Use of specimen turnaround time as a component of laboratory quality. A comparison of clinician expectations with laboratory performance

Validation of the Six Sigma Z-score for the quality assessment of clinical laboratory timeliness

BACKGROUND

The International Federation of Clinical Chemistry and Laboratory Medicine has introduced in recent times the turnaround time (TAT) as mandatory quality indicator for the postanalytical phase. Classic TAT indicators, namely, average, median, 90th percentile and proportion of acceptable test (PAT), are in use since almost 40 years and to date represent the mainstay for gauging the laboratory timeliness. In this study, we investigated the performance of the Six Sigma Z-score, which was previously introduced as a device for the quantitative assessment of timeliness.

METHODS

A numerical simulation was obtained modeling the actual TAT data set using the log-logistic probability density function. Five thousand replicates for each size of the artificial TAT random sample (n=20, 50, 250 and 1000) were generated, and different laboratory conditions were simulated manipulating the PDF in order to generate more or less variable data. The Z-score and the classic TAT indicators were assessed for precision (%CV), robustness toward right-tailing (precision at different sample variability), sensitivity and specificity.

RESULTS

Z-score showed sensitivity and specificity comparable to PAT (≈80% with n≥250), but superior precision that ranged within 20% by moderately small sized samples (n≥50); furthermore, Z-score was less affected by the value of the cutoff used for setting the acceptable TAT, as well as by the sample variability that reflected into the magnitude of right-tailing.

CONCLUSIONS

The Z-score was a valid indicator of laboratory timeliness and a suitable device to improve as well as to maintain the achieved quality level.

Analysis of Patient's Satisfaction with Phlebotomy Services in NABH Accredited Neuropsychiatric Hospital: An Effective Tool for Improvement

Introduction

Patient's satisfaction is the need of the hour and one of the most important quality indicators in the laboratory medicine.

Aim

To assess the patient's satisfaction with phlebotomy services in a neuropsychiatric hospital by a structured questionnaire with grading scale. Also, identify the problems causing dissatisfactions and to undertake necessary Corrective and Preventative Action (CAPA).

Materials and Methods

Total 1200 patients were randomly selected over a period of two months (June and July 2016). A structured self designed questionnaire (feedback form) was devised in both Hindi and English languages containing ten questions with a grading scale for each question. It also included suggestions from the users. All the selected patients or their attendants filled up this questionnaire. At the same time, they were also interviewed by phlebotomy staff. A statistical analysis was conducted using SPSS version 16.0 software and Likert scale.

Results

A total of 94% of the patients were satisfied with the phlebotomy services. Almost 30.0% patients found the phlebotomy services to be very good, but the majority of them (40.5%) found it to be good and another 23.5% found it to be satisfactory while, 4% found the services to be poor and 2% found it to be very poor. The highest rate of satisfaction (4.21) was noted in case of parameter-ease to find collection sample room and lowest rate of satisfaction (3.92) was scored by the parameter-staff's wearing proper uniform. Depending upon the deficient areas some corrective actions were suggested such as strict compliance of personal protective equipments, regular training to improve technical skill, knowledge and behaviour with emphasis on cleanliness of work area.

Conclusion

Even though the overall patient's satisfaction was high, there were areas which needed our attention such as waiting time for phlebotomy procedure, lack of proper sitting arrangement, techniques of sample collection, knowledge of universal precautions etc. Appropriate corrective and preventive actions were taken to solve the problems. Thereby, feedback proved effective in maintenance and improvement of phlebotomy services.

Beacon-based (bbFISH®) technology for rapid pathogens identification in blood cultures

BACKGROUND

Diagnosis and treatment of bloodstream infections (BSI) are often hampered by the delay in obtaining the final results of blood cultures. Rapid identification of pathogens involved in BSI is of great importance in order to improve survival of septic patients. Beacon-based fluorescent in situ hybridization (hemoFISH® Gram positive and hemoFISH® Gram negative test kits, miacom diagnostics GmbH Düsseldorf, Germany) accelerates the identification of most frequent bacterial pathogens of sepsis.

RESULTS

In this study a total of 558 blood culture (377 blood culture positive and 181 negative) were tested with the hemoFISH® method and the results were evaluated in comparison with the traditional culture based methods. The overall sensitivity and specificity of the hemoFISH® tests were 94.16% and 100%, while, the PPV and NPV were 100 and 89.16%, respectively. As the hemoFISH® results were obtained within 45 mins, the time difference between the final results of the traditional culture method and the hemoFISH® assay was about two days.

