The increase in the number of patients accessing the public health system and the disproportionate patient to healthcare provider ratio in developing countries necessitates more efficient and cost-effective approaches to healthcare provision.^1,2 The efficiency of healthcare providers is evaluated in part by how rapidly diagnoses are made and patients are prioritised for treatment.³ In addition, the rate at which laboratory results are made accessible to clinicians impacts both the patient outcome and the overall performance of a diagnostic laboratory.⁴ A prolonged turn-around time (TAT) results in delayed diagnosis and impacts the management of patients. This may lead to prolonged hospital stay and increased costs.^5,6 The consequences of prolonged TAT are more pronounced in an emergency service setting and in outpatient departments, where a narrow window of opportunity exists to make key management decisions.⁷ Therefore, constant monitoring and improvement of the TAT in this setting is important to ensure the efficiency of laboratory services.⁸

The TAT is crucial in clinical practice and is used as a measure of the performance of laboratories.⁵ However, the TAT definition often varies between laboratories and clinicians, often resulting in unrealistic expectations.^5,6,9,10 Total TAT is categorised into preanalytical, analytical and post-analytical stages and some define it as time from collection of the sample to when results are available for review by clinicians.⁹

Clinicians tend to view TAT as the time between requisition of a test and when they view a result.¹¹ Laboratories are inclined to exclude components of the test cycle that they have no control over, such as phlebotomy and specimen transport^12,13 because it is difficult for laboratories to address delays in these phases.⁵ Therefore, in laboratories, the TAT is usually defined as a measure of the time taken from sample registration to authorisation of results, also known as intra-lab TAT.⁵ Although this approach is not all inclusive of the phases of total TAT, it is generally accepted as the best representation of those elements of TAT that the laboratory controls.¹²

To assess the hypothesis that our laboratory performance was within set local benchmarks and comparable with the widely accepted international benchmark of completion of 90% of the sample processing within 60 min, we performed a retrospective analysis to evaluate the respective contribution of the various phases of the test cycle to the total TAT at Tygerberg Academic Hospital (TBH) in Cape Town, South Africa.¹⁴

A total of 1505 FBCs were requested between 01 February and 30 April 2018 from the haematology clinic, TBH, Cape Town. We performed an analysis on a subset of the retrieved FBC reports over the study period. A total of 329 (22%) patient reports were excluded either due to missing data (2 or more missing data points) or being reports for FBCs requested as part of a bone marrow biopsy (Figure 1). In all, this retrospective study included a total of 1176 FBC reports. Delays in registration of samples after receipt by the laboratory would not be reflected on the intra-laboratory TAT but on the total TAT. Therefore, a sub-analysis of the phase between collection and registration was performed for the month of April 2018. This comprised 412 samples for the phase between collection of samples to receipt in the laboratory and 420 samples for the phase from receipt to registration. Seventy percent of the 1176 samples were collected by 9:00 and 90% by 11.00. Considering the closing time of the clinic, the clinicians had a window of 7 h and 5 h to receive results and make clinical decisions for 70% and 90% of patients.

The constant increase in medical care cost and the growing demand for improved quality of care has necessitated the monitoring of determinants of the quality of healthcare services.^17,18 The TAT is one of the determinants that is commonly measured, as it is both objective and easily measured.¹⁹ However, different views exist regarding the definition of what the composition of the TAT should be. These are often compounded by the lack of an interface for dialogue between the laboratory staff and clinicians. Howanitz et al. showed that there was also no agreement among clinicians as to the definition of TAT, with 56% using test requisition as the first step of TAT, while 44% used the time of phlebotomy as the initial step. Although most studies use reporting of results as the endpoint of TAT,¹⁷ this study defined total TAT as the time period from the time of phlebotomy to the time the results are reviewed by clinicians, whereas we considered the intra-laboratory TAT as the time from registration of the sample to reporting of results (authorisation). This was done in efforts to determine the relative contribution of different phases of the laboratory process to TAT and to identify phases requiring the most attention in alleviating delays. This study showed that the phases outside of the laboratory environment needed the most attention and that the laboratory was meeting its predetermined mandate.

