Medical Laboratory Observer
by Bernard L. Kasten, MD

"Printing bar-coded patient ID wristbands in admissions is the first step in getting patient processing and tracking off to a perfect start," says Ann Renner, director of admitting at South Fulton Medical Center, a 427-bed, not-for-profit, tertiary care facility in Atlanta that took the plunge late last year. Once patients are bar coded, positive ID for blood specimens, test orders, X-rays, billing and numerous other hospital procedures can be accomplished accurately and rapidly, with dramatically reduced potential for error.

While no hard and fast figures are available, bar-coded ID wristbands cost a bit more than traditional bracelets. The wristbands, however, reduce patient processing time throughout the hospital and decrease misreading and mis-keying of information more than enough to compensate for the added up-front expense.

Hospitals that have implemented this system have found patient reaction extremely positive. The reduced hassle in admissions typically leaves even the most skeptical patients with the impression that their stay may not be as laden with red tape as they anticipated. Patients see that they are being cared for in an efficient, high-tech environment, and respond favorably to it.
 

"To automate specimen identification, a bar code specimen ID system should be integrated fully with the hospital information system and the laboratory information system," says Franklin Elevitch, MD, chairman of the College of American Pathologists’ informatics committee and director of clinical laboratories at El Camino Hospital in Mountain View, California.

A fully integrated system allows bar code labels in collection list form—printed by an intelligent, wide-carriage printer—to be generated immediately upon an order reaching the lab. That enables the phlebotomist to have labels ready for application at the bedside.
 

Before a phlebotomy round, collection list information is downloaded to a hand-held bar code reading terminal that stores each patient’s name, hospital number, lab accession number, and test order. While in the patient’s room to make the draw, the phlebotomist scans the patient’s bar-coded ID wristband to verify identify and test order match. Once back in the lab, the phlebotomist uploads the information from the terminal to the LIS, giving the lab accurate collection data that includes positive patient ID, phlebotomist ID, time of collection, and time of receipt in the lab. Errors and processing time are minimized simultaneously.
 

"The ideal lab has bi-directional interfaces between its LIS and its bar code-reading analyzers," says Charlotte Taylor, director of laboratory operations at Washington Hospital Center, a 911-bed, not-for-profit facility in Washington, DC. "When bar-coded specimens arrive in the lab, they are scanned quickly using a hand-held laser or wand, rather than entered manually into a computer. Test orders are downloaded automatically to analyzers, eliminating the need for technologists to read work lists and re-label specimens at the analyzers.

"When you consider the number of specimens that pass through the average lab each day and the total amount of time required for manual entry, the time saved by bar coding specimens becomes very apparent," Taylor says.
 

Since re-labeling of specimens and placement of them in a specific order are not required, the chance for specimen identification error is significantly reduced. The analyzer identifies each specimen by its bar-coded accession number and performs the specified tests. Once this process is complete, the analyzer automatically uploads test results to the LIS, making them available on CRTs throughout the hospital. The end result is that the same number of laboratory staff can handle a significantly increased volume of tests.

Elevitch suggests that a hand-held terminal coupled with a mobile instrument cart for point-of-care testing can add to the overall efficiency of a bar code-based system. "The conflict," he contends, "will be whether or not the economy of scale in central lab processing outweighs the convenience of point-of-care testing."

Among Elevitch’s other suggestions for the clever application of bar codes is one that works for an instrument that is not bi-directionally interfaced with the LIS but which has a bar code scanner. The laboratorian can create a work list on the analyzer by lining up a series of specimens—20 or 30 urines, for example—and "wanding" their bar code labels.

In addition, the laboratorian can append comments to a report by wanding a menu of bar-coded comments. Rather than keying in "specimen hemolyzed," for example, he or she can simply wand the bar code next to that particular comment. Such a system of bar codes, with a menu of fees, could also be used to post charges, Elevitch explains.
 

"Because so many patients pass through the emergency room every year and because ER costs are so out of control, the ER is a prime area for the integration of bar-coded ID wristbands," says George Vaughn, administrative laboratory director at South Fulton Medical Center.

The fast-paced environment of emergency rooms makes them perhaps the most highly prone of any department to costly mistakes. Patients are constantly moved around and specimen mix-ups can happen easily. The combination of a patient with a bar-coded ID wristband and a phlebotomist with a hand-held, bar code reading terminal is the ideal remedy for looming identification disasters.
 

The growth in the number of autologous blood donors in recent years has provided the blood bank with increased incentive to adopt bar code technology.

The ideal system provides each autologous donor with a permanent ID number and a removable, bar-coded ID wristband wanded to produce a label (Printed by an intelligent, narrow-carriage, stand-alone printer). The label is placed on a blood bag before the first unit is drawn. Each time an extra unit is drawn, the wristband is wanded again to produce an identical label.