CONCLUSIONS

Considering the good sensitivity and specificity of the hemoFISH® assays as well as the significant time saving in obtaining the final results (p-value 0.0001), the introduction of the system could be rialable in the microbiology laboratories, even alongside the traditional systems.

Utilization of Stat Test Priority in the Clinical Laboratory: A College of American Pathologists Q-Probes Study of 52 Institutions

Context.—Utilization of stat testing priority is a balance between safe, efficient patient management and resource expenditure.

Objective.—To determine the rate of stat testing, compare rates among institutions, and determine the distribution of turnaround time expectations for different turnaround time priorities.

Design.—During a 7-day period, participants prospectively determined the total number of chemistry, hematology, and coagulation billable tests from inpatients and emergency department patients. Among these, the total numbers of billable tests performed stat were identified. Laboratories also reported the levels of test priority they offered and turnaround expectations for each level of test priority.

Results.—Fifty institutions submitted data for the study, with 2 additional participants submitting partial results. Participants identified 639 589 chemistry, hematology, and coagulation billable tests, with 229 896 (35.9%) performed stat. The stat rate varied from 21.3% at the 10th percentile to 55.4% at the 90th percentile, with a median of 37.0% of participants' tests performed stat. Laboratories include a mean of 206 tests in chemistry, hematology, and coagulation test menus, with 67% of these tests offered stat. The fraction of the test menu offered stat varied from 29.0% at the 10th percentile to 97.8% at the 90th percentile, with a median of 73.3% of tests on the menu offered stat. The most common number of testing priorities offered by participating laboratories was 3 (44.2%).

Conclusions.—Among the 52 participating laboratories, the median stat testing rate was 37.0% and a median 73.3% of the test menu was offered stat.

A strategy for optimizing staffing to improve the timeliness of inpatient phlebotomy collections

CONTEXT

The timely availability of inpatient test results is a key to physician satisfaction with the clinical laboratory, and in an institution with a phlebotomy service may depend on the timeliness of blood collections. In response to safety reports filed for delayed phlebotomy collections, we applied Lean principles to the inpatient phlebotomy service at our institution. Our goal was to improve service without using additional resources by optimizing our staffing model.

OBJECTIVE

To evaluate the effect of a new phlebotomy staffing model on the timeliness of inpatient phlebotomy collections.

DESIGN

We compared the median time of morning blood collections and average number of safety reports filed for delayed phlebotomy collections during a 6-month preimplementation period and 5-month postimplementation period.

RESULTS

The median time of morning collections was 17 minutes earlier after implementation (7:42 am preimplementation; interquartile range, 6:27-8:48 am; versus 7:25 am postimplementation; interquartile range, 6:20-8:26 am). The frequency of safety reports filed for delayed collections decreased 80% from 10.6 per 30 days to 2.2 per 30 days.

CONCLUSION

Reallocating staff to match the pattern of demand for phlebotomy collections throughout the day represents a strategy for improving the performance of an inpatient phlebotomy service.

Quality assurance in clinical laboratories. An updated supplement to a bibliography

A supplement to a bibliography (Scand J Clin Lab Invest 1987;47 suppl. 187:1-96) dealing with quality assurance in the clinical laboratory is presented. The increasing role of national and international standardizing bodies is stressed as well as implementation of rules of "good laboratory practice". Objectively established quality goals for all services is highly needed in order to provide a rationale for the efforts dedicated to quality improvements. Quality goals for many clinical chemistry and haematology investigations are now available.

“Turnaround time”: a new parameter for the characterization of the overall efficacy of laboratory diagnostic processes

