Clinical Biochemistry 48 (2015) 308–312

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Decreasing troponin turnaround time in the emergency department using the central laboratory: A process improvement study Arlene M. Boelstler a, Ralph Rowland b, Jennifer Theoret a, Robert B. Takla a,c, Susan Szpunar d, Shraddha P. Patel a, Andrew M. Lowry a, Margarita E. Pena a,c,⁎ a

St. John Hospital and Medical Center, Department of Emergency Medicine, 22101 Moross Road, Detroit MI 48236, USA St. John Hospital and Medical Center, Department of Laboratory Services, 22101 Moross Road, Detroit MI 48236, USA Wayne State University School of Medicine, 540 E Canfield Street, Detroit, MI 48201, USA d St. John Hospital and Medical Center, Dept. of Medical Education, Detroit MI 48236, USA b c

a r t i c l e

i n f o

Article history: Received 7 June 2014 Received in revised form 19 October 2014 Accepted 28 October 2014 Available online 7 November 2014 Keywords: Troponin Turnaround time Emergency department Central laboratory Process improvement

a b s t r a c t Objectives: To implement collaborative process improvement measures to reduce emergency department (ED) troponin turnaround time (TAT) to less than 60 min using central laboratory. Design and methods: This was an observational, retrospective data study. A multidisciplinary team from the ED and laboratory identified opportunities and developed a new workflow model. Process changes were implemented in ED patient triage, staffing, lab collection and processing. Data collected included TAT of door-to-order, order-to-collect, collect-to-received, received-to-result, door-to-result, ED length of stay, and hemolysis rate before (January–August, 2011) and after (September 2011–June 2013) process improvement. Results: After process improvement and implementation of the new workflow model, decreased median TAT (in min) was seen in door-to-order (54 [IQR43] vs. 11 [IQR20]), order-to-collect (15 [IQR 23] vs. 10 [IQR12]), collect-to-received (6 [IQR8] vs. 5 [IQR5]), received-to-result (30 [IQR12] vs. 24 [IQR11]), and overall door-toresult (117 [IQR60] vs. 60 [IQR40]). A troponin TAT of b 60 min was realized beginning in May 2012 (59 [IQR39]). Hemolysis rates decreased (14.63 ± 0.74 vs. 3.36 ± 1.99, p b 0.0001), as did ED length of stay (5.87 ± 2.73 h vs. 5.15 ± 2.34 h, p b 0.0001). Conclusion Troponin TAT of b60 min using a central laboratory was achieved with collaboration between the ED and the laboratory; additional findings include a decreased ED length of stay. © 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Introduction Heart disease is a critical condition that caused nearly 25% of all deaths in the United States in 2008, and each year nearly 785,000 Americans have their first coronary attack [1–3]. Last year over 130 million patients visited the ED [4], with chest pain comprising the second most common complaint [5,6]. Early diagnosis and medical management of patients with acute coronary syndrome (ACS) improves both diagnostic and clinical outcomes in patients presenting to the emergency department (ED) with a complaint of chest pain [7–9]. Cardiac biomarkers are a primary tool to diagnose and stratify risk in patients with chest pain and suspected ACS [8,10]. In particular, cardiac troponin (cTn) has become the

⁎ Corresponding author at: St. John Hospital and Medical Center, Department of Emergency Medicine, 22101 Moross Road, Detroit, MI 48236. Fax. (313) 343-7620. E-mail addresses: [email protected] (A.M. Boelstler), [email protected] (R. Rowland), [email protected] (J. Theoret), [email protected] (R.B. Takla), [email protected] (S. Szpunar), [email protected] (S.P. Patel), [email protected] (A.M. Lowry), [email protected] (M.E. Pena).

biomarker of choice in recognizing patients with ACS and is considered central to the definition of acute myocardial infarction [10–13]. Both physician and laboratory societies recommend a turnaround time (TAT) of b60 min for early detection of ACS [5,14–16] This recommendation, however, is largely not being met [17]. Several studies have suggested that implementation of rapid point-of-care (POC) cardiac biomarker testing may enhance both the clinical and operational efficiency of the ED [18,19]. While point-of-care testing has been proven to reduce the time for test results and medical decision-making, it may be more unreliable, have greater variability, and be more expensive compared to a central laboratory [20,21]. In our ED, utilization review data revealed that our door-to-result troponin time was over 2 h. Consideration was given to obtaining point-of-care testing to help meet the guideline recommendations, however, we decided instead to detail and analyze the workflow process from ED patient arrival to result to see if we could achieve the b60 min TAT goal using current central laboratory. In this way, we could identify which steps were causing the greatest time delays and which steps would benefit from streamlining. The objective of this quality improvement project was to demonstrate how implementation of effective process improvements and

http://dx.doi.org/10.1016/j.clinbiochem.2014.10.014 0009-9120/© 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

