Context.—Rapid diagnosis of acute myocardial infarction in patients presenting to emergency departments (EDs) with chest pain may determine the types, and predict the outcomes of, the therapy those patients receive. The amount of time consumed in establishing diagnoses of acute myocardial infarction may depend in part on that consumed in the generation of the blood test results measuring myocardial injury.

Objective.—To determine the normative rates of turnaround time (TAT) for biochemical markers of myocardial injury and to examine hospital and laboratory practices associated with faster TATs.

Design.—Laboratory personnel in institutions enrolled in the College of American Pathologists Q-Probes Program measured the order-to-report TATs for serum creatine kinase–MB and/or serum troponin (I or T) for patients presenting to their hospital EDs with symptoms of acute myocardial infarction. Laboratory personnel also completed detailed questionnaires characterizing their laboratories' and hospitals' practices related to testing for biochemical markers of myocardial injury. ED physicians completed questionnaires indicating their satisfaction with testing for biochemical markers of myocardial injury in their hospitals.

Setting.—A total of 159 hospitals, predominantly located in the United States, participating in the College of American Pathologists Q-Probes Program.

Results.—Most (82%) laboratory participants indicated that they believed a reasonable order-to-report TATs for biochemical markers of myocardial injury to be 60 minutes or less. Most (75%) of the 1352 ED physicians who completed satisfaction questionnaires believed that the results of tests measuring myocardial injury should be reported back to them in 45 minutes or less, measured from the time that they ordered those tests. Participants submitted TAT data for 7020 troponin and 4368 creatine kinase–MB determinations. On average, they reported 90% of myocardial injury marker results in slightly more than 90 minutes measured from the time that those tests were ordered. Among the fastest performing 25% of participants (75th percentile and above), median order-to-report troponin and creatine kinase–MB TATs were equal to 50 and 48.3 minutes or less, respectively. Shorter troponin TATs were associated with performing cardiac marker studies in EDs or other peripheral laboratories compared to (1) performing tests in central hospital laboratories, and (2) having cardiac marker specimens obtained by laboratory rather than by nonlaboratory personnel.

Conclusion.—The TAT expectations of the ED physicians using the results of laboratory tests measuring myocardial injury exceed those of the laboratory personnel providing the results of those tests. The actual TATs of myocardial injury testing meet the expectations of neither the providers of those tests nor the users of those test results. Improving TAT performance will require that the providers and users of laboratory services work together to develop standards that meet the needs of the medical staff and that are reasonably achievable by laboratory personnel.

The swiftness with which physicians establish diagnoses of acute myocardial infarction (AMI) in patients presenting to emergency departments (EDs) with chest pain may determine the types, and predict the outcomes of, the therapy those patients receive.1 For these reasons, the Joint Commission on Accreditation of Healthcare Organization's recommended list of core performance measurements includes monitoring the time elapsed between the onset of chest pain occurring in patients suspected of having myocardial infarction and the commencement of thrombolytic and angioplasty therapy in those patients subsequently documented to indeed be experiencing myocardial infarction.2 

Included in the total amount of time consumed in establishing diagnoses of AMI are the component intervals required to collect diagnostic data, including those intervals consumed in determining biochemical markers of myocardial injury. Laboratory accreditation by the College of American Pathologists requires that personnel assess whether or not their services meet the temporal needs of clinicians in their medical communities.3 There is as yet no established turnaround time (TAT) benchmark for the delivery of test results measuring myocardial injury.

Since 1989, the College of American Pathologists Q-Probes Program has conducted multi-institutional studies that have determined a broad range of performance benchmarks in anatomic pathology and laboratory medicine.4 Laboratories participating in these studies worldwide, representing the entire spectrum of practice styles, have been able to compare their performances to those of their peers. Previous Q-Probes studies have established TAT benchmarks for a variety of stat and routine services in laboratory medicine and anatomic pathology.5–16 

In this Q-Probes study, we assessed the normative rates of TAT for biochemical markers of myocardial injury ordered for patients presenting to EDs with symptoms suggestive of myocardial infarction, and we examined the hospital and laboratory practices associated with faster TATs. We also assessed the degree of satisfaction with cardiac marker testing TATs among the clinicians ordering those tests.