Bevezetés:A szerzők a laboratóriumi diagnosztikai tevékenység hatékonyságát jellemző paraméter, az ún. „turnaround time” meghatározására alkalmas számítógépes programot dolgoztak ki laboratóriumukban. A turnaround time a minta laboratóriumba való beérkezése és az orvosi validálást követő eredménykiadás között eltelt idő, mely jól jellemzi az eredménykiadás hatékonyságát, és ezért a laboratóriumok működésének fontos minőségügyi paramétere.Módszer:Analízisük során a sürgős, rutin- és speciális vizsgálatokat külön kezelve 6 hónap adatait dolgozták fel, és a turnaround time medián, 5- és 95-percentil értékeit adták meg. Meghatározták emellett a maximálisnak definiált turnaround time értéket (sürgős 1 óra, rutin 4 óra, speciális 2–14 nap) meghaladó turnaround time értékű vizsgálatok („kiesők”) arányát is az összes vizsgálati számra vonatkoztatva.Eredmények:A sürgős vizsgálatok esetében a medián turnaround time 9–70 perc, a rutinvizsgálatoknál pedig 33–190 perc között volt. A speciális vizsgálatok jóval heterogénebb képet mutattak, és általában megállapítható volt, hogy a kis mintaszámú, nem automatizált, immunkémiai és hemosztázis-tesztek esetében magas a turnaround time értéke és a kiesők aránya. A rutinvizsgálatok longitudinális analízise egyértelműen mutatta, hogy 2006 első félévében javultak a vizsgálatok turnaround time értékei a laboratórium valamennyi részlegén. A turnaround time hosszát befolyásoló egyik lényeges paraméter az orvosi validálás ideje, ami jelentősen csökkenthető egy autovalidáló program segítségével. A szerzők adatai alapján az autovalidálás bevezetése akár 1–2 órával is csökkentette a rutinvizsgálatok medián turnaround time értékeit. Az alkalmazott számítógépes program alkalmas akár a mintaszállítás effektivitásának jellemzésére is, amit a szerzők két különböző mintaszállítási infrastruktúrával rendelkező sürgősségi részlegük összevetésével mutattak be.Következtetések:Az itt ismertetett turnaround time analízis az általános rutin része a világ fejlettebb országaiban tevékenykedő diagnosztikai laboratóriumokban, ugyanakkor az első ilyen próbálkozást jelenti Magyarországon.

Routine outpatient laboratory test turnaround times and practice patterns: a College of American Pathologists Q-Probes study

OBJECTIVES

To determine baseline parameters for routine outpatient test turnaround time (TAT), to identify influential factors, and to study the impact of managed care on this testing.

METHOD

Using forms supplied by the College of American Pathologists Q-Probes program, laboratories conducted a self-directed study of routine outpatient TATs over a 4-week period. Data requested included various times of day associated with the collection, laboratory receipt, and result verification of specimens, as well as details on the drawing location and ordering and delivery methods for up to 3 tests, namely, a complete blood cell count (CBC), biochemical profile, or thyrotropin test. For the CBC, an indication was requested if a manual differential was performed. Additionally, practice-related questions were asked, including several about whether the laboratory was associated with a managed care organization (MCO). The main outcome measures included the components of the TAT process and related factors.Participants.-Six hundred nineteen laboratories from those enrolled in the 1997 College of American Pathologists Q-Probes program.

RESULTS

Data were submitted by 614 participants, most US hospitals, and represented 30 240 CBCs, 25 683 biochemical profiles, and 14 801 thyrotropins. Collection to verification TATs increased for specimens received later in the day for all analytes, but the magnitude of the increase was greatest for thyrotropin. Collection to laboratory receipt TAT was similar for all analytes, but the time and distribution increased with time of day. Testing time (receipt to verification) was similar for the CBC and biochemical profile, but was greatly increased for thyrotropin. Most participants tested the CBC and the biochemical profile as they arrived, but many delayed testing for thyrotropin. Most (70%) outpatient specimens were collected within the institution; only about 10% came from local physicians' offices. A median 46.7% of hospital testing involved outpatients. Only 10% of laboratories operated under an MCO; these laboratories reported a median of 45% of specimens coming from their MCO. Being associated with an MCO increased TAT for the CBC and biochemical profile.

CONCLUSIONS

Outpatient testing comprises about half of all hospital testing, yet systems are not optimized. Preanalytic TAT increases during the day, which indicates increasing delays in the collection and transport stages. Imposition of a test schedule on thyrotropin results in a delay pattern that is very different from the CBC and biochemical profile, which are tested on arrival. A laboratory's association with an MCO had a weak impact on TAT.

Physician satisfaction and emergency department laboratory test turnaround time

OBJECTIVES

To determine the length of time for the components of the emergency department (ED) turnaround time (TAT) study in 1998 and to ascertain physician satisfaction concerning laboratory services to the ED.