A.M. Boelstler et al. / Clinical Biochemistry 48 (2015) 308–312

collaboration between the ED and central lab can reduce the troponin door to result time to less than 60 min without the use of POC testing. Methods This was a quality improvement project conducted in an urban teaching hospital with an annual volume of 115,000 ED visits. Project evaluation was done using retrospective lab data collection and chart review. This project was reviewed by the St. John Hospital and Medical Center Institutional Review Board and considered exempt. The goal of the project was to reduce troponin door to result TAT to less than 60 min in adult patients presenting to the ED requiring biomarker evaluation for possible acute coronary syndrome. Process improvement measures were implemented in August and September 2011. Data were collected from the time period between January 2011 and June 2013. Critical to the project was the creation of a Chest Pain Team (CP Team) consisting of the Chest Pain Coordinator/ED manager, ED Observation Unit Medical Director, ED staff, central laboratory management, and phlebotomy personnel. Members of this multidisciplinary CP Team met weekly, at first, to discuss opportunities and solutions for each step, then monthly to discuss the progress of the process improvement measures implemented. Using a shared governance model, ED nurse volunteers were asked to look at the flow of the ACS patient and identify an area of opportunity. The long TAT of cardiac biomarker results and high hemolysis rates resulting in lab redraws were identified as processes that needed improvement in order to identify ACS patients earlier and within the recommended 60 min. Multi-disciplinary education of the importance of early recognition, treatment and appropriate disposition of ACS was also identified as necessary for process improvement. Four steps in the process from door to troponin result were identified: door-to-order (step 1), order-to-collect (step 2), collect-toreceived (step 3), and received-to-result (step 4). Times were extracted from the hospital laboratory information system and our clinical documentation computer system. Door-to-order was defined as the time the patient presented to the ED front desk to the time the troponin order was placed in the computer. Collect time was the time the blood was drawn, received time was the time the lab received the tube of blood, and result time was the time the troponin result was entered in the computer. A time of 15 min for each step was decided upon so that the total door to troponin TAT would equal 60 min. Hemolysis rate data was reported monthly by lab. Each of the four steps in the process from door to troponin including door-to-result and the hemolysis rate was recorded on a scorecard to identify the most significant time delays and where opportunities for improvement may exist. Individual level data were collected for each of the four steps and total troponin TAT, i.e. door-to-result for the entire study period. The non-parametric Mann Whitney U test was used to determine median and interquartile ranges. Individual level data for ED length of stay was also collected; the t-test was used to determine the means. Monthly aggregate data of ED volume and ED boarder hours were compared before and after process improvement to evaluate for confounding factors. The t-test was used to determine means for ED volume, ED boarder hours, and hemolysis rate. A 2-tailed probability of less than 5% was used for statistical significance. Step 1 or door-to-order was first addressed. A new process of an ED triage nurse-initiated cardiac panel blood draw protocol was proposed and drafted by nursing. In this new process, the triage nurse determined if a patient with chest pain required a cardiac panel blood draw and ordered these labs in triage. The patient therefore had labs drawn in ED triage while also undergoing ECG testing. The cardiac panel consisted of a complete blood count, basic metabolic panel, CK/CK-MB and cTnT. Coagulation studies were added if the patient was on anticoagulant therapy. The process prior to process improvement involved the patient being taken from triage to their ED room. Then, the physician would see

