LAB-QM-POST-003 — Turnaround Time and STAT Testing Policy

1.0 Purpose

To define turnaround times (TAT) for Laboratory tests, establish a uniform STAT test policy and procedure facilitating efficient processing of samples in emergency situations, and describe the plan for notifying clients when result availability will not meet specified times.

2.0 Scope

Applies to all areas and personnel in the Laboratory, and to Medical, Clinical, and Nursing staff receiving, processing, and reporting routine and STAT examinations. Basic ABO/Rh slide typing under Hematology is in scope.

3.0 Definitions

• STAT test/service — a result urgently needed for diagnosis or treatment, where delay could be life-threatening; performed immediately, potentially interrupting routine testing. TAT generally within 30 minutes to 1 hour of specimen receipt.
• Routine test/service — collected/batched for efficiency; not immediately needed for diagnosis/treatment; processed/batched within the shift; most results available within the same day.
• TAT (turnaround time) — the interval between specimen receipt in the Laboratory and result reporting.

4.0 Responsibility

4.1 Hospital Director

• Exercises executive oversight and provides institutional resources (standing governance and policy approval per Organization and Governance).

4.2 Pathologist

• Provides clinical direction regarding turnaround times and STAT test prioritization (standing clinical oversight per Organization and Governance).

4.3 Chief Medical Technologist / Laboratory Quality Manager

• Establishes and reviews the TAT policy at least annually; develops, implements, and reviews section-specific TAT targets at least annually; determines whether medical staff should be notified of a testing delay, and notifies them with the corrective action taken.
• Reviews/approves this policy at least annually; ensures compliance with applicable standards.
• Maintains and approves the STAT Test List (Section 5.3).

4.4 Medical Technologists

• Notify the Chief Medical Technologist / Laboratory Quality Manager immediately when a problem is identified that will delay testing beyond the published TAT (unavailable reagents, extended equipment downtime, significant QC/proficiency-testing failures).
• Follow this policy by prioritizing STAT samples/requests.
• Perform STAT testing immediately upon receipt, potentially interrupting routine testing workflow.
• Telephonically notify the requesting unit once a STAT result is finalized per the results-distribution process in Laboratory Reporting Policy Section 5.3.
• Document STAT result notification (date, time, name of person notified) on the Technical Delay & TAT Monitoring Log (F-QM-POST-003-A-V0).

4.5 Laboratory Aides

• Collect, label, and deliver STAT specimens to the Laboratory per Specimen Collection Policy with STAT-identification measures (Section 5.3.3).
• Affix a "STAT" colored sticker label (e.g. red) to the sample and/or legibly write "STAT" with a highlighter/marker, positioned so as not to obstruct any barcode or required information.
• Carry STAT specimens to the Laboratory immediately upon collection.

4.6 Nursing Personnel and Clinicians

• Implement, follow, and ensure compliance with STAT ordering and collection procedures.
• Clearly identify STAT tests on the request form.
• Make prior telephone notification to the Laboratory before sending a specimen when a shortened TAT below standard STAT TAT is needed for critical clinical situations (Section 5.3.5).

5.0 Policy / Procedure

5.1 Policy Statement

The Laboratory takes all necessary steps to ensure immediate, expeditious performance of tests/services when results are required for the immediate diagnosis and treatment of a seriously ill patient.

Each section defines result TAT for each test; when result availability will not meet the specified time, physicians, nursing units, and clients are notified by electronic message, written notice (memo/cover letter), or telephone (documented on the Technical Delay & TAT Monitoring Log, F-QM-POST-003-A-V0).

STAT requests are limited to cases where the patient requires immediate care — inappropriate STAT use increases TAT for both STAT and non-STAT tests.

5.2 TAT Targets

• STAT tests: generally within 1 hour of specimen receipt; may be shortened to 30 minutes or less with prior physician telephone notification.
• Routine tests: most Chemistry and Hematology testing is performed the day the specimen is received; analysis, review, verification, and acceptance are typically available within 3–4 hours of receipt. TAT figures for Microbiology (culture/sensitivity, <5 days) and Cytopathology (<7–10 days) are retained for completeness only — these functions are not currently within TCH's scope per Scope of Service and Laboratory User Information Policy.
• Send-out tests: actual TAT depends on the referral laboratory (see Referral Laboratory Policy); typical range 3–7 days, longer for rare/esoteric tests.

5.3 STAT Testing

5.3.1 Default STAT Areas

CONFIRMED 2026-08-22. TCH's only default-STAT critical-care area is the Emergency Room — laboratory investigations from the ER are treated as STAT by default unless otherwise instructed. TCH's other wards are non-STAT by default: Medical, OB (Obstetrics), Pediatrics, Isolation, and ITC.

Tests from these non-STAT wards are handled as STAT only when specifically ordered STAT by the requesting physician per Section 5.3.3 below. TCH does not operate an ICU, NICU, dedicated OR, or Hemodialysis Unit.

5.3.2 STAT Test List

The tests/services available on a STAT basis are maintained as a controlled reference list (STAT Test List) approved by the Chief Medical Technologist. Any test not on this list must be approved by the Chief Medical Technologist or designee before being performed as STAT.