Laboratory personnel in institutions enrolled in the College of American Pathologists Q-Probes Program participated in this study. The study was conducted and the data were handled in a manner similar to that previously described.17 Upon their enrollment in the Q-Probes Program, participants from each institution submitted certain demographic information, including their geographic location, community classification (city, suburban, or rural), teaching status, residency program status, occupied bed size, and both hospital and laboratory accreditation status.

Participants were asked to record the TATs for serum creatine kinase (CK)–MB and/or serum troponin (I or T) (cardiac markers) measured for patients presenting to their hospital EDs with symptoms of myocardial infarction. TATs were measured from the time that health care personnel ordered these tests (order times) to the earliest time that test results were made available to the health care workers who had ordered them (report times). Designating “earliest” times allowed participants to indicate reporting times that applied to protocols existing in their own institutions. For instance, in some institutions, routine procedures may have directed laboratory personnel to issue results of qualitative testing as soon as those results were available. In other institutions, routine procedures may have directed laboratory personnel to issue final results only after qualitative results were confirmed by quantitative testing.

To avoid skewing the data, participants were asked to select randomly one specimen from the day period (6:00 am to 5:59 pm) and one specimen from the night period (6:00 pm to 5:59 am) and to vary the times during those periods in which the specimens were collected. Participants were asked to include tests that may have been ordered singly, as part of panels that included other laboratory tests (including other markers of myocardial injury), that had been performed on both laboratory and point-of-care (POC) instruments, and specimens that had been collected by nonlaboratory personnel in addition to those collected by laboratory personnel. Specifically excluded from this study were tests ordered after samples were delivered to laboratories.

From the aggregate data, we determined the TATs for all troponin and CK-MB tests. We also calculated the median and 90th percentile TATs (the times by which 50% and 90% of all troponin and CK-MB marker studies were completed) for each participating institution. We organized these times into percentile distributions in order to compare performances among the participants.

We evaluated the effects of various practice characteristics on the TATs. By completing detailed questionnaires, participants indicated the following:

  • The yearly number of patient visits to their EDs. Whether or not the turnaround TAT goals had been established for biochemical markers of myocardial injury in their hospitals. Whether or not hospital personnel routinely monitored TAT for biochemical markers of myocardial injury

  • Which biochemical markers of myocardial injury (CK-MB, quantitative troponin, qualitative troponin, and myoglobin) were performed in their laboratories, which were routinely ordered on ED patients presenting with signs and symptoms of AMI, and which were performed in the ED on POC instruments

  • Whether most ED specimens for biochemical markers of myocardial injury were collected by laboratory personnel, nonlaboratory personnel, or equally by laboratory and nonlaboratory personnel

  • Which type of specimen (whole blood, serum, or plasma) was most often collected for tests of biochemical markers of myocardial injury performed in the ED (on conventional or POC instruments) and the main laboratory

  • Whether the results of biochemical markers of myocardial injury performed on analyzers other than POC instruments were most commonly reported to the ED by telephone, computer, fax, or other methods

  • Whether the results of biochemical markers of myocardial injury, when performed as designated panels, were routinely reported as each result was available or only reported as a panel when all results were available

  • Whether most biochemical markers of myocardial injury were performed in the main hospital laboratory, in the ED, or in some other location

  • Whether positive qualitative troponin results were confirmed by quantitative results prior to reporting their results

  • Whether biochemical markers of myocardial injury were ordered reflexively on patients presenting with diagnoses that required ruling out myocardial infarction or whether cardiac markers were ordered only after patients were seen by ED physicians

  • The types of instruments on which CK-MB and troponin were performed

If a participant failed to answer a question for any of these practice characteristics, that participant's data were excluded from the database for that question only. We evaluated the frequencies of these practice variables occurring in the various percentiles of TATs and used Wilcoxon and Kruskal-Wallis tests to assess differences among these groups. We considered a P-value of .05 or less to be statistically significant. Data from institutions in which fewer than 20 TAT cases were submitted were not included in this analysis.

