Lab,

I think we have an emergency!

The laboratory throughput time as a bottleneck
for patients’ length of stay at the emergency
MB

department of a hospital
Management and Governance

38
 Abstract
The reduction of waiting and treatment times
at hospitals’ emergency departments is a current
topic in Dutch and international health care.
Although patients and staff complain about
performance, few hard data are available. This
research focuses on the role of laboratory testing
in relation to patients’ length of stay at the
emergency department. Waiting for laboratory
tests is a restrictive factor in decision-making
at the emergency department; and reduction
of mean testing times as well as reduction of
variability in this process is recommended.

MB
by Renée te Poele

Management and Governance

Figure 1. How supplementary diagnostics
such as laboratory testing are embedded in
the ED’s care process.
1 Introduction
Being hospitalised after a heart attack or an accident can be a traumatising
experience. When a victim is hospitalised, he or she always passes through the
emergency department (ED), which is therefore one of the most important
entry points to a hospital. The major task of this department is to evaluate
whether a patient needs to be hospitalised. The ED is where physicians
evaluate the gravity of the illness and determine a diagnosis if possible. Some
parameters that are important to this decision, such as enzyme concentration
in the blood, can only be measured with laboratory tests (see Figure 1). 39
Many hospitals struggle with relatively long patients’ lengths of stay and
waiting times at their EDs (Asplin et al., 2003). Generally, people depend
on the ED when they are most vulnerable and urgent treatment is of vital
importance. Accordingly, the better the ED’s performance, the lower the
morbidity and mortality rates. Considerable waiting times and lengths of stay
characterise many segments of the health care sector, and patients are willing
to accept some waiting. Nevertheless, waiting times are not desirable. Thus,
crowding at the ED should be placed on the agenda of every hospital and
community immediately (Bradley, 2005).

No No

Yes Yes
 Laboratory service in support of the ED is a topic of
discussion in the literature, with the time taken to return
a test result being a major component. As in the AMC
hospital in Amsterdam, these tests are often executed by a
centralised laboratory of the hospital. Patients’ diagnoses
rely heavily on the outcome of the tests, and patient
treatment is blocked until results are reported back to
the ED. Presumably, this throughput time is a significant
contributor to the length of stay at the ED (Fernandes,
Walker, Price, Marsden, & Haley, 1997; Fermann &
Suyama, 2002; Lewandrowski, 2004; Holland, Smith,
& Blick, 2005). During this time, the patient occupies a
treatment room, which is not available for new patients. As
MB
Figure 2. Laboratory tests in support of the Emergency Department
a result, queuing can take place. Although ED requests take
precedence over requests from regular departments of the
hospital, staff at the ED experience delays waiting for test
Management and Governance
results, which causes inconvenience for both the staff and
the patient (Steindel & Howanitz, 2001).
However, other factors may be the actual cause of patients’
extraordinarily long lengths of stay, such as waiting for
a physician to arrive at the ED or a treatment room to
become available. Overall data on throughput times were
not available and there was a lack of mutual understanding
40 between the two departments. For example, the ED blames
the laboratory for reporting too slowly and the laboratory
is sometimes frustrated because of the small volumes of
patients’ blood per sample taken by ED nurses. This article
focuses on the work processes at the ED and the laboratory
as well as the cooperation between these two departments.
2 Process analysis
It is essential to understand the basic relationships
governing a system before attempting to optimise
it Therefore, the research started with the author
accompanying nurses and physicians at the ED for four
workdays. This resulted in a general impression of operating
procedures at the ED and the interaction with the
laboratory.
The introduction already showed how supplementary
diagnostics are embedded in the ED’s care processes. In
the case of laboratory diagnostics, one can expand the bold
box in Figure 1 into the process shown in Figure 2. Thus,
besides the actual execution of tests at the laboratory, other
activities precede and follow this analysis.
In former research projects at the AMC (Van Schuppen,
2006); the laboratory process remained a black box (as
shown in Figure 2). To get to know this process as well, a
clinical chemist and a reception executive were interviewed.
Hereafter, joining analysts for one day led to insight into
laboratory operating procedures. In general, the process at
the laboratory involves the following activities: reception,
registration, distribution, preparation, analysis, validation
and reportage.
3 Bottlenecks of the process
The theory of Lean Thinking helped to uncover possible
queuing and/or bottlenecks and to suggest interventions to
improve the process (Womack & Jones, 2003; Glossmann
et al., 2000; Simmons, 2003). Lean Thinking concerns
minimising activities that do not create value for the
customer, in this case the patient. The ultimate goal is to
arrange the jobs that have to be done into a continuous
flow by eliminating so-called ‘muda’. This Japanese term for
waste concerns any human activity that absorbs resources
but creates no value.
By analysing the constructed flow diagrams, one can
distinguish possible bottlenecks in the process. Examples
of such bottlenecks, applied to the laboratory process in
support of the ED, are:
1. Waiting: by laboratory analysts, for process equipment
to finish working;
2. Inventories of goods awaiting further processing: this
is in fact a type of waiting as well, although not by
employees, but for employees. This concerns response
time.
3. Unnecessary processing: performing rework or steps that
are not actually needed
4. Unnecessary movement and transport: movement of
employees and transport of goods from one place to
another without any purpose
5. Errors: mistakes which require rectification
6. Excessive goods/services: production of goods which are
not needed
 4 Laboratory throughput time
During the construction of a previous simulation model (Van Schuppen,
2006), ED nurses estimated the laboratory throughput time, since no data were
available at that time. They stated that it would usually take 50 minutes before
results were available, with a minimum of 30 and a maximum of 90 minutes.
Accordingly, a triangular distribution represented the throughput time.
However, this triangular distribution may not be accurate enough, so testing the
validity of this model was deemed useful.