METHODS

Using forms supplied by the College of American Pathologists Q-Probes program, participants conducted a self-directed study of ED TAT over a 4-week period. Data requested included various times of day associated with the ordering, specimen collection, laboratory receipt, and result-reporting stages of stat ED TATs for potassium and hemoglobin. Additionally, practice-related questions associated with the laboratory were asked. Participating laboratories also provided a physician satisfaction survey for up to 4 physicians who were users of ED services. Results of both the TAT study and the physician satisfaction survey were returned by mail. Participants were drawn from the 952 hospital laboratories enrolled in the 1998 College of American Pathologists Q-Probes study on ED TAT. The main outcome measures included the components of the ED TAT process, factors associated with decreases in ED TAT, and the results of the physician satisfaction survey.

RESULTS

Six hundred ninety hospital laboratories (72.4% response rate) returned data on up to 18 230 hemoglobin and 18 259 potassium specimens. Half of these laboratories responded that 90% of potassium tests were ordered and reported in 69 minutes or less, whereas the TAT for 90% of hemoglobin results was 55 minutes or less. Comparison of the components of TAT for both potassium and hemoglobin with similar studies done in 1990 and 1993 showed no change. Factors found to statistically contribute to faster TATs for both tests were laboratory control of specimen handling and rapid transport time. When whole blood specimens were used for potassium determination, TAT improved. Emergency department physicians chose the study-defined lower satisfaction categories of Often, Sometimes, Rarely, and Never for the questions concerning the laboratory being sensitive to stat testing needs (39.1%) and meeting physician needs (47.6%). Many of the physicians surveyed believed that laboratory TAT caused delayed ED treatment more than 50% of the time (42.9%) and increased ED length of stay more than 50% of the time (61.4%) when compared with other specialty users of the ED.

CONCLUSIONS

Laboratory ED TATs have remained unchanged for almost a decade. Emergency department physicians are not satisfied with laboratory services. Although it appears that one issue may relate to the other, the interaction between the laboratory and the ED is quite complex and has been evolving for at least 30 years. Improvement in interoperability between the departments is essential for operational efficiency and patient care. Effective communication channels need to be established to achieve these goals.

Morning rounds inpatient test availability: a College of American Pathologist Q-Probes study of 79860 morning complete blood cell count and electrolyte test results in 367 institutions

OBJECTIVES

To determine the success with which laboratories were able to report morning test results on time, the laboratory practice characteristics associated with improved success, and the degree of satisfaction among clinicians with the timeliness of laboratory service.

DESIGN

Hospital laboratories participating in the College of American Pathologist Q-Probes laboratory quality improvement program prospectively calculated the percentages of morning-run complete blood cell count (CBC) and electrolyte results that were reported on or before predetermined reporting deadlines, completed questionnaires concerning their departments' practice characteristics as they related to performing morning blood work, and distributed to physician utilizers of morning laboratory services questionnaires evaluating physician satisfaction with laboratory services.

SETTING AND PARTICIPANTS

A total of 367 public and private institutions located in the United States (355), Canada (5), Australia (2), and 1 each in the United Kingdom, Spain, Brazil, Korea, and Guam.

MAIN OUTCOME MEASURE

The percentages of morning-run CBC and electrolyte results reported on or before predetermined reporting deadlines.

RESULTS

Participants submitted data on 40 256 CBC and 39 604 electrolyte specimens. In aggregate, a total of 88.9% of these tests (90.2% of CBCs and 87.6% of electrolytes) were reported on or before the reporting deadlines that the participating laboratories set for themselves. Half of the participants reported 94.6% of their CBC results and 95.5% of their electrolyte results on or before their self-imposed reporting deadlines. No specific demographic features or departmental practice characteristics were associated with higher or lower rates of institutional reporting compliance. Most physician utilizers of early-morning laboratory test results believed that the laboratory is sensitive to and meets the needs of clinicians for timely reporting of early-morning test results.

CONCLUSIONS

Most laboratories are capable of reporting 95% of their routine morning laboratory tests on time, and most physicians are satisfied with their laboratories' morning testing service.

