STAT, ASAP, or Routine, what is your opinion?

[brians34]

I've worked in a medical laboratory for more than 30 years now. My supervisor has tasked me with a job of writing an article for our hospital newsletter on the importance of whether a lab test should be ordered as STAT, ASAP, or Routine.

I would like to get your opinions as to when a provider should order tests as STAT, ASAP, or Routine.

Should a provider order as they wish or should the provider use STAT or ASAP only in certain circumstances?

In our hospital, STAT turn-around-time is within 1 hour. ASAP orders are given a TAT of 2 hours.

If every provider ordered their tests as STAT or ASAP, there could be a backlog of tests with these order types causing delay for those times when these are really warranted.

So, I would like to get your opinions as to when you believe tests should be ordered as STAT or ASAP.

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[Doctor Bob]

Labs from the ER: always STAT
Labs from the ICU other than AM labs: always STAT
Admission labs to the floor: ASAP
AM labs for floor/ICU: Routine (but with the knowledge that the TAT should be standardized as the AM flood can be planned for)
Labs from a doc's office: Routine

 

[dozitgetchahi]

I've worked in a medical laboratory for more than 30 years now. My supervisor has tasked me with a job of writing an article for our hospital newsletter on the importance of whether a lab test should be ordered as STAT, ASAP, or Routine.

I would like to get your opinions as to when a provider should order tests as STAT, ASAP, or Routine.

Should a provider order as they wish or should the provider use STAT or ASAP only in certain circumstances?

In our hospital, STAT turn-around-time is within 1 hour. ASAP orders are given a TAT of 2 hours.

If every provider ordered their tests as STAT or ASAP, there could be a backlog of tests with these order types causing delay for those times when these are really warranted.

So, I would like to get your opinions as to when you believe tests should be ordered as STAT or ASAP.

I will respond with some questions: what's your turnaround time on 'routine' labs? When you say TATs are 1 hour and 2 hours for STAT and ASAP labs respectively, what fraction of your labs are actually completed within the appropriate timeframe?

In my experience, providers will start ordering everything STAT when the lab takes forever to get routine labs back (this is basically the only way to get inpatient lab results in an acceptable timeframe at our VA).

At our university and big community hospitals (same system), there is no such thing as 'ASAP' labs - it's all either STAT or routine.

 

[brians34]

I will respond with some questions: what's your turnaround time on 'routine' labs? When you say TATs are 1 hour and 2 hours for STAT and ASAP labs respectively, what fraction of your labs are actually completed within the appropriate timeframe?

We have a QM meeting each month and STATs make TAT > 95% of the time.

General chemistry, CBC, and coag tests are generally turned around within 2 hours of being ordered after collection, but STATs and ASAPs get put in front of all those that are ordered routine. STATs and ASAPs shouldn't be ordered just to get in front of all other testing, this affects other patients. STATs and ASAPs should only be used for those patients that need immediate attention. Patient's that aren't in any type of distress should be ordered as Routine and wait they're turn.

 

[link2swim06]

We have a QM meeting each month and STATs make TAT > 95% of the time.

General chemistry, CBC, and coag tests are generally turned around within 2 hours of being ordered after collection, but STATs and ASAPs get put in front of all those that are ordered routine. STATs and ASAPs shouldn't be ordered just to get in front of all other testing, this affects other patients. STATs and ASAPs should only be used for those patients that need immediate attention. Patient's that aren't in any type of distress should be ordered as Routine and wait they're turn.

That's not really the metric to use.

I order stat if I need the data now/soon. I am an ER resident therefore I need all of the data now, because they are going to occupy a bed until I can make a dispo. Which means the other 50 patients in the waiting room can't be evaluated because until I get those results back.

Super sick patients get POC labs at my hospital, so that helps. Even our stat labs take 20-60 minutes to come back.

What Doctor Bob said above was spot on.

 

[22031 Alum]

At the last hospital I worked at, nursing asked that we put in all lab orders 'STAT' as that was the only way the nurses could print labels themselves.As far as I know, it didn't actually affect lab processing time- orders placed as 'Routine' took longer, but that was because the labels had to be tubed to the floor from some central printer. That's a quality issue in and of itself I guess. We did have a "Super STAT" option for things that truly did need a rapid turnaround time.

Where I am now, the default is Routine.

 

[Siggy]

That's not really the metric to use.

I order stat if I need the data now/soon. I am an ER resident therefore I need all of the data now, because they are going to occupy a bed until I can make a dispo. Which means the other 50 patients in the waiting room can't be evaluated because until I get those results back.

Super sick patients get POC labs at my hospital, so that helps. Even our stat labs take 20-60 minutes to come back.

What Doctor Bob said above was spot on.

Outside of the ED, however, I agree with that definition. It bugs the hell out of me when I see other IM residents order stat CBCs and chem 7s because they forgot to order AM labs the night before and want the results back before rounding time.

