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The clinical laboratory is changing. Staffing shortages, new technology and increasing demand for accountability from the healthcare industry mean lab medical directors must routinely implement new patient testing protocols and data handling techniques. One of the primary responsibilities of clinical labs today is to provide the information clinicians require to treat their patients quickly and effectively, regardless of where the information resides or where it was collected.
At Miami Children's Hospital, the lab staff oversees lab test data from off-site centers, the ICU, the operating room (OR) and the emergency department (ED), and integrates and manages this information throughout the continuum of care. From my perspective, it no longer matters where the testing is performed, it matters how the information is managed once the test is complete.
 Miami Children's Hospital
The hospital began incorporating point-of-care testing (POCT) into our lab practice more than 10 years ago. At that time, we had a rudimentary POCT program where the principle test was bedside glucose monitoring. The initial expansion of POCT was focused on the hospital's Lifeflight program to support the care of patients transported to our hospital. Subsequently, POCT for blood gases, electrolytes and other chemistries was rapidly expanded throughout key areas in the hospital. With the continued implementation of this strategy, POCT has become an integral component of the lab which has responsibility for regulatory compliance and information management.
At Miami Children's Hospital, the lab staff is responsible for capturing and managing all test data through the laboratory information system (LIS) so we are able to ensure the information is readily available to our clinicians. Integration of our POCT platform with the LIS ensures the same information management as for all other lab tests. Additionally, our POC testing program includes oversight for staff training, quality assurance, quality control and equipment maintenance.
Implementation
When considering adopting POCT, a critical factor to consider when implementing this or any new hospital process is to engage the various stakeholders throughout the hospital. With a clear understanding of the needs of the intensive care units, OR and ED, we spent time critically examining productivity and work flow issues to justify broad POCT implementation. In part, this included eliminating the Stat lab; however, this was accomplished without immediate reduction in staff, many of whom were reassigned to other sections in the lab. While acknowledging there were challenges along the way, the lab staff and clinicians now see and appreciate the benefits of POCT as a vital tool to ensure optimal patient care.
In addition to the adjustments in processes and responsibilities, we needed to overcome a psychological resistance to the "large footprint" blood gas analyzers with the handheld i-STAT (Abbott) devices for both blood gases and chemistries. However, the parallel studies clearly proved the equivalence between the two devices, making this objection moot.
Furthermore, it was important to impress upon our staff that our role is to provide the best service possible to our clinicians and patients, and one of the ways we can accomplish that goal is by taking advantage of the efficiencies provided by new technologies. Once there was a clear understanding about why we were choosing to expand our POCT program and how it would help our laboratory run more efficiently, there was tremendous buy-in.
At Miami Children's Hospital, we were able to replace the high-cost Stat lab with more efficient POC testing without an immediate reduction in staff, which was obviously a hot button issue for members of my team. Because of our aggressive stance regarding cross-training technologists, the Stat lab staff were positioned in other areas of the lab as appropriate. This in turn allowed us to reduce our reliance on temporary staff. Of the more than 800,000 lab tests we perform annually, i-STAT testing accounts for at least 70,000 tests and glucose tests about 25,000. With this level of POCT, the lab staff is able to focus its efforts on other types of testing and reduce turnaround times for other Stat tests.
Advantages
It is very clear POCT increases the lab's ability to get diagnostic information to ICU clinicians quickly, which in turn, allows them to intervene more effectively in patient management. There is little doubt from my colleagues in the different ICUs the ability to receive lab results in 2 minutes at the bedside versus 15-20 minutes (or even longer in some cases) for samples to be processed by a Stat lab is an enormous benefit and unquestionably leads to better patient management. An important study by the Cardiac ICU team at our hospital highlights this observation. Implementing bedside lactate levels alone led to a marked improvements in children with specific congenital cardiac malformations.
In the lab, there are other inherent benefits, including reducing the volume of Stat testing in the core lab. This translates to greater efficiency for other Stat and non-Stat testing and results in additional capacity to implement new technologies.
As anyone working in healthcare today is aware, there is currently a shortage of medical technologists. At Miami Children's Hospital, we have been able to compensate for this situation in part by implementing a POCT program that has reduced the processing workload for lab technologists while still allowing us to maintain control of laboratory standards. In addition, upcoming changes in the healthcare system may require further electronic data collection and quality control initiatives, including POCT for which laboratory professionals will be responsible.
In my experience, POCT has accelerated the availability of critical test information for clinicians and allowed our core lab to expand its influence throughout the hospital.
Dr. Melnick is chief, Department of Pathology and Clinical Laboratories, Miami Children's Hospital.
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