To determine whether or not clinicians were satisfied with TATs for biochemical markers of myocardial injury, we asked participants to distribute questionnaires to at least 25 physicians who ordered cardiac markers on ED patients routinely, including ED physicians, cardiologists, and general internists. Specifically, physicians were asked to indicate the following:

  • Whether they preferred to have the results of different cardiac marker tests reported as each result became available or whether they preferred to have laboratory personnel hold the results and report them as a panel when all were available

  • Whether they relied on the results of CK-MB, troponin, or both equally when making therapeutic and triage decisions for patients with symptoms suggestive of myocardial infarction

  • The frequency with which the TATs of biochemical markers of myocardial injury met their expectations

  • The frequency with which delays in reporting the results of biochemical markers of myocardial injury contributed to delays in the treatment of ED patients or prolonged their ED stays

  • Their opinion of a reasonable, maximum order-to-report TAT for biochemical markers of myocardial injury

This study was not intended to validate the efficacy of biochemical markers of myocardial injury testing, to assess the superiority of tests in comparison with one another, or to evaluate the TATs for other biochemical markers of myocardial injury such as myoglobin. We did not attempt to explore the impact of myocardial injury testing on laboratory efficiency or finances, and we did not attempt to associate the TATs of myocardial injury testing with the clinical outcomes of patients.

Laboratory personnel representing 159 institutions located in the United States (38 states; n = 150, 94.3%), Canada (n = 6, 3.8%), Australia (n = 1, 0.6%), Mexico (n = 1, 0.6%), and Saudi Arabia (n = 1, 0.6%) participated in this study. Table 1 shows the demographics, and Table 2 shows the selected testing practices of the institutions participating in this study. In addition to those practice characteristics listed in Table 2, 36 participants indicated that they performed troponin by qualitative methodology, all but one of which reported the results of that qualitative testing without confirmation by quantitative methods. Eleven (7.2%) participants performed cardiac marker testing in the EDs or other peripheral laboratories more commonly than in the central laboratories. Six (4.1%) participants performed cardiac marker testing on POC instruments located in EDs.

Table 1.

Demographic Characteristics of Participating Institutions (N = 159)

Demographic Characteristics of Participating Institutions (N = 159)
Demographic Characteristics of Participating Institutions (N = 159)
Table 2.

Practice Characteristics of Participating Institutions (N = 159)*

Practice Characteristics of Participating Institutions (N = 159)*
Practice Characteristics of Participating Institutions (N = 159)*

A total of 1441 physicians representing 137 of the 159 institutions participating in this study completed questionnaires that indicated their preferences concerning, and their satisfaction with testing for, biochemical markers of myocardial injury testing in their hospitals. These data are summarized in Table 3. Table 4 shows the aggregate percentile distribution for the 7020 troponin and 4368 CK-MB TATs for which participants submitted data. For instance, 10% of the 7020 troponin results were reported in 36 minutes or less measured from the times that those troponin tests were ordered. Twenty-five percent of the CK-MB results were received in the laboratory in 8 minutes or less measured from the times those tests were ordered.

Table 3.

Physician Satisfaction With and Preferences Concerning Cardiac Marker Testing (N = 1441)*

Physician Satisfaction With and Preferences Concerning Cardiac Marker Testing (N = 1441)*
Physician Satisfaction With and Preferences Concerning Cardiac Marker Testing (N = 1441)*
Table 4.

Percentile Distribution of Aggregate Turnaround Times of Biochemical Markers of Acute Myocardial Injury Measured From the Times Those Tests Were Ordered to the Times the Results Were Reported to Emergency Department Personnel

Percentile Distribution of Aggregate Turnaround Times of Biochemical Markers of Acute Myocardial Injury Measured From the Times Those Tests Were Ordered to the Times the Results Were Reported to Emergency Department Personnel
Percentile Distribution of Aggregate Turnaround Times of Biochemical Markers of Acute Myocardial Injury Measured From the Times Those Tests Were Ordered to the Times the Results Were Reported to Emergency Department Personnel

Table 5 shows the median and 90th percentile order-to-report TATs for the 158 participants providing troponin data and the 112 participants providing CK-MB data. For instance, among the fastest performing 10% of hospitals (90th percentile and above), 50% of all troponin values were reported in 45 minutes or less, and 90% of all troponin values were reported in 66.5 minutes or less, measured from the times that those tests were ordered. Among the slowest performing 10% of hospitals (10th percentile and below), 50% of all CK-MB values were reported in 82 minutes or more, and 90% of all CK-MB values were reported in 131 minutes or more. On average, personnel in participating institutions released 50% of their cardiac marker results in just less than 1 hour and 90% of their cardiac marker results in just more than 1½ hours.