At the same time, there needs to be a way for the inpatient teams to prioritize emergency lab and imaging before the ED. Sorry, your 3 "my belly slightly aches" stat abdomen CTs shouldn't be bumping my, "Gee, the ED missed a widened mediastinum before sending the patient upstairs on bridge orders, so I really need a stat CTA NOW" stat chest CT.


At the hospital I did my intern year at, the blood bank gave all of the residents and attendings a presentation on transfusions. They mentioned that over 70% of the type and screens were ordered stat... which basically meant that all of them ended up being run on the order they came in on. Because of that, I've made a conscious decision to order routine type and screens with AM labs if my patient starts to get close to transfusion territory. When all of the orders are stat, none of them are.

 

[link2swim06]

Outside of the ED, however, I agree with that definition. It bugs the hell out of me when I see other IM residents order stat CBCs and chem 7s because they forgot to order AM labs the night before and want the results back before rounding time.

At the same time, there needs to be a way for the inpatient teams to prioritize emergency lab and imaging before the ED. Sorry, your 3 "my belly slightly aches" stat abdomen CTs shouldn't be bumping my, "Gee, the ED missed a widened mediastinum before sending the patient upstairs on bridge orders, so I really need a stat CTA NOW" stat chest CT.


At the hospital I did my intern year at, the blood bank gave all of the residents and attendings a presentation on transfusions. They mentioned that over 70% of the type and screens were ordered stat... which basically meant that all of them ended up being run on the order they came in on. Because of that, I've made a conscious decision to order routine type and screens with AM labs if my patient starts to get close to transfusion territory. When all of the orders are stat, none of them are.

A STAT transfusion is going to be o negative or positive blood with no type and screen. I get what you are saying but most of the time you are type and screening is because you think you will have to transfuse soon so it's something that needs to come back soon in most situations...apart from a few situations.

If I really need a CT I call the CT tech and tell them the pt is coming down now, and I ask them what room I can come to? I have done this from the floors too before.

The biggest issue is at my hospital it's either routine or stat for most things. There is no middle ground. Example was a 12-lead in the ICU was either stat (tech comes up in a few minutes) or routine (tech comes around every 10 or 12 hours). Hence every EKG was just ordered stat which was ridiculous but also waiting a half of a day is ridiculous too. Half of those EKGs were just to monitor QTc or something like that...and could have been done in a few hour time frame...but that wasn't an option.

 

[brians34]

They mentioned that over 70% of the type and screens were ordered stat... which basically meant that all of them ended up being run on the order they came in on. Because of that, I've made a conscious decision to order routine type and screens with AM labs if my patient starts to get close to transfusion territory. When all of the orders are stat, none of them are.

This was part of the reason the supervisor wanted me to write this article. If everyone is ordering STAT or ASAP, everything gets put in as first come, takes away from the true meaning of the use for STAT and ASAP orders.

 

[Gastrapathy]

If everything is being ordered STAT, it's because your lab sucks. Now, in classic administrator logic, it's the physicians behavior that is the problem.

Improve your routine turn around time, advertise that you've done so and gradually earn back their trust. If some lab admin thinks he gets to decide the quality of my indication, he can go **** himself. But feel free to give your presentation to the medical staff in which you teach them how to practice medicine, I'm sure they will feel differently.

 

[brians34]

If everything is being ordered STAT, it's because your lab sucks. Now, in classic administrator logic, it's the physicians behavior that is the problem.

Improve your routine turn around time, advertise that you've done so and gradually earn back their trust. If some lab admin thinks he gets to decide the quality of my indication, he can go **** himself. But feel free to give your presentation to the medical staff in which you teach them how to practice medicine, I'm sure they will feel differently.

Gastrapathy, I'm glad you wrote this. This is exactly what I told our chief pathologist would be many of the provider's attitudes if she relied on me to write the article. I am now going to show her your response and maybe she can bring this up in a medical board meeting herself.

 

[evilbooyaa]

Labs from the ER: always STAT
Labs from the ICU other than AM labs: always STAT
Admission labs to the floor: ASAP
AM labs for floor/ICU: Routine (but with the knowledge that the TAT should be standardized as the AM flood can be planned for)
Labs from a doc's office: Routine

Agree with ER being STAT all the time.
In an ICU patient, usually STAT, although when consultants shotgun 80 labs, they usually have the decency to do it routine.
Direct admit who doesn't have labs? STAT, because even those take 1-3 hours just for somebody to come draw the damn things.
AM labs - routine, although I've made the mistake of forgetting to order labs and having to do them STAT. Oops!

Routine is pretty much for consultants who will shotgun an autoimmune panel, or a thrombocytopenia work-up panel, or a hypercoaguable work-up panel, etc.
Otherwise outside of AM labs and maybe timed labs (like q6hr BMPs/CBCs depending on the condition), we try to limit the number of times patients get stuck.
Add-ons are preferred if you realize you forgot to order something (like you ordered a BMP but forgot Mg and Phos in the patient with an SBO)

 

[Crayola227]

Agree with ER being STAT all the time.
In an ICU patient, usually STAT, although when consultants shotgun 80 labs, they usually have the decency to do it routine.
Direct admit who doesn't have labs? STAT, because even those take 1-3 hours just for somebody to come draw the damn things.
AM labs - routine, although I've made the mistake of forgetting to order labs and having to do them STAT. Oops!

