Central Clinical Laboratory
Caduceus-Hampstead University Hospital

Hampstead University Hospital's clinical lab was a large room that occupied the center of the hospital's fourth floor. Obviously. it had been designed as a hub for receiving test samples and disseminating critical patient information. Unlike most of the other areas of the hospital where patient care was carried out in an atmosphere of bustling activity and controlled chaos, the lab at the heart of the hospital was a refuge of unhurried order, calm, and quiet.

Pausing in the main entrance to the lab, Will tried to make sense of the setting before him. There were three lab technicians working within the large open area enclosed within a circle of lab tables and counters. An intensity of focused energy appeared to infuse the work of these technicians. They seemed oblivious to each other as they criss-crossed back and forth from one lab setup to another apparently carrying out several procedures at the same time.

So engrossed was Will in watching the intricate work patterns of the lab technicians, he was surprised when an odd metallic voice came from directly behind him. "Excuse me, you are blocking my path. Would you please allow me to pass by."

Startled, Will jumped sideways. He turned to face what appeared to be a four and one half foot high canister painted with blue and white stripes. "Thank you, " said the tinny voice politely. The bizarre barber pole rolled away from him toward the far end of the lab. It seemed to be following a tiny track in the center of the floor which Will hadn't noticed before.

"Ah, I see you've met Rick." Hamid Kasim appeared beside Will smiling broadly.

"Rick?"

"RICC. Robotic Intensive Care Cart. Yes. We are pioneering the use of these AGVs in this state. That's automated guided vehicles. They are used very often in Japan. RICC makes hourly rounds between the lab, the Coronary Care Unit, and the Neonatal Intensive Care Unit. And we've just gotten a new one..." --Hamid's voice was rising with enthusiasm--"…RACC, who goes to the Acute Care Unit. RACC is the most sophisticated. She..."

"She..?" Will was fascinated. Robots with gender.

"Yeah, the staff have decided we needed a more feminine robot. She has pink stripes. They've even programmed her to have a female sounding voice This robot goes to the Emergency Room on the first floor and several clinics and a lab on the second floor. She can commandeer elevators with an infrared connection. Visitors think it's very clever so they don't even mind when they have to make a few extra stops."

By this time RICC had rolled to a position near one of the lab stations. Will heard him announce himself "Hello. RICC is here. Please unload me quickly." A lab technician unlocked and opened a small drawer on RICC's side and removed several test tubes packed in ice. Several other drawers and doors were opened to produce more tubes, several petrie dishes, cups, and small plastic bags. Finally the technician closed all of the compartments and pushed several buttons on RICC's control panel. "Thank you. See you later, alligator." With that RICC rolled out a door on the far side of the lab.

"This fellow who maintains the robots ...he has a very grand sense of humor. He programs these robots to say all kinds of things." Hamid grinned. "The administration had to correct him because for awhile he had the robots rolling around the hospital speaking in rather colorful language--you understand my meaning? And they were insulting the medical staff, particularly the doctors. Needless to say, complaints were lodged."

"More stat tests coming from CCU, I see. Hamid addressed the technician who had unpacked the robot cart. "Let me guess. Dr. Gillespie's orders, right?". The technician nodded and shrugged.

Hamid was clearly irritated. "There are so many doctors around here who continue to order routine tests and label them "stat," he explained to Will. "It is creating a real problem for us. Now we will have to stop what we're doing to process those tests because they were flagged with the "stat" coding. And all the other work gets pushed back. Pretty soon the telephones will begin ringing -- everybody wanting to know what happened to the tests they have sent. "Stats" are supposed to be used for life-threatening emergencies only or when treatment decisions must be made quickly. It is the stated policy. But every doctor in this hospital thinks that his patients are a priority and this Gillespie in particular is, excuse me, a pain in the butt about it. Sends everything "stat." I have tried to explain the situation to her but it did no good."

"I have even spoken about this problem to Aaron Seymour," he continued. "You will not believe this, but he decided we should do a presentation for all the attendings and resident doctors to explain the proper use of the stat designation. So this is what we did. And do you know what?" Hamid leaned towards Will his raised eyebrows expressing his exasperation.

"Okay. I'll bite," said Will. "What?"

"The number of stat requests nearly doubled! The doctors have all decided that the only way to get their test results back is to use the "stat" request. So in the lab we have these great jam ups trying to process all those samples ASAP. Of course, now we can't recognize the real emergencies anymore!" As if to underscore Hamid's aggrieved observations, two phones began to ring simultaneously.

"It is just ruining our TATs."

Noting Will's puzzlement, Hamid went on, "Our turnaround times. We are following the total quality management model at Hampstead and one measure we use here in the lab is TAT. Turnaround time is determined from the time a doctor launches a request for a clinical lab test to be done on a patient until we post the results back to the patient's medical chart. The difficulty is there are so many variables over which we have no control. For instance, the number of stat requests, or how long the samples or requests sit on the floors before the nurses decide to send them off. Not to mention the charts themselves. We are posting to the electronic charts kept on the computer for each patient. But most doctors want to see hardcopy in the paper patient records. So someone on the unit has to be responsible for printing out a copy of the lab report. And that does not always get done."

Hamid pulled out a folder. "Let me show you our TAT reports. You will see how much the robots are improving the turnaround times from three years ago. I have placed check marks beside the tests the RBA is now performing. It is truly wonderful. But it is difficult to maintain these improvements with so many aggravations."

"There are some very fine medical doctors here but then these are the very doctors who complain all the time." Hamid reached out and clapped Will on the arm. "I am a doctor and you are a doctor, too, my friend--but I am afraid that very often in this hospital we are just not doctor enough."

Just at that moment Will was startled by a flashing red light which seemed to spiral down a glass tube from the ceiling in the center of the lab. The signal was accompanied by an audio alert.

A immense grin immediately wreathed itself around Hamid's face. "Great! You're in luck! That is what we call Roberta's Song. A blood sample has been input into a blood analyzer on one of the floors. The machine has done its analysis and the results have been posted to us. Now watch."

A lab tech walked over to a computer monitor and touched the screen. A set of numbers came up and the technologist studied them for a moment then touched the screen in several places. The screen flashed and went blank. The lab tech resumed what she had been doing.

"That's all there is to it. The results of the blood test have been posted to the patient's electronic chart." Hamid's pleasure in this technological feat was clear.

"Ah," Hamid replied, "it is CLIA regulations. The Clinical Laboratory Improvement Act sets the standards for how clinical labs are to be run and these rules say that only qualified laboratorians can approve test results. With this technology it may not be necessary eventually, but for now we must follow the rules."