STAT is from the Latin word statim, which means immediately or without delay. Every service requests STAT testing, usually accompanied by a strong case on how getting results sooner will improve patient care. We need our intraoperative parathyroid hormone results in 15 minutes.
Why does it take so long to get neonatal glucose results? If the laboratory provided results faster, I could discharge my patients expeditiously. A STAT troponin assay will enable us to rule out myocardial injury in 2 hours. When will you have a rapid respiratory panel, so we can improve bed management? Why are hemoglobin A1c results not available for my patients during their outpatient visits?
In my opinion, these are all reasonable appeals. However, without infinite resources, laboratories can’t accommodate every STAT request.
Expectations and goals for STAT testing must be realistic. At one point 40% of the specimens here at Brigham and Women’s Hospital in Boston arrived STAT, which negated the value of STAT. Savvy providers, frustrated with the turnaround time for STAT labs, wrote “super STAT” on or hand delivered specimens. We clearly needed a better system.
Finding Better Approaches
What are the best ways to tackle this confounding STAT issue with its potentially significant impact on patient care played out in an arena fraught with clinical egos (my patients and time are more important than yours)?
One strategy is to optimize pre-analytical inputs for STAT testing, namely specimen collection and processing, which tend to be more variable and more easily modifiable than analytical and post-analytical steps. First, a laboratory might define the percentage of STAT specimens it can handle effectively and then determine which tests/specimens—out of the thousands that arrive daily—should be STAT.
At many institutions phlebotomists collect specimens. How should phlebotomy rounds be organized? Despite clinicians’ unrealistic hopes, phlebotomists can’t draw all patients simultaneously. At Brigham and Women’s we used to prioritize patients on our hematology/oncology floors, with all available phlebotomists deployed first to these floors. An hour or more later, they would travel to the remaining inpatient floors.
To develop a more equitable STAT process, laboratory leadership met with clinical leadership, primarily nurse directors, and revised the rounding schedule in consideration of our resource constraints. We created assignments and established priorities within those assignments, with a goal of collecting STAT specimens within 30 minutes. This change disappointed the hematology/oncology department, but most other services had results earlier for their critical patients.
Once collections are prioritized, there should be a strategy for triaging specimens when they arrive in the laboratory. Meeting with clinical leadership such as the medical executive committee may help define a specimen triage protocol and obtain buy-in from key stakeholders.
At our institution, code specimens with their special bright orange requisitions are our first priority. Other priority areas have color-bordered specimen labels. Operating room and blood gas specimens are priority two, while priority three encompasses the emergency department, procedural areas like the catheterization lab, and baby microtainers. Our intensive care units lobbied hard for color-bordered labels, but we had to draw the line somewhere and keep STAT testing to a manageable volume. We don’t de-prioritize any locations or tests but rather work with administration—sometimes unsuccessfully—to ensure we have adequate staff to process specimens and optimal infrastructure to expedite processing.
Setting Realistic Goals
Another strategy for managing STAT requests is to address them case by case. This typically involves multi-disciplinary meetings analyzing current procedures, confirming clinical impact, and discussing realistic goals.
Why are results needed urgently and how do they affect patient care? Can we improve the current process? What resources will be required? Will there be cost savings? Does technology exist to support the STAT request? How are other hospitals handling this type of testing? How will we measure success (or failure)?
Labs can avoid preferential treatment of certain providers or locations by defining a policy for decision-making about and approval of STAT requests.
Based on discussions at our institution we have made some changes and exceptions to our STAT processes. For a limited number of tests like troponin, we default the orders to STAT in our electronic health record. In some cases, we implemented point-of-care testing (POCT) because POCT arose as the best solution to barriers identified in our meetings, such as the need for intraoperative blood gas results. We also tried to optimize central laboratory procedures only to fall short of our goals at times, thereafter implementing POCT, as in the case of creatinine results in radiology.
Another strategy involves decompressing central laboratory test volume to allow additional STAT requests or improve existing STAT testing. Lucky labs might successfully change the culture around laboratory test ordering, something we’re still working on. Eliminating daily laboratory orders should reduce test volume and enable both phlebotomy and the laboratory to focus on more urgent specimens. Implementing robust duplicate checking logic, which will probably require information technology support, also may help to reduce unnecessary testing.
In summary, several strategies have helped us manage our ever burgeoning STAT testing volume. These include collaborating with clinical colleagues while following a standard protocol, defining and continuously monitoring goals, and accepting that we won’t achieve these goals 100% of the time. Finally, we found that sharing our metrics with clinicians increases transparency and underscores our hard work and successes.
Stacy E.F. Melanson, MD, PhD, is associate director of clinical laboratories, co-director of chemistry, and medical director of phlebotomy at Brigham and Women’s Hospital in Boston and an associate professor of pathology at Harvard Medical School. +Email: [email protected]