Maintaining a Successful POC Department

By Darlene L. Sobucki, MLT(ASCP), CLS(NCA), RN

Several articles have been written over the past few years about the rapidly growing area of point-of-care (POC) testing. These articles have dealt with topics including: forming the hospital POC committee, determining if POC tests are cost effective and the implementation of the various tests. The articles also have discussed the issues of compliance amongst the different regulatory agencies.

But when the instruments are finally in place, the tests are being performed and you review the data, is that all there is to it? Is your job as POC coordinator of this new department done? Not quite. For this relatively new laboratory area to run smoothly, it takes much more than what you may be aware of, or actually willing to put into practice. It takes good communication, accessibility to the operators, and implementing a quality improvement/quality assurance program.

Communication
The first thing that’s necessary for maintaining your POC department is good communication. When you start thinking of all your POC operators (including nursing personnel) as your “customers,” your communication efforts will result in a more positive outcome. No matter what service a company provides these days, customer satisfaction is the key to success. The nursing staff and any other department that performs POC testing are your internal customers. Providing a service to your customers means giving them information, your presence and feedback.

What kind of information actually needs to be communicated? The familiar phrase “keep it simple stupid” comes to mind. Don’t overburden them with the statistical work you have to go through to tighten the control ranges. Linearity and calibration verification are not common vocabulary words to nursing personnel. You also will find that most nursing personnel have never heard of CAP (College of American Pathologists) and are not interested in hearing about your checklist items. However, most are quite familiar with the words “Joint Commission” (JCAHO). It may behoove you to use that strategy when trying to garner nursing personnel compliance. Approximately three to four times a year, I write a brief newsletter. I keep it short, upbeat and usually one or two pages long. It contains information such as:

• any new instruments or tests that may have been introduced;
• POC training that may be taking place within the facility;
• if the laboratory will be going through a CAP or JCAHO inspection;
• how they can help prepare for any inspection coming up;
• recognition to any of the units that have achieved compliance; and
• any other information I feel needs to be communicated.

Even if your facility has a regularly scheduled POC committee meeting, this does not guarantee that the information gets back to all the people involved. Everyone loves to be kept informed as to what is going on. Posting a copy of this newsletter on each unit will achieve this.

Feedback to the nursing units needs to be both positive and negative. If they are not complying with guidelines, this must be brought to their attention. Once again, though, how something is communicated can make a world of difference. We all know that it’s easier to be corrected on something when it’s done in a tactful manner. Giving positive feedback is just as important as giving negative feedback. When a unit is doing well, let them and everyone else know it. If your facility has any type of in-house publication, make arrangements with the editor to publish the units that are complying with guidelines. This is a good way to let all the units know who is doing well. It would not be in good taste, however, to publish those units not doing well.

If POC testing does well in its regulatory inspection, reward the staff–let them know it was their success as well as yours. One way to do this is to have an “open-house” where you could serve punch and cookies. Perhaps some type of small item could be given away to all those who attend this gathering. Your facility’s Public Relations Department may be able to help with this. Items such as key chains, nail files or pens go over well. By including the staff in your accomplishments, it breaks down some of the barriers between the departments. Above all, it has a powerful impact on your rapport with the staff.

Compliance
There are some excellent opportunities available to aid in your quest toward compliance in POC testing. For example, the new AccuChek HQ glucose meter (Roche Diagnostics Corp., Indianapolis) offers many outstanding features, one of which is the “operator lockout.” This eliminates the possibility of operators who have not been “certified” to perform glucose testing. It also has bar code reading capabilities. This will decrease the amount of time spent on entering operator and patient ID numbers.

For excellent data management, the RALS continuum from MAS (Medical Automation Systems Inc., Charlottesville, VA) provides data management solutions. It enables the facility to take control of its POC testing data management in a user-friendly, Microsoft Windows environment. RALS software enables users of the Roche GTS or HQ glucose meter to automatically download data directly to a control monitoring station. Data can be transferred automatically, after meeting predetermined criteria, to the hospital laboratory information system. Results that do not meet that criteria are held in a flagged results table for review by the POC coordinator.

