Evaluating STAT Testing Alternatives by Calculating Annual Laboratory Costs

Evaluating STAT Testing Alt~rnatives by Calculating Annual Laboratory Costs· Bernard E. Statland, 'M.D., Ph.D.; and Karen Brzys, M.A.

when the Deficit Reduction Act (DRA) U ntilwas1984, passed, hospitals and their clinical labora-

tories were fully reimbursed for near~y all test analyses that were performed. The DRA established a Medicare system that indirectly pays for laboratory tests as part of a total-care reimbursement fee based on the diagnosis-related group (DRG) that classifies the patient's clinical condition. Under this system, a hospital makes money if its actual patient care costs are less than the DRC reimbursement, or it loses money if its costs exceed the predefined DRG level. Two-thirds of health care reimbursements are now paid by Medicare or similar prospective payment programs. In addi~on to the prospective payment environment, several emerging trends impact the financial management ofa hospital laboratory service: (1) Competition for Resources- Laboratories now must compete with other hospital departments for available resources. MQre than 70 percent of operating laboratories have experienced budget reductions. 1 (2) Increased Costs-The cost of operating laboratories has increased faster than the general inHation rate, primarily due to an increased volume of testing caused by advances in technology, worry over malpractice liability risk, easier access to testing, and an increase in the acuity of illness in our aging population. 2•3 (3) Higher Standard ofCare Demands-Clinicians expect laboratories to quickly deliver reliable results to help them make immediate patient management decisions. The American Heart Association and the Emergency Care Research Institute recommend, for example, that blood gas and electrolyte results in open heart surgery be available within five minutes. 4•5 The expected required turnaround time for these same tests in other critical care settings varies, but it is generally in the range offive to 15 minutes. These standards are

*From the De~ent of Pathology and Laboratory Medicine, Methodist Hospital of Indiana, Inc, Indianapolis (Dr. Statland), and the Department of Regulatory Relations, Mallinckrodt Sensor Systems, ~n Arbor, Mich (Ms; Brzys).

DRA=De6cit Reduction Act; DRG=Diaposis Related

or

Group; CAP-WLR=College American PathOlogy-Workload Recording Method; IeAT Instrument Cost Accounting Tech-

=

=

nique; CALC Calc~lating Annual Laboratory Costs; ABC arterial blood gas

=

1888

not currently met by most medical centers. 6 (4) Shortage of wboratory ~sonnel-Recent surveys indicate that more than 80 percent oflaboratories have encountered a shortage of technical personnel. 7 To make matters worse, 40 percent of the accredited medical technology training programs have closed since 1983. 8 The impact of these issues may be to increase laboratory costs without concurrent increases in reimbursement since most prospective payment programs have not adjusted their fee schedules for such changes. 9 H hospital laboratories are to survive and prosper, managers will need to identify and implement new financial management JDethods that can track and control their "true" costs as well as to evaluate the actual costs of using alternate testing sites or instrument configurations. ANAL'YZING LABORATORY COSTS

The cost of providing testing includes a variety of different expenses that vary with each laboratory testing configuration. Some expenses are fixed and continue as long as a configuration is in place. If testing is done in a stat lab, for example, the cost of salaries, equipment, utilities, and other overhead expenses continue regardless of the number of tests performed. Other expenses, such as test-specific supplies, correlate directly with the number of samples processed. These expenses are variable and are subject to management aimed at increasing cost-effectiveness. To our knowledge, the laboratory industry has not yet developed a standard accounting fonnat for collecting and recording cost information. Some techniques have been developed to assist in determining test charges by identifying the amount of labor and supplies used to perform each test. One such approach, developed by the College of American Pathology, is the Workload Recording Method (CAPWLR) that is used to 'evaluate laboratory productivi~ This approach only calculates the time spen~ performing the test, ignoring other work (paid) hours that are not directly related to actually performing test' analyses. 10 Although this method can help in setting test charges, it is not useful for analyzing the financial impact ofalternatiye laboratory configurations because Evaluating STAT Testing ~ (Statland, Brzys)

it.does not account for many of the variable expenses such as labor costs for collecting specimens and documenting results; supplies used for collecting specimens and repeating tests; and nonproductive time involving administrative activities, meetings, vac~­ tions, illnesses, and holidays. One study found that 38 percent of consumable costs and 57 percent of labor costs were not a direct component of the routine analysis function; therefore they would not be accounted for by most cost-pe~test techniques. 11 Another approach, the Instrument Cost Accounting

Technique (I CAl), is a more comprehensive method for analyzing the cost of using a testing system over a defined period of time.l~ All expenses required for operatfug the system over the defined time period are divided by the number of tests processed during that period. A drawback to the ICAT approach is the need to perform detailed time analyses to determine labor costs. Not only can these time studies be tedi9uS, but their results may be iQaccurate since the tiJpe of each labor component will vary with the productivity of the individuals being timed.

