A common downside to rapidly changing, developing and improving technologies is a struggle to maintain a high level of efficiency and quality with minimal errors. Point-of-care testing (POCT) is no exception--as more facilities adopt the practice and new platforms and applications become available, common deficiencies in POCT programs may arise.
But in the quality-centric healthcare industry, methods for eliminating problems are rarely far behind the identification of a concern. Assess your own POCT program for the deficiencies below and ascertain which improvement measures might work for your facility.
Identifying Common Issues
Peggy Mann, MS, MT(ASCP), POC and Lab/Facility coordinator, University of Texas Medical Branch, Galveston, Clinic Administration, lists a few of the most frequently seen deficiencies as:
- lack of required competency documentation,
- lack of required quality control (QC) performance,
- failure to recognize out-of-range QC values,
- improper or lack of required instrument maintenance and/or documentation,
- lack of appropriate personal protective equipment, and
- lack of awareness that testing sites must have appropriate CLIA certificates for the type of testing performed.
For large facilities and healthcare systems in particular, keeping competency assessment records for all POCT device operators requires organization and dedication. Making sure everyone has regular competency assessments is a massive task, Cynthia Foss Bowman, MD, FCAP, medical director, Long Island Jewish Medical Center in New York, conceded, "but it's an opportunity to re-train people and check their techniques."
Similarly, checking device correlation on a regular basis can be a daunting task, but POCT results must be correlated with results from the central lab. If you're using results from different sites to treat a patient, ensuring those devices are testing the same thing and producing the right results is of paramount importance.
Annabelle Joson, MT, POC coordinator, supervisor, Long Island Jewish Medical Center, added reagent labeling problems to that list. At her facility, users must sign the reagent bottle itself with the date it was received, the date it was opened and the date it will expire. "Sometimes they don't appreciate the fact that in kits, the reagents are lot-specific," Dr. Bowman said.
Improvements the Wireless Way
As wireless technologies become increasingly pervasive in our everyday lives, POCT will continue to see options for improved patient and test result management. Embracing wireless capabilities can be a key element in eliminating problems and errors in POCT.
Mobile workstations, smart phones and mobile PCs can be implemented in POCT departments for physician order entry, positive patient identification and electronic medical records. Wireless communications, when utilized properly, can eliminate the inconvenience of having to return to docking stations to upload results and save significant amounts of time.
Of course, wireless technology for the POC isn't without limitations. Dr. Bowman noted the capacity for wireless networks may vary in different areas of the facility, and some POCT devices have varying levels of receptivity for wireless. The cost justification of implementing wireless technology throughout a facility also is a challenge, although "in the end, it's well worth the expense," she said.
Maintaining the highest level of quality can be challenging for POCT departments segmented from the central laboratory and at times not quite sure where they fit in--with the lab, in the nursing department, as part of the ICU team. Eliminating this disconnect by designating a POC specialist or coordinator is one of the most important things a POCT department can do to ensure quality and reliability while contributing to patient care and safety.
The AACC deems the role of a POC specialist so crucial that they've developed a certificate program in which qualified individuals can go through an online certification program, covering administration, communication, connectivity and information technology, education and training, instrument selection and validation, policies and procedures, quality management and regulation. The trained POC specialist works with laboratorians, clinicians and nurses to ensure all appropriate lab regulations and quality standards are applied throughout the program.
The POC specialist or coordinator is primarily responsible for implementation of new testing or at new sites; overseeing compliance of testing to organizational/facility or accrediting agencies; writing and maintaining standard operating procedures and policies; training and competency of POCT device users; assessing instrumentation and selection of kits; and designing and updating the QC program.
An important part of Joson's role is to serve as a liaison between POC device operators and the lab director. These operators--often nurses or medical office assistants--view her as a colleague and relate and communicate with her in ways they might not with the pathologist or manager. Joson, in turn, communicates concerns to Dr. Bowman, her lab director.
"I can't imagine operating without a coordinator," Dr. Bowman told ADVANCE. "The POC coordinator is the liaison or point person. They need the pathologist's guidance and backup and support, but it's really important in these settings to have someone with the technical skills who can relate to people at various levels."
"Often, the POC coordinator is also assigned to work the bench or oversee areas involving safety or proficiency testing or clinical lab science students," Mann added.
POCT is growing and will likely continue to do so. Manufacturers and users alike are looking at the options, Dr. Bowman noted, and in the future we'll see increasingly durable devices with more built-in fail-safes and better connectivity options.
While uses for POCT will continue to expand, Dr. Bowman made an interesting point about rationalizing its use. Use POCT where it's needed and it will make the greatest improvements--but when the central lab, with its robotics and automation, can produce results for a particular test as rapidly or faster without affecting other workflow issues, keep that test in the lab. "We're trying to focus our efforts on where POCT should be done and trying not to spread ourselves too thin," Dr. Bowman said.
A good POCT program requires a great deal of energy and manpower. Putting measures in place to eliminate deficiencies--implementing wireless technologies, staying up-to-date with all documentation, and designating a POC coordinator or specialist--can help ensure that high-level technology is matched by high-level quality.
Kelly J. Graham is associate editor at ADVANCE.
"There should be a fairly consistent review and audit process from someone experienced in POCT who doesn't work at your facility. Even at sites that have had several consecutive no-deficiency quarterly audits and where I have great confidence in the POC operators and the site supervisor, someone stumbles on QC performance or forgets to pull controls past their discard date. The most frequent response I've heard after pointing out a discrepancy is, 'I cannot believe I missed that.' I assure them it's far easier for me to see the obvious things they will miss by working there every day. Each time I feel I can relax the review/audit process, something occurs indicating to me another pair of eyes is worthwhile."
--Peggy Mann, MS, MT(ASCP), POC and Lab/Facility coordinator, University of Texas Medical Branch, Clinic Administration