Additionally, MAS offers different systems to meet your specific needs. If your facility has multiple POC tests throughout one or more institutions, there’s the RALS PLUS. With this version, you can completely customize your data management needs. The test stations can be configured to control POC instruments, glucose downloads and allow manual data entry. Patient results go through an auto-verification process and are sent through the interface to the patient chart. The POC coordinator can manage all POC results, update certifications and handle quality control management through one information management system.

Quality Improvement
In addition to compliance, you’ll want to incorporate quality improvement practices. If you have a committee in place, which may include the nursing staff, lab representatives and possibly administration, suggest implementing quality improvement for this area. Some excellent monitoring indicators could include, but are not limited to:

1. reagents labeled with the open and expiration dates;
2. if reagents have been used before the expiration date;
3. controls done on each day of testing (only for tests where there is no instrument lockout);
4. the number of unknown operators (for tests where the operator ID is programmed into the instrument before each use); and
5. ensuring that test results are recorded on the patient’s chart (chart audit).

It’s not necessary to have more than two indicators being monitored at one time. The data you obtain can be put into a graph and distributed to the various nursing units for viewing. Improvement will usually begin when competition comes into play. You may also wish to send your data to nursing administration and to the facility’s CEO. A reward could be given to the unit that shows the most improvement over a six-month or one-year period. Plan and arrange the reward prior to beginning monitoring of the data. Make sure you inform your POC operators of your plans. Let them know what you will be monitoring, how and where the results will be displayed and who will be rewarded.

At the close of your monitoring period be sure to announce, via fliers or the hospital newsletter, which unit won. Everyone loves recognition!

Quality Assurance
We know that companies with products incorporate some type of quality assurance into their production process. A random sampling is usually checked to assure the product’s quality. The same can be done for POC testing. However, you must look beyond the additional cost of reagents and time this may take to accomplish. The goal is to ensure accurate results are produced on a routine basis (anywhere from monthly to quarterly).

How do you accomplish this? Do random sampling of actual patient testing. By repeating a test that was already done by a POC operator, you should expect to obtain the same result the POC operator obtained (e.g., for a qualitative test, I look for positive or negative). If a numerical value was obtained, there are established guidelines set by the regulatory agencies that can be followed.

Timing and type of specimen guidelines must also be taken into consideration. If a pattern of maximal variances is noted, this will alert you to someone who may be in need of retraining. Again, the data you obtain can be put into a graph format and displayed in the laboratory for viewing.

Whether or not this type of monitoring is necessary is a controversial subject. Some feel that if it isn’t on the checklist for your regulatory agency, then why bother. Well, you should bother for the same reason companies bother–to be assured of a quality system. Remember, these are usually non-laboratory personnel performing the tests.

Accessibility
Being accessible to nursing personnel means more than being available by phone or pager. If you take the time to visit the units on a routine basis, this is time well spent that can actually serve multiple purposes. It’s an excellent way to build a good relationship with the nursing staff. Whether you use the time to check reagents for open or expiration dates, do random chart auditing or check log sheets (if still used), this time can also serve as a time for customer service. Ask if everything is running smoothly or if there are any questions. You will be amazed at what positive results you will derive. It gives those who have questions or concerns the opportunity to address them with you face-to-face. It also gives the impression of individualized attention, which is something we all like.

Conclusion
In conclusion, some laboratorians who oversee POC testing have a rather negative opinion of the nursing staff. There is a feeling that nurses just don’t care about POC testing. In their defense, be patient with them. Try remembering what all nurses must contend with daily–coworkers, patients, doctors and families of their patients. And although we may consider it a bad day when an instrument is not working well or the computer is down, try to imagine how nurses feel when they must deal with a demanding doctor, an irrational patient or an irate patient’s family. This helps put things into perspective.

Nursing awareness of POC testing may not be as extensive as it is in the laboratory circa, but it will get there.