Table I-CALC Model Example-EBtimaIed Comfor AlIerntJtioe CcmfigurtJtioru that fDill Beduce 7UnatIfOUtId Mooing Temrtg Nearer to the lbtimt (New Stat lAb va ~ 1atirag) Date: 11/14189 Hospital Name: Remedy General Tests Offered: Po., Peol, pH, I{+, Ca++, Na+, Het

Number of tests per day: 50 Number of tests per year: 18250

Site 1: Stat lab

Site !: Bedside testing

I. Site Preparation Cost Item total $ Construction $10,000 Furniture 2,000 Subtotal $12,000

3.

Cost list price $31,500 25,000 1,000

5

$2,400

Subtotal

$Iyr

Item GEM-STAT GEM-STAT

total $ $19,500 10',000

Subtotal

$29,500

cost $3,780 3,000

Item GEM-STAT GEM-STAT

list price $19,500 19,500

$6,900

Subtotal

$29,500

No.ofyrs

5

5 5 5

Eq~pment Maintenance

Item Primary bchtp Back-up bchtp Centrifuge Subtotal

X

$42,500

contrct % 12% 12% 12% 12%

Item None

$Iyr

400

6,300 2,000 200 $8,500

120

4. Incremental Labor Cost Dedicated labor: medical technologist 2080 hrsIyr X $151hr X 5 StaJI" Additional labor: none

o

156,000 1.3 $202,800

Direct labor cost X bene6t~cient Subtotal 5. Supply and Disposable Cost Item quantity Jleagents: Primary unit ($Iyr) Bkup (w/discount) Gas source 2 Electrodes 18,250 Capillary tubes 18,250 Syringes 2,920 QC solqtions Subtotal

X

•

$2,000

5

I. Equipment Depreciation Cost Item total $ Primary bchtp $31,500 10,000 Back-up bchtp Centrifuge 1,000 Subtotal $42,500

total $ 0

No.ofyrs 5

unit cost

Subtotal of Annual Operating Costs Hospital Overhead Coefficient TOTAL ANNUAL OPERATING COST (subtotal X overhead coefficient)

$Iyr $ 9,000

1,800 1.00

1.30

.80

2,000 1,000 3,600 18,250 23,725 2,336 $59,911 $280,511 1.30 $364,664

$

+

Tirna""

No.ofyrs 0

0

$

•

0 +

X

No. ofyrs

$Iyr

5

$5,900

contract % 12., 12%

cost $2,340 2,340

12%

$4,680

2,000

M50 5,475 5,925 1.3 $7,703

Subtotal

Syringes

0

$3,900

X bene6t~cient

QC solutions

0

5 5

Dedicated labor: nurse training 2 hrsIyr X $151hr X 30 Staff Additional labor: MTs-perform maintJQC 1 br/day X 365 days X $151b Direct labor cost

Item Reagents: STAT-PAl{ GEM-Samplers

tlyr

unit cost

$Iyr

365 20,075

$300 .25

$109,500 5,019

18,250 1,825

1.30 3.33

23,725 6,077 $144,321

quantity

X

Subtotal

Subtotal of Annual Operating Costs Hospital Overhead Coefficient TOfAL ANNU~ OPERATING COST (subtotal X overhead ~cient) CHEST I 97 I 5 I MA'( 1980 I SuppIemn

$162,604 1.30

.11,381

1. .