External Quality Assessment of stat test intralaboratory turnaround times. Pilot study from the Members of the Working Group for the Standardization and Promotion of Turnaround Time Control under the Auspices of the Comitato Italiano per la Standardizzazione dei Metodi Ematologici e di Laboratorio

We describe procedures, results and prospects of a pilot program in External Quality Assessment (EQA) of the stat test intralaboratory turnaround times. Our goals are to promote quality by systematic monitoring and comparison of performances by laboratories, continuous investigation into the state of the art of the processes from receipt of sample to transmission of results and creation of a data base for standardization of measures and definition of consensus values for turnaround time. Of 30 laboratories invited to participate, 25 took part, agreeing to record times of arrival and transmission for all determinations of three analytes (blood hemoglobin, serum/plasma potassium and plasma prothrombin time) for seven consecutive days and to continue for one or more further periods of seven days as necessary if there were less than 300 determinations for each analyte. Within a preset time limit, data were sent by e-mail on an Excel file and we sent back two reports per analyte, showing: i) the graph for time vs. percentage of tests completed and several measures of turnaround time; ii) results of all laboratories in graph form, allowing each laboratory to identify only its own data. The high proportion of participating laboratories among those invited (83%) encourages us to implement the EQA program systematically, on a half-yearly basis, extending it to all laboratories wishing to participate in Italy or elsewhere in Europe.

Lessons for the laboratory from a general practitioner survey

AIMS

To assess the current performance of the clinical biochemistry service provided to general practitioners, with particular attention to result turnround times, and to identify and improvements required.

METHODS

Postal questionnaire survey of general practitioners in the London Borough of Tower Hamlets who used the clinical biochemistry laboratory of the Royal London Hospital. A flow analysis study of turnround times for general practitioner samples was also performed.

RESULTS

Responses to the questionnaire showed that although 82% of general practitioners thought the current quality of service provided was better than fair, the actual turnround times achieved were longer than the acceptable times required. There was also a strong demand (> 66% of responders) for additional information-such as highlighting of abnormal results-to be provided with results. There was wide variability between practitioners in their use of the laboratory (from none to > 800 requests per year), with no apparent correlation to practice size. Of the repertoire of tests requested, a surprisingly high percentage (14.3%) were for thyroid function. Flow analysis of turnround times for thyroid function tests showed that problems lay not with the time taken for analysis (only 7.8% of the total turnround time) but with the pre- and postanalytical phases, that is, the sample collection and results delivery service.

CONCLUSIONS

Increasing the proportion of health care delivered in the primary care sector will inevitably increase the requirement for pathology services. Improvements in the specimen collection and results delivery service to general practitioners are needed to meet their expectations. It remains to be determined whether increased investment in these aspects of laboratory service would result in improved patient care in the primary sector.

Timeliness of automated routine laboratory tests: a College of American Pathologists Q-Probes study of 653 institutions

Benchmarks for timeliness of early morning routine clinical laboratory tests were developed from over 17,000 urea nitrogen and 16,000 white blood cell count measurements made for inpatients in 653 institutions participating in the College of American Pathologists Q-Probes program. Urea nitrogen and white blood cell counts were considered surrogates for routine chemistry and hematology tests. Laboratories at the 50th percentile reported median urea nitrogen and white blood cell counts by 09.04 and 08.51 h, respectively, whereas those at the 10th percentile reported these median measurements by 11.30 and 11.18 h, respectively. Results were available sooner in non-teaching than teaching institutions, and in smaller rather than larger institutions, with the degree of computerization affecting test availability. Timeliness also was affected by instrument type and mode of operation, but was unaffected by the percentage of stat testing. Based on modeling by regression analysis, there was little evidence that longer routine test turnaround times affect patient length of stay.

Diagnostic blood analysis using point-of-care technology

Rapid analysis of selected laboratory tests is essential in the management of critically ill patients. These tests facilitate accurate diagnosis of clinical problems and the initiation and evaluation of appropriate therapeutic interventions. Instruments are now available to perform analysis at a site near the patient, or "point-of-care" testing. These instruments incorporate electrochemical and optical sensors capable of providing information on multiple analytes from a small sample of whole blood. In this article, the author explores the technologies behind point-of-care testing, as well as the advantages and disadvantages of in vitro, in vivo, and ex vivo modalities.

Improvement of emergency and routine turnaround time by data processing and instrumentation changes

A retrospective study of stat and routine laboratory analysis turnaround time was performed in a 1000-bed public hospital before and after the implementation of instrument and computer changes. Significant decreases in turnaround time were found for enzyme tests in the stat laboratory and for all analytes studied in the routine laboratory. The decrease in TAT was evaluated using a physician satisfaction scale, elaborated in conjunction with specialists from several fields, that disclosed an increase in perceptive quality. Results from other authors and recommendations by the College of American Pathologists for turnaround time are discussed.