Samples from the haematology outpatient department at TBH are regarded as urgent because for most patients, FBCs are required to make decisions on chemotherapy, transfusion and other interventions before leaving the clinic. The results of this study were therefore compared to findings of studies on TAT of emergency departments. Our findings were similar to those previously reported.^5,20 The preanalytical and post-analytical phases accounted for a greater proportion of the total TAT, with a median of 60 min transportation time (preanalytical phase) and 48.9% of the post-analytical phase taking more than 120 min. In contrast, most of the samples were processed in the laboratory within 90 min. The median intra-lab TAT was 55 (IQR 40–81) min and 90% of samples were authorised within 134 min. Therefore, our findings suggest that the laboratory is performing within the set threshold of 3 h as stated by the TBH laboratory standard operating procedure HAE1813 for tests from the haematology clinic. This highlights the need to further interrogate the phases that the laboratory has no control over, that is, the preanalytical and post-analytical phases.

In addition to the lack of consensus on the definition of TAT, there is also no specific benchmark for TAT parameters.²¹ However, databases used to benchmark TAT thresholds can be obtained from the College of American Pathologists Q-Probes and Q-Tracks programmes.¹⁶ We therefore used these databases and experiences from other international hospitals to assess our performance. The 1998 College of American Pathologists Q-Probes study of emergency department TATs showed a 90% completion time for haemoglobin testing of 55 min or less.²² In this study 90% completion time of 60 min or less is recommended,²² as opposed to that of TBH which is 134 min. In a survey carried out in Nigeria involving 109 doctors, 91.3% of the respondents considered a TAT of less than 2 h as ideal for their laboratory, although their median TAT in emergency rooms was 5.12 h.²³ In a Chinese national survey the median intra-lab TAT for white blood cells was 44.7 min.²⁴ Although our laboratory performance was within the local threshold, our laboratory performed below the expectations when compared to other laboratories in a similar setting.^5,7,23,24 The April sub-analysis exposed the sorting area as a problematic area that is responsible for prolongation of the intra-lab TAT and ultimately total TAT. Few studies focus on the analysis of this phase as the time of receipt of samples in the laboratory is often missing; therefore, the study at New York Presbyterian Hospital, which analysed total TAT with emphasis on quantification of sorting time, was best suited for comparison with this study.¹² As with this study, sorting time was also prolonged at New York Presbyterian Hospital. Opening of sample bags, generation and printing of barcodes and decoding handwritten requests were responsible for the delays in the sorting area, which is also partly the case at TBH.¹² Electronic requesting of tests as well as the generation of barcodes at the time of requesting tests were suggested as solutions to this delay.¹²

Total TAT was significantly prolonged compared to the expected TAT, with phases outside the laboratory causing the most delay. The time taken to view results by clinicians was the longest with a median time of 114 (IQR 37.0–1338.5) min. This could be due to the limited period during which clinicians can view results. Once this window has elapsed the results can only be viewed on the patient’s next appointment which can vary from a day to several months later. This is a limitation of total TAT in assessing laboratory performance, which explains in part why laboratories resort to the use of intra-lab TAT.¹² These delays can be improved by ensuring patients’ punctuality and having the laboratory contact the clinicians with results as soon as they are authorised. The other cause of delay for total TAT was the time taken to transport samples from the clinic to the laboratory as well as sorting time. Porters tend to wait for samples to pile up before transporting them. Having a set time for phlebotomy and ensuring that patients avail themselves at this time may mitigate this problem. In addition, the use of pneumatic tube systems results in faster and reliable transportation of samples.^25,26

As it is noted that a pragmatic approach is to set TAT goals locally, informed by both the published literature and by local expectations,⁵ we made the following recommendations: establishment of point-of-care testing at the haematology clinic, employment of additional staff for the sorting area or the use of an automated barcode system, and the use of pneumatic tube systems. We also recommend the use of an interactive TAT dashboard, a recently described system that offers information to enable the review of performance in real time.²⁷ This may help in ensuring timely response to changes in performance. However, solutions requiring extra funding may take time to implement due to economic challenges facing the health sector in South Africa.^2,28 As noted earlier, some results are only reviewed on the patient’s next visit and this may pose serious challenges to patient care. Therefore, the use of other communication avenues such as short message services, WhatsApp, or emails to send authorised results to clinicians is recommended. Not only will this improve the total TAT, but it will also allow clinicians to act on results immediately rather than waiting for the patient’s next appointment. Another suggestion is for clinicians to employ a clerk to review results even after the clinicians have left the clinic. For the laboratory, we recommend that considerations be made to incorporate phlebotomy and specimen transportation services into its armamentarium of service delivery. This will increase laboratory influence on preanalytical processes and subsequently improve total TAT.