THE CALCULATING ANNUAL LABORATORY COSTS

MODEL

(CALC)

To identify which of two or more testing configurations is most cost-effective, laboratory managers need an all-encompassing assessment tool. The Calculating Annual Laboratory Costs (CALC) technique has been developed to provide a method for comparing costs of identical testing services from alternative testing con6~rations. The process of comparing the costs using the CALC technique involves the following: Define the Settings

Identify the site locations and/or equipment configurations, the tests which are to be offered, and the number of samples expected to be processed. If one alternative offers more tests or processes more samples than the other, use only the costs attributable to those . tests provided by both configurations. There are several reasons that may prompt this comparison. A hospital may expand the number of beds by building' a new intensive care unit, thus increaSing the overall testing load beyond the capabilities of the central laboratory. To meet this expanded need, alternative configurations, either a stat lab or bedside testing, could be considered. There are other situations wherein new testing configurations may be ~nsidered simply to reduce turnaround times.' In the ~x~ple shown (Table 1), the cost ofproviding testing to an intensive care unit with a new stat lab is compared with the cost of providing testing with an automated bedside analyzer. It is assumed that 50 test profiles will be 'performed each day, including POi' Peol' pH, K+ , Ca+ +, Na+ , and hematocrit. Record Cost Information

The cost of establishing and operating the testing service should be recorded for each configuration. Actual costs should be verified by r~ferringto invoices. There will be situations whe'rein the costs of providing testing nearer to the patient are ~sessed in terms of their impact on central laboratory costs. In some cases, bedside or stat lab testing may actually add to the overall cost of providing testing (to achieve quicker turnaround times), while in other cases there may be central laboratory savings attributable to relocating ~esting closer to ~e patient. To complete Table 1, we have used actual cost information that was collected from several hospitals and averaged to present an example that is' not specific to one institution: (a) Site Preparation Costs: The cOst of establishing a laboratory facility includes constructio~ costs as well as preparation cos"ts for electrical Of pl~mbing upgrades, oomputer hook-ups, ventilation contracting, furniture, and saDlpl~-transport systems. The cost allocated to each y~ar is generally equivalent to ,the

zoos

initial cost divided by the number of years the site will be used. The Internal Revenue Service has the following guidelines: 13 Estimated Actual Use Life

No. of Depreciation Years

under 5 4to 19 10 to 16

3 5 7

Relevant site preparation estimates can be obtained by checking With facilities management departments or by obtaining site preparation cost estimates from outside contractors. In Table 1, we assume the site preparation costs for a new stat lab to be $10,000 for renovation and $2,000 for furniture. With a depreciation period of five years, th~ annualized cost is estimated to b~ $2,400. No site preparation cost is included for the bedside unit since the instrument can simply be placed on a convenient surface in the intensive care unit. (b) EqfJ,ipme~t Depreciation Costs: When hospitals purchase capital equipment, the cost is expensed over the number of years the equipment is expected to be used. The fonnu~ for depreciating capital equipment is: allocated, initial purchase price - residual value annualized depreciation number ofexpected years ofuse life cost The depreciation peIiod for equipment ranges from three to ten years, depending on the h!>spital's accounting policies. In Table 1, we 'assume that the relocation of testing to a stat lab would require acquisition of new benchtop systems, including a primary and a backup blood gaslelectrolyte analyzer and a centrifuge for hematocrit The estimated p~chase price for the two units is $31,500 for the primary system and $10,000 (discounted) for the backup 'unit required to ensure continuity of service. Oth~r altemaqves, such as the retention of current equipment, could have been considered for the backup unit, but this was thought to inv~lve risks associated with uncertain correlation between the primary and backup units. The cost of a centrifuge is estimated to be $1,000. With a depreciation period of five years, the annual depreciation cost for equipment in the stat lab is $8,500. In Table 1, the bedside alternative also assumes the acquisition ofnew equipment, suc~ as the GEM-STAT System (Mallinckrodt Sensor Systems, Ann Arbor, MI) with a list price of $19,500. The bac~p unit is discounted to $10,000. The annualized cost of instruments for bedside testing, depreciated over five years, is $5,900. (c) Equipment Mainten(lnce Costs: Maintenance Evaluating STAT Testing AIt8rnalNes (StaIIand, Brzya)

costs represent the expense ofcleaning, repairing, and keeping each instrument operating throughout its expected life. Generally, daily checks of critical components and periodic maintenance checks are required by regulations. Since these daily checks are usually performed by the operator, the associated costs can be classified as a labor expense. Periodic maintenance is, sometimes, performed by the manufacturer for a fee as part of an extended warranty contract. The fee is usually 8 to 12 percent of the instrument's list price, depending on the extent of service desired or required. 14 In Table 1, maintenance costs include the fees for annual service contracts, which are assumed to be 12 percent of instrument list price (not purchase price), for all instruments including the backup units. (d) Incremental Labor Costs: Labor costs, which usually make up 60 to 70 percent of direct laboratory operating expenses, can be the most difficult cost component to quantify because of the number of people involved in providing a testing service. IS Personnel costs include actual salaries as well as the cost of benefits such as vacations, sick leave, holidays, health insurance, retirement, etc. Labor costs for all staff should be considered, including directors, supervisors, technologists, technicians, support staff, phlebotomists, and individuals responsible for transporting samples to and from the laboratory (Table 2).12(pp26-7).16 Labor expenses can be categorized as being allocated or incremental. Allocated time occurs when