309

and evaluate the patient before the cardiac panel was ordered electronically in the patient electronic medical record. The new process would involve bypassing these two steps and empowering the ED triage nurse to order the cardiac panel in the patient electronic medical record. This process was first piloted to ensure ED physician buy-in to the change in process of nurse-initiated orders. Triage guidelines for cardiac panel blood draws that included signs and symptoms consistent with possible ACS were included on a separate sheet of paper kept in ED triage. If the triage nurse decided that a cardiac panel was indicated, any criteria the patient met would be checked off and the paper attached onto the patient's chart. This checklist also served as an educational tool for nursing of ACS recognition. After the patient was placed in an ED bed and evaluated by the ED physician, the ED physician would check off if the blood draw was or was not appropriate for that patient. All papers were collected at the end of each day. After three weeks, it was noted that only 4 sheets returned with the box for ‘blood draw not appropriate’ checked off. This information was brought to the ED chief and physicians who approved it for regular practice. These guidelines were incorporated into advanced patient care guidelines for nurseinitiated cardiac panel draws to be used by the ED nurses if a patient arrived by ambulance and was placed in an ED bed. In order to address step 2 order-to-collect, it was decided that a phlebotomist would be stationed in triage to do the initial cardiac panel blood draw. In the original process, after the nurse received the physician order for a cardiac panel draw, the nurse would draw the blood from the IV catheter immediately after placing the IV such that the patient would therefore only require one venipuncture. In the new process, the patient would have two venipunctures, one for the initial blood draw at triage and then another when the nurse placed an IV after the patient was placed in an ED bed. (See Fig. 1 for a graphical summary of steps 1 and 2.) The separate blood draw could have the benefit of decreasing the hemolysis rate, thus decreasing the number of repeated blood draws and positively impacting TAT. In step 3 collect-to-received, pre-process improvement laboratory CK/CK-MB and troponin testing were performed on gel tubes (gold top, no anticoagulant). Once collected, an extra 10 min is required to allow for clotting prior to centrifugation. The new process involved replacing the gel tubes with mint green tubes (lithium heparin anticoagulant tubes) which can be spun immediately upon receipt in the

Fig. 1. Flow diagram of door-to-collect before and after process improvement.

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laboratory thereby reducing troponin TAT by at least 10 min. These blood tubes have labels with a green stripe that are unique to the ED (i.e. other non-ED mint green tubes do not have a label with a green stripe), and therefore easily recognized and identified by lab as ED specimens. In addition to these changes, other non-clinical process improvement measures included having a label maker for requisitions, and reconfiguring the triage room space to accommodate an ED nurse, ED tech and phlebotomist. All blood tubes drawn in ED triage are placed in a tube system located less than 10 feet from the ED triage rooms. In Jan of 2012, two process changes occurred. The first was a collaborative decision with Cardiology to eliminate CK/CK-MB and the second was central laboratory renovation due to flooding, assisting to improve step 4, received-to-result. The renovation was made with a focus to expedite ED lab and specifically troponin TAT. The footprint for this lab space was consciously kept small so everything was easily accessible. Central laboratory personnel were stationed next to the tube system for immediate tube collection. The tube system was placed less than 10 feet from the centrifuge and analyzers, and a computer for input of results into the EMR was placed adjacent to the analyzers. The troponin assay used during this time period was the Roche 4th generation cTnT with a lower limit of detection of 0.01 mcg/L, and a 10% coefficient of variation of 0.03 mcg/L. The analyzer used was the Roche e170 with an analysis time for cTnT of 18 min which then decreased to 9 min beginning in January 2012 when the Cobas e601 stat Troponin –T method was implemented. Multidisciplinary ACS education to all members of the three departments represented on the CP Team that would be involved in this new workflow were given in the form of lectures and department meeting presentations of key messages developed by the CP Team. The key messages highlighted the importance of reducing troponin TAT in ED patients with possible ACS symptoms and the impact on decreasing time to diagnosis, treatment and ensuring appropriate disposition. Results The mean monthly number of electronically reported troponin tests performed during the eight months pre-process improvement was lower than during the twenty-two months post-process improvement (1324.13 +/- 100.444 vs. 1466.32 +/−118.149, p b 0.005). After process improvement and implementation of the new workflow model, overall TAT decreased for door-to-order, order-to-collect, collect-toreceived, received-to-result, and overall door-to-result. See Table 1. Hemolysis rates also decreased, as did overall ED length of stay. See Table 2. Mean ED volume was similar both pre- and post-process improvement, however ED boarder hours were higher during the post-process improvement period. Troponin TAT data by month shows that a TAT of less than 60 min was realized beginning in May 2012. See Table 3 and Fig. 2. Discussion Multidisciplinary collaboration and teamwork between the ED and laboratory were central to the success of reducing troponin TAT

