hence, it is necessary to incorporate IT into the overall emergency laboratory test process and constantly conduct summarizations and optimizations in clinical practice, thereby maximizing automation and early warning during each step. Based on this, the working efficiency can be improved and the laboratory test report time can be reduced, which is consistent with the core values of the hospital: “Focus on the perceptions of patients and employees.”

This scientific study lays a solid foundation for appropriately applying emergency laboratory tests in clinical practice, enhancing the quality of medical services, ensuring patient safety, and improving patient satisfaction.

Data and methods

General data

As a contemporary tertiary second-class general hospital, our institution seamlessly integrates medical treatment, scientific research, teaching, rehabilitation, prevention, and healthcare services. We cater to approximately 1.8 million outpatients and admit around 50,000 inpatients annually. The hospital encompasses a sprawling site area of 108 mu, with a combined utilization area totaling 140,000 square meters. Our facilities include 32 open wards, housing a total of 1,000 beds, and a dedicated workforce of over 1,500 employees. In our department, the IT-based optimization of the emergency laboratory test process was implemented between October and December 2021. The emergency laboratory test reports from January to September 2021 were assigned to the pre-optimization group, while those from January to September 2022 were categorized into the post-optimization group. The emergency laboratory test report time limit for routine blood test + CRP, routine urine test, routine fecal test, blood group test, urine pregnancy test, and blood gas analysis was ≤ 30 minutes, while that of biochemical, immune, and other tests was ≤ 1 hour.

Methods

Materials

A laboratory information management system (LIMS) was purchased from Hangzhou Lingyun Technology Co. Any problems encountered in emergency laboratory tests were discussed within the department and then reported to software engineers. Subsequently, IT engineers conducted repairs and optimizations to solve these issues.

Circumstances and problems in the laboratory test process before optimization

Specimens obtained from patients in outpatient or emergency departments labeled as “emergency” and collected by clinicians in clinical departments for laboratory tests are referred to as non-hospitalized specimens. In contrast, specimens collected from inpatients with “emergency” labels in clinical departments for laboratory tests are designated as hospitalized specimens. The emergency laboratory test specimens of outpatients were manually entered into the corresponding category in the LIMS system, with a category specified for each item. However, for inpatients, the emergency laboratory test specimens were first input into the receiving system and then manually entered into the corresponding category in the LIMS system. Subsequently, an automated or manual test was conducted. The results were then submitted and reports reviewed as necessary, while all problems were resolved according to the operating procedures. The specific laboratory test items are listed in Table 1, and the detailed workflow is presented in Fig. 1.

Table 1. Emergency laboratory test items and corresponding detection instruments and reagents. Note: (1) After IT-based optimization, the electrolyte test, biochemical test, and (new) biochemical test were combined into one biochemical test. The immune test, four-item pre-surgery test, and BNP were combined into one immune test. (2) Before IT-based optimization, there were 13 test items and 36 test sub-items. After optimization, there were 12 test items and 50 sub-items. Item name Sub-item Instrument and reagent Before optimization After optimization Routine blood test + CRP (1 or 2 items) Routine blood test Sysmex XN-B4 (Sysmex, Japan) Automatic Blood Cell Analyzer BC-7500CRP (Shenzhen Mindray Bio-Medical Electronics Co., Ltd.) CRP Immune Analyzer Jet-iStar3000 (Joinstar Biomedical Technology Co., Ltd.) Routine urine test Routine urine test GEB-600 Urine Chemistry Analyzer (Guangzhou Huadu Gaoerbao Biotechnology Co., Ltd.) Sysmex Urine Analysis Modular Assembly Line (Sysmex, Japan) Routine fecal test Routine fecal test Semi-quantitative pyramidon method (Zhuhai Baso Diagnostics Inc.) Semi-quantitative pyramidon method (Zhuhai Baso Diagnostics Inc.) Respiratory influenza virus antigen (1 to 5 items) Influenza A virus, influenza B virus, respiratory syncytial virus, adenovirus, and mycoplasma pneumoniae Hangzhou Genesis Biodetection & Biocontrol Co., Ltd. Hangzhou Genesis Biodetection & Biocontrol Co., Ltd. Novel coronavirus antibody Novel coronavirus IgM/IgG antibody Nanjing Vazyme Biotech Co., Ltd. Nanjing Vazyme Biotech Co., Ltd. Urine pregnancy test Urine pregnancy test Blue Cross Bio-Medical (Beijing) Co., Ltd. Blue Cross Bio-Medical (Beijing) Co., Ltd. ABO + Rh blood group identification ABO blood group identification Shanghai Hemo Pharmaceutical & Biomedical Co., Ltd Hamilton Automatic Blood Grouping Instrument (Hamilton, Switzerland) RhD blood group identification Jiangsu Libo Medicine Biotechnology Co., Ltd. Blood gas analysis Blood gas analysis ABL90 FLEX Blood Gas Analyzer (Radiometer, Denmark) ABL90 FLEX Blood Gas Analyzer (Radiometer, Denmark) Electrolyte test Electrolytes (Na+, Cl−, and K+) Electrolyte Analyzer XD 690I (Shanghai Xunda Medical Instrument Co., Ltd.) Automatic Biochemical Analyzer DxC 700 AU (Beckman Coulter, USA) Biochemical test Liver function (ALT and AST), renal function (urea and creatinine), myocardial zymogram (AST, lactate dehydrogenase, creatine kinase, and creatine kinase isoenzyme), blood glucose, amylase, and cholinesterase Accute TBX-40FR (Tosoh Bioscience Shanghai Co., Ltd.) Biochemical test (new) Total bilirubin, direct bilirubin, indirect bilirubin, total protein, and albumin globulin Not performed Immune test (1 or 2 items) TnI and β-HCG Automatic Immune Analyzer AIA-360 (Tosoh Bioscience Shanghai Co., Ltd.) Anility i Automatic Chemiluminescence Immunoassay Analyzer (Abbot, USA) Four-item pre-surgery test HIV antigen and antibody, treponema pallidum antibody, hepatitis C antibody, hepatitis B virus surface antigen, hepatitis B virus surface antibody, hepatitis B virus e antigen, hepatitis B virus e antibody, and hepatitis B virus core antibody Not performed BNP test BNP Not performed HIV antibody test Human immunodeficiency virus (HIV1 + 2) antibody Beijing Wantai Biological Pharmacy Beijing Wantai Biological Pharmacy Coagulation function (1 to 5 items) Coagulation function (PT, APTT, FIB, TT, and D-dimer) Sysmex CA-1500 (Sysmex, Japan) Sysmex CS-2000i (Sysmex, Japan)