Table 2-UJbor Costa/or AfItIlyzing Clinical UJboratory Tests Preanalytical

Equipment start-up Preparation of daily quality controls Perfonning quality controls (if done separately from sample analysis) Obtaiing patient demographic infonnation and relevant clinical information Order submission Specimen collection Specimen transport Specimen receiving and accessioning (logging in and assigning to laboratory work station) Preparation and/or storage of specimen for analysis Analytical Performing quality controls/standards Analyzing sample Error checking of results

Postanalytical

Result reporting Delivery of hard copy printout (with reference ranges) Entering results in laboratory record keeping system Entering results in patient record Other routine instrument maintenance Shut-down time

staff who are already being paid perfonn a new task that is typically not in their job function. Incremental labor costs are incurred when new staff are hired or reassigned to perform specific job duties. Incremental labor increases overall costs while changes in work responsibilities do not generally increase labor expenses. In Table 1, we assume that a shift in testing from the central laboratory to a stat lab would require an increase in staffing level. Five medical technologists would be hired (or reassigned) to operate a 24-hour service, each to work 2,080 hours per year. If a stat lab is being set up to reduce turnaround time, labor savings may either be realized in the central laboratory because of the shift in testing load or may not be realized if staffing has to be maintained. to provide service to other hospital departments. The incremental labor costs for dedicated equipment operators in the stat laboratory can be calculated by two methods. Either the hourly salary can be multiplied by both the number of hours each person works per year and the number of staff members, or the number of full-time employee slots can be multiplied by the appropriate annual salary. Additional labor expenses may also be incurred for phlebotomists, runners responsible for transporting samples, and laboratory staff who perform quality control, calibration, and maintenance on off-site equipment. Expenses required for training equipment operators also should be included when calculating labor costs. Ifclinicians working in the critical care unit are able and willing to operate the testing equipment as part of their patient care responsibilities, it is likely that no additional labor charges would be incurred unless the testing load exceeds each nurse's ability to do it in the time available. This is not an unrealistic assumption; it has been shown that nurses spend more time tracking down laboratory results than would be required to operate bedside testing systems. 17 It is assumed in Table 1 that nurses in the critical care unit will operate the bedside analyzer as a patient car~ responsibili~ thus incurring no labor expenses other than for equipment training. The maintenance of the system would be the laboratoryts responsibility and would be incurred as a labor expense. The total direct labor costs for both con6gurations are then multiplied by a benefit coefficient, which is 30 percent shown in the example in Table 1, to yield the total labor expense. (e) Supply and Disposable Costs: Supplies are consumed to collect and analyze samples as well as to perform quality control checks, calibrate equipment, report results, and perform other maintenance tasks (Table 3). The easiest way to calculate supply costs is to estimate the quantity of materials used per year. Invoices for consumables used with existing equipCHEST I 97 I 5 I MA~ 1990 I Supplement

201S

Table 3-Supply and Other DiBpoBable Costa for Ana1Fing Clinical Laboratory Teata Fluids

Reagents Reagent preparation chemicals Reference fluids Calibration solutions Linearity standards Other SUf'Plies Syringes Thbing Reagent vessels Cuvettes Needles Probes Fittings Electrodes and membranes

Quality control solutions Rinse solutions Diluents Deionized water Cleaning solutions Seals and valves Sample cups Gas tanks Paper labels and test order forms Ribbons Water cartridges Filters Pipettes and tips