Table 2 Emergency department length of stay, hemolysis rate, monthly ED volume and boarder hour data before and after process improvement. Metric

TAT prior to PI Mean (min)

TAT after PI Mean (min)

p-value

ED Length of stay (h) Hemolysis rate (%) Monthly ED Volume Monthly ED Boarder hours

5.87 ± 2.73 14.63 ± 0.74 9771.50 438.13

5.15 ± 2.34 3.36 ± 1.99 9871.14 891.09

b0.0001 b0.0001 0.502 0.010

(TAT = turnaround time; PI = process improvement; ED = emergency department)

to b 60 min using central lab vs. POC testing in the ED. During each step of the project, members representing the ED and lab had to rethink the silo work while trying to accomplish improvement in each of their respective areas, and work collectively to address each step. See Table 4 for a summary of the collaborative solutions to each step. The largest improvement in TAT was in step 1 after the triage protocol was initiated See Table 1 and Fig. 2. Clearly the ED nurse-initiated triage protocol and blood draw by phlebotomy in triage is an effective process to decrease overall troponin TAT. The number of troponins ordered increased after process improvement but did not impact TAT. A possible explanation for the increase in the number of troponins ordered may be that there was a heightened awareness and suspicion for ACS due to educational efforts. Since ED volume was similar before and after, this did not seem to be a confounding factor impacting troponin TAT. ED boarder hours were higher post-process improvement. However, as ED LOS for troponin patients was less post-process improvement, it seems that boarder hours also did not have an impact on troponin TAT. The hemolysis rate significantly decreased post-process improvement from 15% to 3%. In drawing blood for troponins via an IV start, there may be an increased risk of hemolysis thus requiring a redraw and a further delay in the patient's results both of which are likely to be patient dissatisfiers. The separate venipuncture seems to have the benefit of decreasing the hemolysis rate, thus decreasing the number of repeated blood draws and positively impacting TAT. There is likely to be a positive impact on TAT with a lower hemolysis rate because the TAT for received-to-result includes the time required for redraw since the result time is the time when a troponin value is placed in the computer. Hemolyzed specimens have no troponin value reported in the computer; instead it is reported with an asterisks and ‘specimen hemolyzed’ in the result column. The repeat valid result is placed in a new column with the new result time that marks when the clock stops for the troponin TAT. As a side note, our ED nursing staff has not reported any patient dissatisfaction with the separate venipunctures. Reconfiguration of the central laboratory space into a smaller footprint where troponins were collected, analyzed and results placed into the electronic medical record increased efficiency and contributed to decreasing step 4, received-to-result. At the beginning of the project, POC testing was discussed by the CP team as an option to decrease troponin TAT. Some of the factors that

Table 1 Troponin turnaround time data before and after process improvement. TAT metric

TAT prior to PI Median (min) (IQR)

TAT after PI Median (min) (IQR)

Door-to-order (min) Order-to-collect (min) Collect-to-received (Min) Received-to-result (min) Door-to-result (min)

54 (43) 15 (23) 6 (8) 30 (12) 117 (60)

11 (20) 10 (12) 5 (5) 24 (11) 60 (40)

(TAT = turnaround time; PI = process improvement; IQR = Interquartile range).

A.M. Boelstler et al. / Clinical Biochemistry 48 (2015) 308–312 Table 3 Monthly median (interquartile range) troponin turnaround time data.

2011

2012

2013

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

127

124

124

116

106

122

107

107

66

60

68

72

(65)

(61)

(63)

(49)

(48)

(76)

(60)

(63)

(47)

(36)

(43)

(45)

68

67

65

60

59

57

58

60.5

62

60

51

51

(48)

(48)

(44)

(45)

(39)

(38)

(33)

(38)

(37)

(36)

(31)

(32)

53

49

54

59

55

56.5

(32)

(21)

(39)

(42)

(42)

(38)

Numbers in red = Pre-process improvement. Numbers in blue = Post-process improvement.