Figure 1. Emergency laboratory test workflow before IT-based optimization.

Existing problems

(1) The instruments were outdated since most of them were purchased during the relocation of our hospital in 2013. Since a majority of the instruments were not equipped with two-way communication, it was necessary to enter the test items and record the test results manually in some instruments. (2) The specimen’s name could only be entered by manual code scanning, which amplified the workload and increased the likelihood of missing entries or incorrect set entries. (3) There were no relevant prompts throughout the whole process and no relevant tracking function for adverse events such as sample omission or timeout. (4) The items with critical values were reported by manual telephone notification or manual registration, which was time-consuming and also led to data entry errors (Table 2).

Table 2. Issues with emergency laboratory tests before IT-based optimization and corresponding solutions. Problems Solutions All specimens are manually entered into the corresponding category of the LIMS system, which increases the workload and may lead to incorrect categorization or missing entries. The LIMS system numbers for outpatient specimens are automatically generated during collection, while those for inpatient specimens are automatically generated on reception of the specimens. Therefore, the number of specimens is generated automatically, which reduces the workload of employees and prevents errors. The electrolyte (Na+, Cl−, and K+) test results are entered manually. After the instruments are updated, these test items are integrated into the biochemical test and two-way communication is realized. The biochemical, immune, and coagulation function test specimens are numbered manually before detection on the instrument. Also, these specimens are manually placed in their corresponding positions, which increases the workload and may result inhuman error. Upgraded instruments allow the implementation of IT methods that realise automated detection and two-way communication. During the manual identification of blood groups, the manual entry of results increases the workload and may cause human error. After the purchase of automated equipment, IT methods are employed to realize detection automation and two-way communication. The test items are relatively scattered and it is necessary to collect several specimen tubes to facilitate detection. The electrolyte (Na+, Cl−, and K+) test items are integrated into the biochemical test, and the HIV antigen and antibody test items are added to the immune test to replace the human immunodeficiency virus (HIV1 + 2) antibody test item. One tube of specimens is collected for the biochemical test to reduce the number of blood collection tubes. The items with critical values are reported by manual telephone notification and manual registration. The information system is optimized to generate critical value system report notifications and achieve constant monitoring. If the recipient fails to accept the notification within the specified time, an alarm prompt is sent to the target computer. Manual notification by telephone is performed if the recipient fails to accept it within five minutes of the alarm prompt display. There is no prompt function for the timeout of a specimen report. This real-time laboratory specimen monitoring system displays the specimen report with a timeout on the screen. Specimen reports with timeouts are highlighted and signaled with an alarm. The layout in the laboratory is inappropriate and the placement of computers and equipment is not conducive to operation. Based on the layout of higher-level hospitals, all employees in the department formulate feasible schemes according to the actual situation in this department. The layout of the laboratory is redesigned scientifically to facilitate operations. The ABO blood group identification is performed manually and there is no reverse grouping. The Hamilton automatic blood group identification instrument increases the reverse grouping function and realises automatic detection. This reduces manual operation and ensures rapid and accurate blood group identification. Invalid symbols such as “-”, “*”, and “0” are sent to the LIMS system in case of uncertain or undetected test results. The laboratory test report can be reviewed but there is no relevant prompt. The LIMS system is optimized. If there is an invalid symbol in the laboratory test report, a prompt is displayed during the report review and the review is performed after revisions.