Physician satisfaction with human immunodeficiency virus type 1 and hepatitis B virus testing in San Diego County

Physician satisfaction with the laboratory testing process is one indicator of the physician's perception of the quality of laboratory testing and the effectiveness of the communication of the laboratory results. This study compares the level of satisfaction of physicians reporting their experience with human immunodeficiency virus type 1 (HIV-1) testing with the satisfaction levels of those physicians reporting their experience with hepatitis B virus (HBV) testing. By mail, 6,570 licensed San Diego County physicians were surveyed. Among those who tested for HIV-1 or HBV, their satisfaction with four different HIV-1 or HBV testing parameters was assessed: 1) specimen submission process, 2) test accuracy, 3) clarity of test report, and 4) turnaround time. Overall, physician satisfaction with both HIV-1 and HBV testing was high, particularly for test accuracy (means of 2.79 and 2.84, respectively on a 3-point scale), although slightly lower for turnaround time (means of 2.40 and 2.43, respectively). Mean satisfaction with the specimen submission process and test accuracy were higher for physicians who ordered HBV tests than for those who ordered HIV-1 tests. Satisfaction with the four HIV-1 testing process parameters varied significantly by physician specialty, practice type, and type of laboratory used. For HBV testing, significant differences were observed only for turnaround time. For both HIV-1 and HBV testing, those who received a final interpretation of laboratory results were more satisfied with test report clarity than those who did not. Although physician satisfaction with HIV-1 and HBV testing is high, this study identifies the least satisfied groups and specific areas in the testing process than may need improvement.

Laboratory turnround time: closing the loop

AIMS

To institute recommendations from a laboratory turnround time study; to evaluate audit methods; and to quantify improvements achieved.

METHODS

Changes to result report distribution and specimen delivery were affected by posting results directly from the laboratory followed by the introduction of a twice daily courier service. Improvements were evaluated by repeating the turnround time audit described in an earlier report. Pre-, peri- and post-analytical turnround times were compared before and after changes had been instituted.

RESULTS

Directly posting general practitioner (GP) results increased the percentage of reports which reached their destination within one and two days after they were generated from 13 to 29% and from 68 to 82%, respectively. Pre- and postanalytical times were superimposable before and after posting was started. Corresponding improvements to the satellite hospital service were from 25 to 78% and from 60 to 82%, respectively. The courier service shortened the median total turnround time from 50 to nine hours for GPs and from 69 to 18 hours for the satellite hospital. Fifty three per cent of GP reports and 21% of satellite hospital reports arrived on the same day as the sample was taken: 99% and 94%, respectively, had arrived by the next day. The number of analytically "old" samples which arrived the day after they had been taken, thus invalidating many results, fell from 25 to 3%.

CONCLUSIONS

These audits of laboratory turnround time have been used to present a valid case for changes to laboratory transport and to quantify the improvements achieved. They produce consistent and repeatable results, which may also be used to monitor future performance, to assess further changes and to establish the cost-effectiveness of resources used.

New whole blood analyzers and their impact on cardiac and critical care

Miniaturized whole blood biosensors, patient-focused hospitals, and rising expectations of patients and physicians are shifting laboratory diagnostics to the point of care. Expanding transplantation and intensive care are increasing the need for rapid test results. Whole blood analysis improves accuracy, eliminates centrifugation, reduces response time, and conserves blood volume. Several hand-held, and over 20 portable or transportable whole blood instruments are now available. Criteria for instrument evaluation include test menus, point-of-care features, analysis time, on-site performance, and information integration. Whole blood analyzers measure several vital indicators (pO2, pCO2, pH, hematocrit, K+, Ca2+, Na+, Cl-, glucose, and lactate) simultaneously in less than 2 min with less than 200 microliters of whole blood. Other in vitro tests are available (Mg2+, osmolality, CO2 content, urea nitrogen, beta-hydroxybutyrate, hemoglobin, coagulation) or under development (HCO3- phosphorus). Some can be monitored in vivo (O2 saturation, pO2, pCO2, pH, glucose) or ex vivo. The clinical impact is demonstrated by ionized calcium, now established in importance for cardiac and neurologic problems, and ionized magnesium, a promising new measurement. The hybrid laboratory (a composite of conventional clinical laboratory and patient-focused testing), performance maps, and quality paths facilitate implementation of new whole blood analyzers for optimal support of cardiac and critical care, and improved patient outcomes (prospects).