When the patient is admitted to the hospital, the permanent bar code ID number on his or her wristband allows virtually fail-safe matching of patient and blood during surgery.
 

Let’s look at the hardware and software found in an ideal bar code system.

While the initial cost of a system is generally of concern to hospital administrators, bar coding is a "can no longer function efficiently or cost-effectively without it" technology. Hospitals are left with no choice but to start planning for its arrival.

There are, however, ways to trim costs. According to Taylor, creating a collection list using an intelligent, wide-carriage printer with resident interface software saved Washington Hospital $10,000 a year over the secondary relabeling method and $1,4000 a year over upgrading the LIS to permit the creation of collection lists.1 Also, a bar code collection list system that uses an intelligent printer can be brought on line faster than a LIS upgrade.
 

The selection of a bar code printer is critical in the establishment of the ideal system. The guidelines are simple: the higher the intelligence of the printer, the better it will perform and the easier interfacing will be.

In addition, higher intelligence printers allow multiple bar coding symbologies (styles or languages) to appear on the same collection list. Although higher prices typically accompany greater intelligence, the return on investment renders the initial cost trivial.
 

One of the most common problems that labs experience with bar coding equipment is a poor quality printout resulting in a low first-read rate. Check print quality before buying a printer. Less expensive units may reduce implementation costs, but the end result may be major disruptions in processing due to the need to key by hand the accession numbers on "no read" bar code tubes.

Thermal bar code printers are the most efficient for printing laboratory collection lists. These machines provide a higher quality bar code by heating sections of thermal labels to form black characters on label stock that is barrier coated to resist solvents and other liquids commonly found in the lab. Thermal printers have relatively few moving parts and require no ribbon changes or toner additions. Although they are typically more expensive, the advantages of thermal printers make them well worth the cost.

Wide or narrow carriage? Wide-carriage printers are the best choice for bar-coded collection lists. If they are intelligent, they allow the printing of multiple symbologies on the same line of labels. Since only one of several bar code symbologies that an analyzer is capable of reading achieves the greatest read rate, labs can create the label that works best for each instrument.

Wide-carriage printers also allow labs to custom design their own label format, an option that is especially important if future lab growth entails the addition of equipment that requires different label formats and layouts. It is also possible to print large and small bar codes together and still have space for readable information.2

Narrow-carriage printers are best for stand-alone uses such as point-of-application labeling and generating labels for aliquots and derivative specimens.
 

Bar code readers play an important role in the overall efficiency of a system. Contact light pens, non-contact, and hand-held laser scanners extract the information that is optically encoded in bar code symbols.

Light pens or wands are the most common and inexpensive bar code input devices used in the laboratory. A light pen with a keyboard wedge adds bar code reading capability to an existing computer without the need for special programming. All data collected from the scanning of a symbol are treated as though manually entered on the keyboard and remain available for simultaneous use on other work.

Since hand-held laser scanners require no direct contact with bar codes, they are ideal for the rapid reading needs of the laboratory during specimen log in. They can connect to a keyboard using a wedge and can read a code from moderate distances. This feature eliminates the need for technologists to concentrate on aligning the tube in a certain way. Laser scanners also allow the reading of bar codes on moderately irregular surfaces.

Though hand-held laser scanners are more efficient than light pens, the fact that they typically cost three to four times more often makes them less attractive to laboratory managers. Many feel their efficiency overrides the cost factor, however.
 

Battery-powered and hand-held, portable data collection terminals combine scanner, decoder, and data storage. They allow the user to retain data as it is collected and download it to a host computer at a later time.

Data collection terminals can be used in many settings, including the bedside, the laboratory, and the emergency room. They are essential to rounding out the ideal bar code system.
 

There are hospitals across the country that can attest, from first-hand experience, to the fact that bar coding is a tremendously efficient and cost-effective technology. It is already well established in the departments mentioned in this article. Wider application, perhaps along the lines of Elevitch’s creative suggestions, will certainly follow suit.

Ever since the implementation of a bar code collection list system at our institution, I have been impressed with the high level of efficiency, productivity, and cost savings that have resulted. We are happy with our accomplishments in the bar coding arena so far and are looking forward to further integrating the technology in other hospital departments including intensive care and cardiac care.

By the end of the decade, all hospitals will use bar coding in the lab. Many hospitals will be well on their way to implementing the ideal system, one that integrates patient ID with the delivery of many health care services. By that time laboratorians, among others, will strain to remember just how patient and specimen ID was accomplished before the advent and integration of such a useful technology.