ment can be reviewed or manufacturers can be consulted to estimate costs for projected testing volumes. In Table 1, the costs of reagents and supplies to operate the stat lab systems were taken from actual invoices; the reagent cost is less for the backup unit because it is used only to handle peak testing volumes and periods when the primary unit is down. The electrode cost for both benchtop systems is the annual charge for a warranty contract guaranteeing electrode replacement. The syringe cost is for heparinized arterial blood gas (ABC) syringes. The capillary tube cost for the centrifuge is also for heparinized tubes. The quality control frequency for the benchtop system is assumed to be two levels twice per da~ For the bedside units, almost all the supplies are incorporated into a disposable pack (list price, $300 each). It is assumed that one pack, which can process 50 samples, would be used each da~ alternating "instruments from day to da~ Other supply costs are based on the list price for samplers, which allow aspiration of samples into the instrument, ABC syringes, and quality control solutions. The quality control frequency recommended by the manufacturer is two levels per day for the hematocrit sensor and three levels per day to check the other sensors. (f) Indirect Costs: Some costs cannot be traced to a specific test or to a particular piece of equipment. These expenditures are related to the nontechnical aspect of the laboratory (eg, hospital-allocated overhead, administrative expenses), while other costs are for materials used to run the lab, such as office supplies and other generic consumables (Table 4).l2(pp27-9) Hospital accounting systems recover these indirect costs by adding an overhead charge as a percentage of known direct costs. The total cost ofproviding a service is equal to the direct costs (categories a through e above), plus a proportional share of the indirect costs. This proportion is often calculated by multiplying the 202S

Table 4-lndirect Coati for AtItJlpng Cliraicol Laboratory Teats Sales and marketing salaries Administrative and office salaries Employer payroll taxes Free samples Entertainment and travel expenses Rent and/or depreciation Utilities Stationery and printing Indigent care Postage Freight Advertising

Auditing expenses Licensure fees Legal expenses Uncollectible accounts Insurance-fire and liability Defective work Experimental work Other hospital-allocated overhead for cafeteria, library, maintenence, data processing, etc Third-party reimbursement losses Continuing education expenses

total direct cost by an overhead coefficient, which ranges from 25 to 40 percent, but can be as high as 148 percent.l2(p28)·18 The accounting department can provide the indirect overhead coefficient for your hospital. In Table 1, an indirect cost coefficient of 30 percent is used to cover all the nontest specific costs. Calculate the Annual Testing Cost The example in Table 1 estimates the cost of moving testing to a new stat lab or to a bedside instrument. Using the assumptions given, servicing the testing load with the bedside testing alternative seems to be more economical (Table 5-A). The cost of labor is higher for the stat lab alternative, while the cost of disposable reagent packs is higher for the bedside testing alternative. If desired, the CALC technique can also be used to adjust for the cost of moving some of the testing load out of the central laborato~ thus realizing a savings in test-specific supplies, as shown in Table 5-B. Similar savings may also be realized in a stat lab for variable supplies if there is a similar shift in location. DISCUSSION

The CALC technique can be used to estimate and compare the "true" cost of using different approaches for meeting a hospital laboratory's service demands. Other issues, however, need to be considered because both direct and indirect costs are associated with intangible factors that may be difficult to quan~ How; for example, can you estimate the cost incurred when nurses try unsuccessfully to find a physician to transmit results in the critical care unit, or when nurses repeatedly try to call the laboratory for test results? Delays in reporting results can cause clinicians to request additional tests that they would not otherwise need if results had been available while they were still at the patient's bedside. When testing is moved to reduce turnaround times, most ofthe expenses incurred in the central laboratory are unchanged or lower (Table 5-B), making the cost of processing tests at the bedside appear to be higher. Evaluating STAT Testing AIternatN8s (Statland, Btzys)

Table 5-SummtJry of an Emmple Determining the Annual Coat of Alternative Site Tating A- Costs for processing tests in a stat laboratory or with bedside testing perfonned by nurses or physicians Cost Categories Site preparation Equipment depreciation Equipment maintenance Incremental labor Supplies/disposables Direct Expenses 0.3 X direct expenses Total Expenses

Stat Laboratory $ 2,400 8,300 6,900

202,800 59,911 280,511 84,153

$364,664

Bedside Testing Alternative $ 0 5,900 4,680 7,703 144,321 162,604 48,781 $211,385

B-Costs for moving testing nearer to the patient to reduce the turnaround time, including the savings in variable supply costs which will occur in the central laboratory; in some cases, a savings may also result in labor costs if the test load reduction in the central laboratory lowers staffing requirements Cost Categories Site preparation Equipment depreciation Equipment maintenance Incremental labor Supplies Direct expenses Adjusted direct expenses (with transfer of savings from central lab to bedside) 0.3 x direct expenses Total expenses

Central Laboratory $ 0

Bedside Testing Alternative

(58,111)

