When asked why point-of-care (POC) testing is gaining popularity, the most common answer is real-time test results; next is cost efficiency and ease of use. But there are so many more benefits of POC. With ever-advancing technology and interface capabilities, and when utilized properly, POC can be used by labs to remotely monitor and offer support in multiple areas, such as instrument functions, regulatory compliance, and patient safety.
While there are numerous choices of interface systems in the market, I am most familiar with Telcor because it is the system used at my institution. And after speaking with POC coordinators from other organizations, I realized that many of us follow the same daily, weekly, and monthly tasks. I wonder how many of us truly understand the significance of these routine tasks and how they benefit the clinical staff and, ultimately, patients?
MONITORING ESSENTIAL INSTRUMENT FUNCTIONS
One of the daily tasks POC coordinators do is checking instrument functions in the interface system — in our case, Telcor’s QML. We check to see when the instruments last communicated with the system. From the time stamp, we can determine if there is a potential issue with the interface connections. We then contact the unit if their instrument has not communicated for some time.
The specific time frame is dependent on the instrument type and facility location. For example, Inform II, ID NOW, Coaguchek, and iSTAT instruments should always stay connected. On the other hand, we have found that Cliniteks sometimes take a while to connect or reconnect, especially in rural sites where interface connections or Dynamic Host Configuration Protocol (DHCP) IP addresses are not as abundant. We typically wait a couple of days prior before contacting the units for Clinitek connections.
The benefit of this monitoring process is detecting potential issues before they become significant problems. It can be either the interface or the instrument that is having issues. For example, a common cause for Inform II meters not communicating with our system is that the meter is not sitting and charging in the dock properly. This enhanced feature of remote monitoring enables our POC team to proactively contact the units before they even realize the problem — or contact us — due to instrument trouble.
REMOTE QUALITY CONTROL REVIEW
Reviewing quality control (QC) performance and results is another daily task. We review QC performance for all interfaced instrument types, including those instruments that have QC lockout. This is to ensure instrument settings have not been changed in error. Though many instrument types have QC lockout, there are still some that do not, such as iSTAT or ID NOW. During the daily monitoring/review, we confirm that QC was repeated with acceptable results if there was a QC failure. If there are no acceptable repeat QC results, we check to see if any patients were tested during that timeframe.
We have noticed that for Cliniteks, if a QC is repeated within a minute of the failed result, the repeat result sometimes does not cross over to the QML system. In this case, we check the instrument on-site to see if the QC was indeed repeated with acceptable results.
QC review also helps monitor operator performance. If we see the same operator repeatedly failing QC, we may reach out to see if they would like retraining or need other assistance. At one of our sites, we recently noticed an increased number of QC results not crossing into the system, even though review of the Clinitek results in the instrument on-site showed they had been performed. After investigating, we discovered that if the operator scanned the 2D barcode on the QC vials, the results would not cross from the instrument to QML. To resolve the problem, we recommended the site black out the 2D barcodes on the QC vials and instructed staff to manually enter the QC lot number.
For iSTAT, we monitor in QML to confirm that QC frequency was within the 31-day timeframe and to ensure compliance with the individualized quality control plan. We also review cartridge lot numbers used for patient testing and confirm that QC was indeed performed on each new lot prior to patient testing. This monitoring process ensures regulatory compliance, instrument performance, and patient safety.
In addition to QC review, we also review monthly wipe tests for instruments such as Liat and ID NOW. Wipe tests must pass in order to continue patient testing. This ensures regulatory compliance and protects against contamination.
MANAGING OPERATOR ACCESS AND ASSIGNMENT
The next routine monitoring task is to add, renew, or remove operators from the system. Many of the interfaced instrument types in use do have operator lockout. Due to the number of sites we oversee, we synchronize the sites to seven competency cycles. Regardless of when new hires start, their competency cycles get synchronized to their department. To monitor training for manual tests, we grant access to interfaced tests only after the manual test training has been completed as well.
Before granting access, our POC team checks the learning management system (LMS) to confirm if the operator has completed both components of the course: an online course and a hands-on observation checklist, both completed by an approved POC train-the-trainer. Upon completion, unit managers can validate the training in the LMS.
We grant permanent staff instrument access by their badge ID barcode. Traveling staff are granted instrument access based on a temporary barcode we create.
For nonwaived instruments, we monitor and assign courses for initial, 6-month, and annual competencies accordingly. Unit managers also confirm that operators of nonwaived instruments have fulfilled the diploma requirements. All these steps are implemented to ensure all operators performing patient testing are trained properly. This translates into better patient safety and more accurate, reliable results.
In addition to ensuring appropriate training, we also assign the specific locations where the operators perform testing. This is especially important for the nonwaived test platforms, where competency must be completed at each individual site. At the time of assignment, we also set the access expiration date to ensure annual competency is completed to retain access.
EXCEPTIONS OR RESULT CHARTING ISSUES
Each day, our POC team reviews exceptions where the test results are not posted to patient charts due to a variety of reasons, such as scanning the wrong label, instrument error codes, or the presence of critical results or emergency barcodes. There are multiple reasons a sample label scan might be incorrect, such as the encounter label being wrong due to a patient registration error, or scanning a label not associated with the correct patient encounter.
The system automatically stops the questionable result from being delivered if the patient scanned did not have a valid encounter for that date and time. This is a safeguard against results charting to the wrong patient. Emergency barcodes are used for cases where patients have not yet been registered but need immediate assistance. In this case, the unit provides the test date, test time, patient name, date of birth, and the patient MRN or account number to the POC team. Once we obtain the needed information, we add the result to the patient chart.
USING INFECTION CONTROL REPORTS
Due to feedback and observations, we started compiling monthly infection control reports for some of our sites to ensure proper glucose meter cleaning between patients. This process was recommended by the hospital infection control team. There were concerns that the portability of the glucose meter may spread disease from one patient to another.
Using the QML software, we can pull monthly data of the glucose results by site. We analyze this data using a Microsoft Excel macro. The final report shows the percentage of tests that were not in compliance with the glucose meter cleaning policy. This is the number of tests where the test time between patients was less than 4 minutes.
To ensure proper cleaning and sanitation, the meter needs to be wiped and left to air dry for 4 minutes. This cleaning/drying time is dependent on the bleach wipe type. Though this method is not perfect, it does offer a minimal check to assess compliance with the proper cleaning time.
The report also includes the list of units and operators that were not in compliance. Each month, these reports are sent to the infection control team, compliance team, and managers of each facility. They use the information to educate their team and to take needed action to improve patient safety.
ADDING UP THE BENEFITS
The POC functions mentioned above provide a general picture of the benefits to the healthcare system. With the current monitoring process, we have been able to view instrument functions, QC review, operator access, and resulting issues. We also have been able to gather data and create reports to meet the specific needs of different testing sites. As technology continues to advance, these monitoring capabilities will enable POC to further improve its capacity to ensure compliance and patient safety.
Alice Pedersen, MBA, MLS(ASCP), is a point-of-care medical laboratory scientist at TriCore Laboratories in Albuquerque, New Mexico. +Email: [email protected]