Table 5.

Percentile Distribution of Median and 90th Percentile Institutional Cardiac Marker Order-to-Report Turnaround Times (Minutes)

Percentile Distribution of Median and 90th Percentile Institutional Cardiac Marker Order-to-Report Turnaround Times (Minutes)
Percentile Distribution of Median and 90th Percentile Institutional Cardiac Marker Order-to-Report Turnaround Times (Minutes)

The Figure shows the median TAT expectations among clinicians ordering biochemical markers of myocardial injury studies, the estimates of reasonable TATs among the participating laboratorians performing these studies, and the actual institutional TATs for the 119 participating institutions providing data for all 3 of these measures. For instance, the median maximum TAT for biochemical markers of myocardial injury acceptable to all clinicians was 37.5 minutes. The median maximum TAT that laboratorians believed to be reasonable was 60 minutes. (This time encompassed opinions ranging from the 22nd to the 82nd percentiles.) The median time by which participants in these 119 institutions reported 90% of their myocardial injury test results was 91 minutes. The differences among these 3 groups were statistically significant (P < .001).

Comparison of physicians' expectations, laboratorians' reasonable test turnaround time estimations, and actual median test turnaround time that institutions reported 90% of their myocardial injury test results. The box plots denote percentile rankings of turnaround times. Higher percentile rankings denote shorter turnaround times, and lower percentile rankings denote longer turnaround times. The bottom thick horizontal lines represent the 90th percentiles, and the top thick horizontal lines represent the 10th percentiles. The height of the box encompasses the middle 50% of participants; the bottom of the box represents the 75th percentile, and the top of the box represents the 25th percentile. The broken horizontal line represents the median. TAT indicates turnaround time

Comparison of physicians' expectations, laboratorians' reasonable test turnaround time estimations, and actual median test turnaround time that institutions reported 90% of their myocardial injury test results. The box plots denote percentile rankings of turnaround times. Higher percentile rankings denote shorter turnaround times, and lower percentile rankings denote longer turnaround times. The bottom thick horizontal lines represent the 90th percentiles, and the top thick horizontal lines represent the 10th percentiles. The height of the box encompasses the middle 50% of participants; the bottom of the box represents the 75th percentile, and the top of the box represents the 25th percentile. The broken horizontal line represents the median. TAT indicates turnaround time

Close modal

Two of the institutional practices about which we inquired were associated with shorter median and 90th percentile troponin order-to-report TATs. These TATs were 54.8 and 81.8 minutes, respectively, in hospitals in which laboratory personnel collected ED cardiac marker specimens, compared to 60.0 and 101.5 minutes, respectively, in hospitals in which nonlaboratory personnel collected these specimens, and were 44.5 and 76.5 minutes, respectively, in hospitals in which cardiac marker tests were performed in EDs or other peripheral laboratories compared to 58.5 and 94.0 minutes, respectively, in hospitals in which these tests were performed in main hospital laboratories. These differences were statistically significant (P < .05). Nearly identical trends were found for the CK-MB data, but too few participants submitted CK-MB data to exhibit statistical significance (data not shown).

The AMI treatment guidelines of the American College of Cardiology and the American Heart Association recommend that ED physicians initiate thrombolytic therapy in patients presenting with AMI (so-called door-to-needle time) within 30 minutes.1 The diagnosis of AMI is usually confirmed by examination of the electrocardiogram. Occasionally, electrocardiographic changes are nondiagnostic, and clinicians must rely on other clues, including the results of biochemical markers of myocardial injury. In such circumstances, the timely delivery of those results is crucial in advancing therapy. In this Q-Probes study, we endeavored to determine the normative distribution of order-to-report TATs for the delivery of troponin and CK-MB results ordered for patients presenting to EDs with signs and symptoms of AMI and to examine selected hospital and laboratory practices associated with shorter TATs.