required consideration for operationalizing POC included equipment purchase, testing, and maintenance; monitoring of quality; number of personnel required; training and proficiency testing of personnel, accreditation and regulatory requirements; and integration of results into a central accessible computer laboratory information system and then into the electronic medical record. In the 4-step process, POC testing would address step 3 and possibly step 4. Looking at our pre-process improvement times, it was obvious that steps 1 and 2 had almost twice the turnaround time compared with steps 3 and 4 (69 min vs. 36 min) and therefore it was here that our efforts should start. A brief literature search of studies where POC was implemented demonstrates receivedto-result times of 14.8 to 17 min [22,23]. The less than 10 min difference between our received-to-result time post-process improvement compared with the published POC times mentioned above did not to us justify the added expense or outweigh our other concerns of POC testing. Furthermore, our findings are in line with other randomized controlled trials of POC vs. central lab that note the importance and impact on outcomes of workflow models [24–26]. In the study by Bradburn et al

311

investigating hospital variation in the RATPAC (Randomized Assessment of Treatment using Panel Assay of Cardiac markers) study, what they found was that outcomes and cost-effectiveness were dependent on the setting where POC was used, protocols in use, existing guidelines and standards, and the attitudes of staff to new technologies [24]. It has been stated that the impact of POC testing on ED bed availability is dependent on optimizing brain-to-brain time, which is divided into three components: pre-analytic time (physician order to test analysis), analytic time, and post-analytic time (test result to physician interpretation) [26]. However, it can be argued that ED bed availability is also dependent on time from ED patient arrival to time of physician order as patients are frequently placed in an ED bed for various lengths of time before physician evaluation and subsequent orders placed. In this study, the step that contributed most to overall pre-process improvement troponin TAT but also had the greatest improvement was doorto-order. We did find this translated to a decrease in ED LOS. Perhaps this is why other studies that did not address the door-to-order step were able to demonstrate a decreased draw-to-result troponin TAT using POC vs. central lab but did find it decreased the ED LOS [26]. Furthermore, our mean decrease in ED LOS of 43 min is similar to the 47 min decreased ED LOS seen with POC testing of cardiac biomarkers [26]. The CP team was committed to adherence of best, evidence-based practice. Guidelines and recommendations by the American Heart Association, the American College of Cardiology, and the Society of Cardiovascular Patient Care (SCPC) were discussed and incorporated into the process improvement measures [5,11,14,27]. Specifically, the triage guidelines used by nursing during the pilot and thereafter followed ACC/AHA recommendations [21]. Process improvement suggestions concerning biomarker TAT from the Society of Cardiovascular Patient Care chest pain center accreditation tool that promotes multidisciplinary collaboration was used as an overall guide. Chest pain center accreditation has been shown to be associated with better Centers for

Fig. 2. Graph of monthly median troponin turnaround time data.

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Table 4 Summary of collaborative solutions before and after process improvement. Pre-Process improvement

Post-Process Improvement

Door-to-order (Step 1) Patient taken back to an ED bed after triage; troponin order placed after the physician evaluates the patient Order-to-collect (Step 2) ED nurse receives a physician order for troponin; blood is drawn from the IV catheter

Door-to-order (Step 1) ED triage nurse-initiated cardiac panel blood draw protocol Order-to-collect (Step 2) Phlebotomist stationed in ED triage to do separate (from IV catheter draw) venipuncture for the cardiac panel ED triage room reconfigured to accommodate phlebotomist Label maker and printer added to ED triage room Collect-to-received (Step 3) Mint green top tubes can be centrifuged immediately ED tube system and central lab tube system adjacent to personnel Centrifuge and analyzers situated few steps from tube system Received-to-result (Step 4) Central lab space for ED specimens and analyzers reconfigured to a smaller footprint New faster analyzer

ED nurse has to collect all the equipment to start an IV prior to the troponin draw Label maker is at the nurses station with all the other labs that are ordered Collect-to-received (Step 3) Gold top tubes require 10 min prior to centrifugation ED tube system and central lab tube system not adjacent to personnel Centrifuge and analyzers situated over 20 feet from the tube system Received-to-result (Step 4) ED specimens analyzed in the same central lab area as non-ED specimens Older analyzer (ED = emergency department; IV = intravenous).

Medicare and Medicaid Services core measures for acute myocardial infarction [28]. Conclusion A troponin TAT of b 60 min used in the evaluation of ED patients with possible ACS was achieved using central laboratory and creation of a new workflow model that involved collaboration between the ED and laboratory. This required regular meetings and collective brainstorming by the CP Team for solutions to challenges, ACS education to all three departments, and development of key messages for all staff members of each department involved in the new workflow process with emphasis on the clinical importance of decreasing troponin TAT in a patient with possible ACS.

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