When laboratory test results become available, reports are automatically printed
at the ED. These test reports provided data of realistic laboratory throughput
time. Statistical testing revealed that the formerly used triangular distribution
was a misrepresentation of this throughput time. A gamma distribution with
parameters α = 3.83 and β = 17.02 appeared to represent the throughput time
much better (see Figure 3). Pearson’s chi-square test showed that this hypothesis
is indeed more likely.

Obtained data and gamma verus triangular distribution

MB
0,035
Probability density

0,03
0,025

Management and Governance

0,02
0,015
0,01
0,005
0
0
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
240

Laboratory lead time (minutes)

Figure 3. Laboratory test throughput time was formerly represented by a triangular distribution. Pearson’s chi-square test revealed this
distribution did not match the collected data. The gamma distribution is a better representation of the collected data. 41

5 Impact of laboratory throughput time on patients’

length of stay
Sensitivity analysis regards changing input parameters and observing the relative
change in output. In this study, sensitivity analysis aimed to determine the
impact of changed throughput time distributions on patients’ length of stay, in
other words: whether laboratory throughput time is indeed a restrictive factor
in the minimisation of patients’ length of stay, and thus a bottleneck for the
processes at the ED.

Thus, the study focused on the impact of reducing the mean of the realistic
distribution, while keeping the variability (i.e., standard deviation divided by
mean) constant. Yet, some researchers claim that it is not the mean that hinders
the average length of stay, so much as the percentage of outliers (Holland,
Smith, & Blick, 2005). That is why this research also studied the impact of
changing the extent of variability.
Reducing throughput time variability appeared to have remarkably minor
 effects on the mean length of stay (see Figure 4a). Thus, unnecessary rework and extra steps in registration at the
throughput time variability is not such a restrictive laboratory occur.
factor on mean patients’ length of stay as expected from
theoretical background. Many people each execute only a small part of the process.
As a result, the process passes from one person to another
However, throughput time variability did affect the and the work has to wait for the response of the next
variability of patients’ length of stay (see Figure 4b). This person. In addition, it takes some time for analysers to
strongly indicates that outliers in the throughput time only finish their work. Although the analysis itself is automated
affect the length of stay of the patient who needs the test to a great extent, the total process still is labour-intensive,
result, and not any other patients present in the ED. especially when the machine fails or is out of order. All
the bottlenecks mentioned above cause the laboratory
For reduction of mean laboratory throughput time, the processing time to be quite variable, with a great extent
conclusions are different. Since only one-sixth of all ED of outliers. Data collection and statistical analysis revealed
patients require laboratory tests, we can check if the that ED nurses’ estimates of laboratory throughput time
Figure 4a: On mean patient length of stay
underrated the extent of the outliers.
101,5
Mean patients’ length of

101
100,5
Sensitivity analysis using the simulation model showed
stay (minutes)

100 that laboratory throughput time was indeed a bottleneck

99,5
99 of patients’ length of stay at the ED. In the introduction,
98,5
98
the question was posed of whether queuing at the ED is a
result of extraordinary long laboratory throughput times.
MB

97,5
1,38 1,30 1,23 1,15 1,07 1,00 0,92 0,84 0,77 0,69 0,61 0,54 0,51 0,46 0,38 0,31 0,23 0,15 0,08
Labaoratory lead time variability Simulation outcomes regarding reduction of variability and
mean support the same conclusion: outliers in throughput
time only seem to affect the length of stay of the patient
Figure 4b: On patients’ length of stay variability that needs the delayed test, but not the length of stay of
other patients present in the ED at that time.
Management and Governance