Q-Probes studies are designed to accomplish this task. Unlike most published investigations that describe the experiences within individual institutions, many of which are academic and/or presumably have homogeneous practice environments, Q-Probes studies reflect the daily experiences of a large, heterogeneous group of hospitals that serve diverse community populations and that vary widely in their practice characteristics. In short, Q-Probes studies are designed to provide a snapshot of laboratory practices in the United States. By having the normative rates of selected parameters of quality available to them, participants in Q-Probes studies are able to derive benchmarks of quality that they believe are appropriate to apply in their own communities. Most participants in this Q-Probes study practiced in private (68.6%), nongovernmental (79.3%), and nonteaching hospitals (70.1%) with 300 or fewer occupied beds (79.6%).

The TATs for the 7020 troponin and 4368 CK-MB determinations performed in this study were nearly identical. The most rapidly delivered one fourth (75th percentile and above) of the cardiac marker test results were released to clinicians within 45 minutes of the time the tests were ordered. In general, these samples reached the laboratory within 10 minutes of the time that the studies were ordered, and the tests were performed within about 30 minutes of the time that those samples reached the laboratories. At the other extreme, the most prolonged one fourth (25th percentile and below) of the cardiac marker test results took more than 1¼ hours to reach clinicians from the time the studies were ordered. These TATs reflected delays in both preanalytic (order-to-receipt times) and analytic (receipt-to-report times) phases of testing. In general, these specimens took ½ hour or more to reach the laboratory and almost 1 hour to complete testing.

TAT performances varied considerably among participants. The top-performing one fourth of the institutions took more than 1 hour (at most 73 minutes) to generate 90% of their myocardial injury test results. The bottom-performing one fourth of the institutions took longer than 1½ hours (at least 108 minutes) to generate 90% of their myocardial injury test results. In 10% of participating hospitals, clinicians waited more than 2 hours for results of myocardial injury testing.

Most (80%) participants had established TAT goals and were actively monitoring their TAT performances at the time of their enrollments in this study. However, the establishment of TAT goals was not associated with shorter TATs. Although the findings of a previous Q-Probes study showed that setting deadlines for reporting test results was not associated with laboratories' abilities to meet those deadlines,18 data from a Q-Tracks monitor for a 2-year period showed steady ongoing improvement in the performance of 4 different quality indicators.19 

Too few participants (4.1%) performed myocardial injury testing on POC instruments to allow us to evaluate their use on TAT. However, responses to a similar survey question inquiring where, rather than on what type of instrument, myocardial injury testing was performed indicated that shorter troponin TATs were associated with performing cardiac marker studies in EDs or other peripheral laboratories than with performing cardiac marker studies in central hospital laboratories. We have no way of knowing how many of these ED or satellite laboratory tests were performed on POC instruments and how many were performed on conventional stationary instruments located in these areas. This finding is in contrast to that of a previous Q-Probes study, which showed that shorter ED stat test TATs were not associated with laboratory testing in ED satellite laboratories.6 Additional TAT studies that include larger numbers of participants using cardiac marker POC testing will be necessary to determine whether or not POC testing shortens TATs for tests of biochemical markers of myocardial injury.

Troponin TATs were shorter when laboratory personnel obtained cardiac marker specimens than when nonlaboratory personnel obtained these specimens. This finding was consistent with that from a previous Q-Probes study, which demonstrated shorter TATs when laboratory personnel rather than nonlaboratory personnel obtained ED specimens and transported them to the laboratory.6 We have no way of knowing whether the training of laboratory personnel instills in these health care workers a greater commitment to the urgency of transporting laboratory specimens than that already present in nonlaboratory personnel. Specifically, we were unable to exclude the possibility that specimens on which cardiac marker studies were ordered immediately upon collection by nonlaboratory personnel were in fact held for some time prior to their conveyances to central laboratories.

