Playbook for Better Point-of-Care Glucose Testing

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Policy and educational interventions can improve compliance with point-of-care testing (POCT) quality standards, according to a study conducted by members of the Eastern Ontario Regional Laboratory Association (EORLA) in Canada. The investigators writing in Practical Laboratory Medicine discuss how they applied interventions such as meter notifications and policy updates to encourage staff to repeat critically high glucose results.

Blood glucose is the most common POCT performed in hospitals, but staff members conducting POCT typically haven’t been trained in lab skills. As a result, they don’t always appreciate the importance of quality assurance (QA) practices, Julie Shaw, PhD, FCACB, associate professor with The University of Ottawa’s Department of Pathology and Laboratory Medicine, and the study’s corresponding author, told CLN Stat. These personnel are extremely busy and have many demands on their time.

“Clinical staff are focused, appropriately so, on caring for their patients, and they see QA as a barrier to obtaining a test result they need in order to treat their patient. QA for POCT just adds one more task to an already very busy schedule,” noted Shaw, who also heads the division of biochemistry and POCT program at The Ottawa Hospital and serves as regional lead for biochemistry and POCT for EORLA.

EORLA hospitals are required to repeat critically high POCT glucose results prior to taking action. Auditors regularly monitor this policy. “Monthly quality indicator data from EORLA member hospitals illustrated consistent and systemic noncompliance with the critical repeat policy at most sites, prompting a thorough investigation and development of strategies aimed at improving compliance,” wrote Shaw and colleagues. Their goal: to examine whether interventions by labs overseeing POCT programs could spur compliance improvements in clinical staff performing POCT. The researchers also evaluated the necessity of repeating critically high glucose results prior to taking action and explored the reasons for high discordance rates of repeat results.

Audits of POCT glucose tests for compliance with the critical repeat policy took place in 11 EORLA hospitals between June and December 2018 and June and December 2019. Investigators determined the discordant repeat rate for each period. Lab staff conducted interventions to improve compliance between January and May 2019. These included: updating POCT policy, implementing critical repeat alerts on meters, and educating nursing staff. Physicians were also encouraged to support initiatives for improving compliance.

Each hospital had a medical advisory committee made up of physicians from the hospital, explained Shaw. “Within EORLA, the laboratory director at the hospital usually sits on the medical advisory committee. The issue of noncompliance of POCT operators was brought up at the medical advisory committees for some sites, so that physicians would be aware of the quality issues associated with noncompliance,” she explained.

Clinical staff not only had low compliance with repeating critically high glucose results, but also a sizable minority of repeat results conflicted with initial results. “When critically high glucose results were repeated, we found a relatively high rate (25% across sites) of discordance between the initial result and the repeat result (defined as 20% different),” said Shaw. In consulting with nurses on the reasons behind the discordant results, investigators learned that patients’ hands not being sufficiently clean prior to testing might have been the reason the initial result was often falsely elevated.

Following interventions, compliance with the critical repeat policy rose from 30% in 2018 to 58% in 2019. Most sites also showed improvements in the rate of discordant repeat results. Notifications on the glucose meters, which alert operators to the need for repeat measurement when they receive a critically high measurement, was likely the intervention that had the greatest impact, though Shaw cautioned that she had no way of proving this.

Investigators recommended that hospitals develop strong POCT multidisciplinary committees with input from senior and clinical management to improve compliance. Additionally, clinical labs that don’t have procedures for repeating critical results might consider implementing such a procedure, said Shaw. “Labs may want to consider auditing their own data to see if their findings are similar,” she added.

In future research, she’d like to investigate whether patients with falsely elevated glucose results show signs of hypoglycemic events, triggered by inappropriate insulin treatment. “We plan to keep auditing and providing feedback to clinical areas on this indicator. We also plan to develop more quality indicators to monitor with the aim of identifying other areas for improvement.”