Identification of problems in clinical practice and relevant optimizations

(1) Update equipment: The problems associated with instrument operation were dealt with. Some instruments were equipped with two-way communication with the aid of the manufacturer and the LIMS system engineer. Additionally, some new instruments were purchased to replace the existing ones, and all new instruments were equipped with two-way communication during installation. After automation and information integration of the equipment across the whole process was realized, manual numbering, manual entry of test items, and secondary entry of test results during instrument operation were eliminated. Meanwhile, various errors caused by manual operation were also resolved, thereby improving working efficiency and laboratory test quality.

(2) Set up relevant prompt functions: According to the actual situation in the department, real-time specimen monitoring software was created to display upcoming timeout items (within five minutes) and timeout items (sound alarm) with the aid of a display screen and audio installed in a conspicuous position.

(3) Automatic reports of the items with critical values and monitoring of the whole process: After the critical value report system was optimized, inspectors rechecked the test results in cases with prompts on items with critical values. After the test results were checked, they were manually entered into the LIMS system and sent to the prescriber. If the recipient failed to accept the notification within the specified time, an alarm prompt was sent to the target computer. Manual notification by telephone was performed if the recipient failed to accept the notification within five minutes of the alarm prompt. These measures eliminated human error and timeouts in the manual reporting of items with critical values.

(4) IT-based optimization: The laboratory test items were optimized according to clinical practice. The blood collection tubes were integrated to reduce the volume of blood taken from patients and improve test efficiency. Additionally, problems encountered during daily operations were optimized individually, thereby contributing to user-friendly operation and close connection to the LIMS system (Table 2). The related process is presented in Fig. 2.

Figure 2. Emergency laboratory test workflow after IT-based optimization.

Observation indicators

In this study, relevant evaluation indicators were compared before and after optimization:

• Laboratory test report time (outpatients) = Time when the test result is reported - Time when the specimen is collected
• Laboratory test report time (inpatients) = Time when the test result is reported - Time when the specimen is accepted
• Laboratory test report time limit coincidence rate = Number of laboratory test reports within the specified time limit/Total number of laboratory test reports × 100%
• Laboratory test report error rate = Number of laboratory test reports with errors / Total number of laboratory test reports × 100%

Additionally, an anonymous satisfaction survey was performed on all employees involved in the emergency laboratory test process. The Management System of Quality Monitoring Indicators of Medical Community was developed in accordance with the standards outlined in the Joint Commission International Accreditation Standards for Hospitals (6th Edition). [15] Subsequently, 128 patients were randomly selected each month for the satisfaction survey. Satisfaction was evaluates as such:

• Satisfaction = Number of patients that are very satisfied or satisfied / Total number of patients in the satisfaction survey × 100%

Statistical analysis

Data processing was performed using SPSS 26.0, and the Kolmogorov-Smimov normality test was used to analyze the data distribution. The two-sample independent t-test was performed to make comparisons between both groups. Normally distributed measurement data were expressed using x̄ ± s, while non-normally distributed measurement data were expressed using M (IQR). Moreover, the rank sum test was used for comparisons between groups that did not conform to normal distribution, and the chi-square test was performed on the comparison of rates. P < 0.05 indicated that there was a significant statistical difference.

Results

Changes in the emergency laboratory test report time before and after IT-based optimization

After IT-based optimization was implemented, the median emergency laboratory test report time in each month from January to September 2022 was shorter than in the corresponding months from January to September 2021 (i.e., January 2022 vs. January 2021), with statistically significant differences. After IT-based optimization, the overall emergency laboratory test report time was also shorter than before optimization, and the difference between the groups was significant (P < 0.05), as indicated by Table 3.

Table 3. Comparison of laboratory test report times before and after IT-based optimization. Note: There were 13 test items before IT-based optimization and 12 test items after optimization. Month 2021 (before optimization) 2022 (after optimization) Z P Number of items Report time M (IQR) (minutes) Number of items Report time M (IQR) (minutes) January 23,936 28 (22) 26,384 25 (24) -19.139 < 0.001 February 18,411 27 (22) 17,598 24 (24) -11.516 < 0.001 March 26,436 29 (23) 25,592 26 (26) -16.288 < 0.001 April 20,448 28 (23) 28,012 25 (24) -20.460 < 0.001 May 21,366 29 (23) 30,929 25 (25) -28.326 < 0.001 June 26,533 31 (24) 32,894 27 (25) -33.300 < 0.001 July 34,820 30 (23) 32,699 26 (24) -21.733 < 0.001 August 26,562 32 (24) 33,126 27 (26) -39.652 < 0.001 September 23,627 30 (25) 32,417 26 (24) -38.696 < 0.001 Total 222,139 30 (24) 259,651 25 (25) -32.153 < 0.001

Notes

This presentation is faithful to the original, with only a few minor changes to presentation. In some cases important information was missing from the references, and that information was added.