In the aspect of working process reengineering, when the ER physician issues a laboratory order at the computer terminal, the nearby phlebotomy station will print out the laboratory order sheet, which the station uses to prepare the test tubes needed, and adheres the paired number labels to the corresponding test tube and laboratory order sheet for identification. Upon completing specimen collection, the specimen and the laboratory order sheet are sent to the laboratory together. It takes about 20 seconds through the pneumatic delivery network, and alert is sounded at arrival. In synchronization with the bar-coding required for process automation, the laboratory must first produce specimen serial number bar-code and number sticker for the test tube and the laboratory order sheet respectively, then input the serial number on the requisition form for one to many laboratory order sheets and new specimen serial number, and concurrently complete the receipt procedure and pairing of test item and specimen.
Thereafter follows the preliminary works for centrifugal processing before placing in auto analyzer.
The results therefore shall be verified by the laboratory technicians prior to input into the computer as the final laboratory report for access.
This completes the entire flow; the particular attributes of the reengineered process are as follows:
l Unify the identification system
Program the software to enable the phlebotomy station’s computer to automatically incorporate the laboratory order requested according to the unit of test tubes required in producing specimen serial number and printing out labels
90 containing bar-code to be adhered to the test tubes.
This allows the station personnel, the laboratory technicians and the laboratory devices to uniformly identify the specimen by the specimen serial number.
Other than saving the laboratory technicians the step of placing another bar-code for machine identification, this function yields the benefit of bar-code scanning to complete the auto receipt procedure.
Figure 1
l Integrate the laboratory order sheet and bar-code label
Further integrate the laboratory order sheet’s data onto the bar-code label to produce a man and machine readable “bar-code laboratory order sticker”
(per Figure 1). The data on the “bar-code laboratory order sticker” shall include the specimen serial number for machine identification and scanning for receipt, together with text descriptions of patient related data such as bed number, name, chart number, triage, and specimen related data such as time laboratory order requested, specimen variety, required specimen volume, test tube type, delivery destination and test items. All personnel involved shall can clearly see the laboratory order data timely on the test tube, timely scan for laboratory receipt that effectively precludes mis-matching of laboratory order sheet and specimen out of human negligence.
Figure 2 Bar-Code Laboratory Order Sticker
l Auto update of test items
Furthermore, integrate the HIS (Hospital Information System) and LIS (Laboratory
Information System) so that when the physician execute add or delete laboratory tests, the software will automatically update the current status of the laboratory tests as “Not Executed” or “Executing”.
With this function integration, there is no need to produce new bar-code sticker which saves phone correspondence and manual correction and minimizes delay and error.
l Real -time monitoring and alert
On the computer terminals at the phlebotomy station and the laboratory, provide a listing of the various units’ work agenda in prioritized order. From the listing and the alert message, the personnel can stay constantly updated, and discover, eliminate any possible error in the flow.
Laboratory Triage by Prioritized Multi-Level
Queue
l Inherited from emergency triage
Emergency triage is a process that predicates the order patients receive immediate medical treatment based on the severity of patient conditions.
The process enables acute cases to receive timely proper treatment in reducing disability and mortality rates while increasing the efficacy of emergency medicine. Aligned with the logic, the initial classification of laboratory orders inherits that of emergency triage and scheduled by prioritized multi-level queue.
l Reprioritized by aging and incident
Each level is set with an “upgrade waiting time”; once exceed this time frame, the order is automatically upgraded by one level to prevent perpetual delay due to repeated queue cutting of higher levels.
To reflect the actual needs, the prioritized management mechanism shall can timely modify according to changes of patient condition and treatment handling, e.g.: when a patient takes a worse turn and is transferred to resuscitation room; when takes a better turn and is kept under watch; or for invasive treatment or examination, the computer will automatically change the priority level of the original laboratory order. Table 2 lists the incidents and the corresponding priority levels that will change the priority level of a laboratory order. If the time
validity of an incident is sustaining, such as resuscitation room bed number or observation bed number, the change of priority level holds. If the time validity of an incident is temporary, such as laboratory tests required before invasive treatment or examination, or resampling, the priority level of the laboratory order is changed only temporarily.
Table 1. Incidents that will change priority level
Incident Time
Validity
New Level For Resuscitation Room
Bed No.
Sustaining Level 1 For Observation Bed
No.
Sustaining Level 4 For Invasive Treatment
or Exam
Temporary Level 2 Resampling Temporary Level 1
Result
The new flow provides greater automated operation as well as work sequencing list and alert function to reduce the turnaround time; it also curtails the outlier range and ratio to enhance the overall quality of emergency laboratory process. This in turn mitigates the emergency personnel’s work stress and cuts short the patient’s observation time.
This study proposes a working process controlled by prioritization based on case severity to accord greater quality protection in the laboratory process to more severe cases. The prioritized management mechanism can modify timely according to changes of patient condition and treatment handling for more expedient diagnosis and proper treatment.
Table 2. Comparison of Original, New Prioritization Mechanism
The numerals 1, 2, 3, 4 denote the priority levels. On the left is the sequence of laboratory orders organized according to time of request; on the right is the sequence of laboratory process. The original flow is based on the principle of first-in first-out. The new flow adopts a prioritized
multi-level queue as its management mechanism that distinguishes laboratory orders into four levels in priority: Level 1 will be processed first, followed by Level 2, 3 and 4 respectively.
Additionally, the emergency triage is further extended to the second-line medical units outside the emergency medicine, so that despite the unpredictability of peak traffic time and length, valuable medical resources can be allocated to the most needed patients, and thus deters the deficiency of first-in first-out practice.
Discussion
Notwithstanding the new system being able to provide real-time precision error detection, alert function and suggest prioritized order of patient treatment, the emergency room and the laboratory should still carry out periodical analysis and compile statistics of overload occurrence, level upgrade frequency and period, analyse and review cause of error, and adopt appropriate solution such as allocating manpower or work description, update equipment and laboratory instruments, or consider extending the “upgrade waiting time”, etc. to ensure smooth processing flow. It is only through sustained monitoring, analysing of the flow to make concrete, effective improvement can the quality of emergency laboratory process be assured.
Reference
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