144,321

o o o

(58,111)

$

0

5,900 4,680 7,703

162,~

104,493

31,348

$135,841

As noted in other articles in this symposium, ho~ever, there may be significant cost savings for other aspects of the patient's care. Reduced morbidity and a reduction of ~e stay in the critical care unit or the hospital can· more than offset any incremental bedside testing costs. Another concern involves liability risk if a hospital is unable to provide results within a clinically acceptable time frame. Would this make the hospital more vulnerable to lawsuits? What would be the cost if the ~ospitars defense in a case is jeopardized because result reporting is slower than the accepted standardof-eare? Other issues ·concem the ·integrity of the specimen when transport is delayed. If a delay or other mishandling reduces the Po! by only a few millimeters of mercu~ a patient could be denied needed oxygen therapy. 19

To most effectively select configurations that will

address these concerns, a careful evaluation must be

made ofeach alternative. The following considerations should he made: What tests will be required? What volume of testing is expected? What level of test accuracy is required? What turnaround times for results are needed? Will there be a need to provide seven-da~ 24-hour testing services? What level of training will be required for operators? Who will

operate the equipment? Who will maintain the equipment? Once the CAL(; t~hnique is used to estimate costs and these issues and questions have been addressed, it will be possible .to .evaluate the cost and clinical impact of different con6gurations. Consultation between laboratory professionals and the clinical staff can be useful in developing the best testing alternative. The challenge will be to simultaneously manage the decision process from. a medical, scientific, and ec0nomic perspective. Communication and coordination between all interested de~ents will be the key to preserving and hopefully improving the quality and cost-effectiveness of laboratory service. REFERENCES 1 Benezra N, 00. Lab salaries: many think compensation bas to get better (special report-part 2). Med Lab Observer 1989(Jan);

29-30

2 Hardwick DF, Morrison JI, Cassidy PA. Managing lab oosts and utilization: balance supply and demand. Dimensions 1985(Sept); 18 3 Martin BG. Cost containment: strategies and respo~ibilitiesof the laboratory manager: symposium on cost containment iii the laboratory. Coo Lab 1985; 5:700 4 Scannell JG, et ale Report of the InteraSociety Commission for Heart Disease Resources: optimal resources for cardiac surgery: guidelines for program planning and evaluation. Circulation

Moo

1975; 52:A-33

5 Emergency Care Research Institute. Risk analysis: cardiopulmonary' perfusion equipment. J Extra-Corplreal Tech 1987; 19:238 6 Zaloga G~ et aI. Bedside blood gas an4 electrolyte monitoring in critically iU patients. Crit Care Med 17:920 7 Medical technologist shortage now acute. CAP 1bday 1988(July);

47

8 Cepil 8R. Assessing the survival of an MT school. Med Lab Observer 1989(Jan); 49 9 Haughney JD. Test cost analysis: more vital than ever. In: Fitzgibbon RJ, Statlan BE, eds. DRG survival manual for the clinical lab. OrdeU, NJ: Medical Economics Boob; 1985; 82 10 Conn RB, AUer RD, Lundberg GD. Identifying costs of medical care. JAMA 1985; 253:1587 II Tarbit IF. Costing c~ical biochemistry services as part an operational management budgeting system. J Clio Patboll986;

or

39:817

12 Travers EM, Krochmal CF. A new way to determine test cost per instrument (part 1). Med Lab Observer 1988(Oct); 25 13 Internal Revenue Service. Depreciation. publication 534, revised Dec 1987; 98 14 Aller RD. Maintaining the quality of laboratory services in a cost-eontainment environment: Symposium on cost containment in the laboratol")'. Clio Lab Med 1985; 5:629 15 Travers EM, Krochmal CF. A new way to determine test cost per instrument (part 2). Med Lab Observer 1988(Nov); 59 16 Bernstein LH, Davis GL. The cost impact of decentralized testing. Moo Lab Observer 19&9; 38 17 Zaloga GE Evaluation of alternative bedside options for d1e critical care unit. Chest 18 Sharp ~ A fiscal survival plan: In: Fitzgibbon RJ, Statland BE, eds. DRG survival manual for the clinical lab. Oradell, ~J: Medical Economics 8004 1985; 218 19 Fonzi e, Clausen JL. Quality control ofblood gas measuremenb: an update. Respiratory Management 1988(Marcb-April); II CHEST I 97 I 5 I aM'( 1980 I SUppIemeN

2038