The failure of this study to associate other specific practices with shorter TATs is not to say that altering some of these practices would not improve performance in certain institutions. We have no way of knowing whether personnel in faster performing institutions lacking these practices compensated by using other practices about which we neglected to inquire or whether, in slower performing institutions in which personnel did use these practices, there were other operational flaws about which we neglected to inquire. Certainly, hospitals with prolonged TATs, especially those performing at or below the slowest 10th percentile, would do well to investigate the possibility that any of the practices enumerated in this study would improve performance in their own institutions.

TAT is a quality control measurement of process that evaluates, among other things, the efficiency with which laboratory services are provided. Measuring the outcome of that service is a more complicated matter. It requires determining whether or not timely service is associated with better treatment results. Such a measurement is beyond what Q-Probe studies are designed to accomplish. Perhaps the next best measurement of outcome is determining whether or not the timeliness with which laboratory services are provided meets the needs of the physicians who require those services. We assessed this satisfaction by asking ED clinicians how they felt about their laboratories' performances with regard to the testing of biochemical markers of myocardial injury.

A total of 1441 physicians who routinely treated ED patients presenting with AMI in 137 of the 159 participating hospitals completed questionnaires indicating their preferences regarding the reporting of biochemical marker results of myocardial injury and their satisfaction with the myocardial injury testing services in their hospitals. Although 84% of these clinicians preferred that, when performed as part of a myocardial injury testing panel, each test result be reported as it became available, only 64% of participating institutions reported such results in that way. In one third of the institutions, laboratory policies dictated that no result be reported until all results were available. Policies such as this, well intentioned in their aim to maximize efficiency as they may be, may unknowingly run counter to the needs of physicians using laboratory services. As a result, laboratory services may be delayed, and service users may perceive that service providers are insensitive to their needs. In about half of the hospitals participating in this study, specimens were ordered by protocol before clinicians even saw their ED patients. This may explain why most myocardial injury specimens were obtained by nonlaboratory health care personnel. The clinicians ordering these tests may have had their mental TAT clocks running for some time before these tests were ordered and certainly before laboratory personnel were requested to run the tests. A scenario such as this may heighten the urgency associated with the delivery of these test results.

Indeed, more than one fourth of the ED physicians using laboratory services claimed that TATs for biochemical markers of myocardial injury did not always or did not usually meet their expectations, half believed that prolonged TATs delayed treatment of patients presenting with AMI, and more than half believed that excessive TATs prolonged ED patient stays. We believe these negative opinions are explained by the distances that separate the perceptions of the users from the suppliers of laboratory services. On average, users believed that biochemical markers of myocardial injury should be reported in less than 40 minutes, and providers believed it acceptable to report these results in 1 hour measured from the time that the tests were ordered. With such divergent standards, the level of dissatisfaction among clinicians is not surprising. On average, participants reported 90% of their order-to-report cardiac marker results in more than 90 minutes, which met the expectations of neither the providers nor the users of these tests.

The first step in delivering laboratory services or, for that matter, in delivering any ancillary medical services in a timely fashion, requires that the providers and users of those services agree on standards that meet the needs of the medical staff and that can be reasonably accomplished by the service providers. Achieving these standards is a cooperative effort. Certain tasks, such as specimen processing, specimen testing, and result reporting, may necessarily be the responsibility of laboratory personnel. Other tasks, such as test ordering, specimen procurement, and specimen transport, may be the responsibility of nonlaboratory ED health care workers. Reaching the end goal of, say, a 30-minute door-to-needle time, of which a specified CK-MB or troponin TAT is merely one component, becomes the responsibility of all involved health care workers, regardless of where in the hospital those individuals report for work each day. Once standards are established, service providers can gauge their performances by continually monitoring the desired outcome of those services. Subsequently, service providers must assess whether or not clinicians are truly satisfied with services and whether or not standards require revision.

The authors thank Kimberly M. O'Donnell for her editorial contributions.

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Author notes

Reprints: David A. Novis, MD, Wentworth-Douglass Hospital, Department of Pathology, 789 Central Ave, Dover, NH 03820 ([email protected])