Routine is pretty much for consultants who will shotgun an autoimmune panel, or a thrombocytopenia work-up panel, or a hypercoaguable work-up panel, etc.
Otherwise outside of AM labs and maybe timed labs (like q6hr BMPs/CBCs depending on the condition), we try to limit the number of times patients get stuck.
Add-ons are preferred if you realize you forgot to order something (like you ordered a BMP but forgot Mg and Phos in the patient with an SBO)

Common sense above.

If the docs aren't practicing common sense here, I do wonder if it's an institutional problem with turnaround time rather than docs not having some basic abstract notion of what "STAT" and "ASAP" and "Routine" mean.

 

[Gastrapathy]

Gastrapathy, I'm glad you wrote this. This is exactly what I told our chief pathologist would be many of the provider's attitudes if she relied on me to write the article. I am now going to show her your response and maybe she can bring this up in a medical board meeting herself.

She probably wanted you to write it so she'd have plausible deniability when the trial balloon crashed like the whale in Hitchhiker's Guide to the Galaxy

 

[brians34]

If the docs aren't practicing common sense here, I do wonder if it's an institutional problem with turnaround time rather than docs not having some basic abstract notion of what "STAT" and "ASAP" and "Routine" mean.

Our lab, during the day, draws routine labs in the am between 5 and 7, 11a.m., 1p.m., and 3p.m. When phlebotomists return from the ward at 7a.m., they are very busy drawing outpatients until almost noon. That's why there is that gap between morning and 11a.m. draws.

Some, not all STATs and ASAPs are ordered because the provider doesn't want to wait for the next routine draw time. The phlebotomist does stop what they are doing and go to draw an inpatient when called (the provider or ward clerk must call if they order a STAT or ASAP because labels do not automatically print when ordered) for a STAT or ASAP. This will sometimes cause a backup in outpatient draws. Is it good practice to order STAT or ASAP because provider forgot to order a.m. labs? Is it good practice to order STAT or ASAP because the provider doesn't want to wait a few extra hours to check back on a patient when they aren't in any distress? If the patient is waiting on discharge lab collection, maybe those orders are fine with ASAP.

The biggest thing to realize is when a phlebotomist leaves their station to collect a STAT or ASAP, about 10 to 12 outpatients could have been collected in the time it takes them to cover that one STAT or ASAP patient. This is big especially in the mornings.

I think the biggest reason she was wanting me to write the report was to bring attention, not to "tell" providers how to do their job, to what degree a STAT or ASAP affects the lab. If it's absolutely necessary, STATs and ASAPs are great, but for those times when a patient is not in any distress and they can wait until the next collection time when phlebotomists make their routine rounds, routines are the better option. More patients can be cared for when STATs and ASAPs are ordered appropriately.

 

[gutonc]

STAT = I need this result to make a decision on the management of this patient today...or tomorrow...definitely sometime in the next 48 hours though, thanks for your help
ASAP = I need this result to help manage this patient after discharge...if it comes back before then, so much the better
Routine = I ordered this because somebody else told me to or it's just a reflex at this point. It's essentially irrelevant to patient management but I suspect that somebody will give me s*** for not having ordered this lab so I'm just covering my ass.

 

[Gastrapathy]

Again, that is the perspective of a lab manager, no one else. You need more people, not my problem. Stuff waiting until the afternoon has second order effects. The follow-on procedures/tests/consults get delayed, discharges get delayed, etc. You think the flow of everything else should stop because its more convenient for your set up. We just don't care.

 

[dpmd]

I'm just thinking about how stat lab to me means I want results right damn now and a routine lab I want results within 4 hrs from my order, but since that isn't what actually happens (4 hrs from whenever the lab comes around to draw it isn't really conducive to planning patient care) and I try to order labs as needed instead of just getting a bunch of am labs on everyone it means I will order things however will get me what I am looking for (meaning at some hospitals I order everything except daily labs as stat and when I really want an immediate answer I either walk it down myself or get on the phone shortly after it is received to speed things up). Thankfully this is not so common where I am at now.

 

[PTPoeny]

I noticed several people said outpatient labs should never be stat. But if you are in a system where outpatient docs can direct admit from their clinics, there will be times they get labs to decide whether or not to admit and those labs need to be stat.

 

[mvenus929]

I noticed several people said outpatient labs should never be stat. But if you are in a system where outpatient docs can direct admit from their clinics, there will be times they get labs to decide whether or not to admit and those labs need to be stat.

I'd also argue that some outpatient tests should be stat, even if the docs can't admit directly... That bilirubin in the newborn baby may be okay, but it may also be at 'need to admit to a NICU now' level. A CBC from heme/onc clinic can be the deciding factor as to whether or not a patient gets admitted.