0,73
Patients’ length of stay

0,71
variability

0,69 For this reason, it might not seem worth the effort to reduce
0,67 variability in laboratory throughput time. Although there
0,65
1,38 1,30 1,23 1,15 1,07 1,00 0,92 0,84 0,77 0,69 0,61 0,54 0,51 0,46 0,38 0,31 0,23 0,15 0,08 is an element of truth in this, we have to remember that
Labaoratory lead time variability
the individual patient who experiences increased laboratory
Figure 4. The impact of laboratory throughput time variability on (a) patients’ throughput time (and as a consequence: increased length
mean length of stay and (b) variability. Mean length of stay is affected to a of stay at the ED) is the one that will complain about ED
42 minor extent. Length of stay variability depends on throughput time variability. performance.

Reduction of laboratory throughput time mean and

simulation outcomes regarding mean length of stay are
variability therefore is a good opportunity to avoid
to be expected. Viewed arithmetically, reducing the mean
frustration of both patients and ED staff and to maintain
laboratory throughput time by a certain amount would
the hospital’s good reputation.
lead to a mean length of stay reduction of one-sixth of
this amount. Figure 5 shows that simulation outcomes are
slightly lower than expected from an arithmetic view. In
The impact of mean laboratory lead time on mean patients’ length of stay
other words, the mean length of stay is shortened slightly 102
Mean patients’ length of stay

more than expected. 100

98
(minutes)

6 Conclusion 96

94
Possible bottlenecks, which might delay the process, were 92
identified at both the laboratory and the ED. It is a process 90
in which two departments that have to work together 65,20 60,00 55,00 50,00 45,00 40,00 35,00 30,00

closely are located far from close together. The interaction Mean laboratory lead time (minutes)

between the two departments is not optimally attuned, so

Figure 5. Reduction of mean laboratory throughput time influences mean length
of stay and thus is a restrictive factor in the minimisation of patients’ length of stay
at the ED.

Author
Renée te Poele started her Bachelor’s
degree in Industrial Engineering and
Management in 2003. This article
presents the research she did for her
Bachelor’s thesis. Acknowledgments
go to Koos Krabbendam, Remco
Rosmulder, Jan Luitse, Johan
Fischer and Joyce Reijerse-
Ettekoven. Currently, the author is
studying for her Master’s in Health
Care Technology and Management.
Contact information:
r.tepoele@student.utwente.nl
Overview
Waiting for laboratory tests is a restrictive factor
in decision-making at a hospital’s emergency
department.
Mean throughput times and variability in this
process should be reduced.
Process improvements can be made at both the
emergency department and the laboratory, as
well as in the cooperation between these two
departments.
MB
References
Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A. (2003). A conceptual
Management and Governance
model of emergency department crowding. Annals of Emergency Medicine, 42 (2), 173–180.
Bradley, V. M. (2005). Placing emergency department crowding on the decision agenda. Nursing Economics, 23
(1), 14–24.
Fermann, G. J., & Suyama, J. (2002). Clinical laboratory in emergency medicine: Point of care testing in the
emergency department. Journal of Emergency Medicine, 22 (4), 393–404.
Fernandes, C. M. B., Walker, R., Price, A., Marsden, J., & Haley, L. (1997). Root cause analysis of laboratory
delays to an emergency department. Journal of Emergency Medicine, 15 (5), 735–739.
Glossmann, J., Schliebusch, O., Diehl, V., & Walshe, R. (2000). “Lean Management” im ärztlichen Bereich,
Medizinische Klinik, 95 (8), 470–473.
Holland, L. L., Smith, L. L., & Blick, K. E. (2005). Reducing laboratory turnaround time outliers can
reduce emergency department patient length of stay. American Society for Clinical Pathology, 124 (5),
672–674.
Lewandrowski, K. (2004). How the clinical laboratory and the emergency department can work together to
move patients through quickly. Journal of Clinical Leadership & Management Review, 18 (3), 155–159.
43
Simmons, J. C. (2003). Turning teamwork into quality care. The Quality Letter, 15 (12), 2–11.
Steindel, S. J., & Howanitz, P. J. (2001). Physician satisfaction and emergency department laboratory test
turnaround time. Archives of Pathology and Laboratory Medicine, 125 (7), 863–871.
Van Schuppen, J. C. (2006). A simulation tool for the emergency department. Master’s thesis, University of Twente,
Enschede, the Netherlands.
Womack, J. P., & Jones, D. T. (2003). Lean thinking (2nd ed.). New York: Free Press.