5.3.3 Ordering and Collection

STAT tests are ordered by a physician or authorized designee, clearly identified on the request form.

STAT samples are collected, labeled, and delivered to the Laboratory per Specimen Collection Policy, with the following additional STAT-identification measures: a "STAT" colored sticker label (e.g. red) affixed to the sample and/or the word "STAT" legibly written with a highlighter/marker, positioned so as not to obstruct any barcode or required information.

5.3.4 Result Notification

Once a STAT result is finalized, the requesting unit is telephonically notified per the results-distribution process in Laboratory Reporting Policy Section 5.3. If the STAT result is also a critical/panic value, it is additionally handled per Reporting Critical Values Policy. The call (date, time, name of person notified) is documented on the Technical Delay & TAT Monitoring Log (F-QM-POST-003-A-V0).

5.3.5 Shortened TAT for Critical Clinical Situations

When the patient's clinical condition is deemed critical by the attending/requesting physician, the TAT may be shortened below the standard STAT TAT (see Section 5.2 above for standard TAT targets), provided the requesting physician or designee makes prior telephone notification to the Laboratory before sending the specimen.

5.4 Delay Notification Process

• Medical Technologists notify the Chief Medical Technologist / Laboratory Quality Manager immediately upon identifying a delay risk, and document it on the Technical Delay & TAT Monitoring Log (F-QM-POST-003-A-V0); the affected test's pending log is retrieved.
• The Chief Medical Technologist determines corrective action: hold specimens until testing resumes, or send specimens to the referral laboratory (see Referral Laboratory Policy).
• The Chief Medical Technologist determines whether medical/clinical staff should be notified, and if so, distributes the notification and publishes revised results-availability expectations.
• During unexpected/extended interruption of TCH's own result-distribution process (see Laboratory Reporting Policy Section 5.3), the Laboratory notifies each nursing unit and provides hard-copy interim reports by pre-arranged pickup or hand-carry by authorized staff (see Figure 1).

Figure 1 — STAT specimen prioritization and turnaround time delay notification flow

5.5 Add-On, Verbal, and Standing Orders

• Add-on testing may be ordered on a previously submitted specimen if sufficient volume remains and the request falls within the test's specimen-stability window; a written physician order is required, documented on the Technical Delay & TAT Monitoring Log (F-QM-POST-003-A-V0) where applicable.
• Verbal orders are accepted but must be authenticated by a written physician order within 48 hours; the order is read back to the physician/authorized representative, accuracy confirmed, and documented on F-QM-POST-003-A-V0. Verbal orders for inpatients are referred to the responsible nursing unit.
• Standing orders (for an extended course of outpatient treatment) are permitted for a maximum of six months, specifying frequency, duration, test(s), diagnosis/medical necessity, physician signature, and order date; they expire at six months and require reauthorization before further testing.

5.6 Reflex Testing

Reflex testing (performed automatically based on certain results, e.g. confirmation of a positive result) is limited to standard medical practice; physicians may contact the Laboratory for reflex-testing information or to request the initial test without the reflex component.

5.7 Test Cancellation and Recollect Requests

Cancellation requests are accepted before test set-up at no charge; requests after set-up cannot be honored. Specimens are assessed for integrity before testing; a recollect is requested if the specimen is hemolyzed, clotted, of insufficient volume, mislabeled/unlabeled, the wrong specimen type, or otherwise compromised (see Specimen Collection Policy Section 5.6).

Processing of a suboptimal or irreplaceable specimen is approved at the discretion of the Chief Medical Technologist.

5.8 Repeat Testing

If the validity of a result is questioned relative to clinical findings, the Laboratory repeats the assay upon notification/request from the technical section where testing was performed.

5.9 Specimen Storage for Add-On Testing

Sera, urine, and body-fluid specimens of sufficient volume are refrigerated and stored per Laboratory Retention Schedule Policy, and remain available for add-on testing during the applicable retention window.

6.0 Records

The Technical Delay & TAT Monitoring Log is shared with Laboratory Reporting Policy. The STAT Test List is maintained as an approved controlled clinical reference document under Document Control Policy.

7.0 References

• DOH QMS Tool for Clinical Laboratories (2024), Section 4 — Monitoring Performance and Section 6 — Information Management System
• DOH Administrative Order No. 2021-0037, Annex A Section V.B.2–V.B.3
• ISO 15189:2022, Clause 5.5 — Objectives and policies and Clause 7.2 — Pre-examination processes
• WHO Laboratory Quality Management System Handbook, Chapter 5 — Sample management
• JCI Accreditation Standards for Hospitals, AOP.5.4 — Timely availability of laboratory results

Companion policies:

• Laboratory Reporting Policy — official reporting, delay notification, and result distribution workflow
• Reporting Critical Values Policy — critical value notifications and urgent escalation workflow
• Laboratory Retention Schedule Policy — specimen availability and retention schedule for TAT monitoring records

Controlled visual annex:

• IG-12 — Turnaround Times — one-page visual annex to this policy, controlled under Document Control Policy Section 5.2.6 and registered in F-QM-002-B-V0. Master files: infographics/IG-12-Turnaround-Times-LAB-QM-POST-003.png (PNG, print PDF, and editable HTML).