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From nurses, POC testing gems

August 2000
Cover Story

Karen Titus

Your worst point-of-care testing nightmare is about to come true.

It’s POC payback time: We’re going to tell you what nurses and other nonlaboratory personnel really think of POC-and of you, the laboratory.

Oh, relax. The news is (mostly) good. As nurses and other nonlaboratory professionals have taken on bedside testing, far more than their workload (though we’ll get to that later) has increased. They’ve gained a greater appreciation of the high standards you bring to medical care. They can see, a little more clearly, the impact CLIA and other regulations have on your work lives. And they know you care about patients.

But much as they appreciate the work you do and the support you provide, your POC colleagues have a few bones to pick with you. And, since they arguably are the omphalos of bedside testing-they’re the ones drawing the specimens, running the tests, helping to choose the devices, tackling checklists and inspections, and talking to patients about laboratory results-you may want to heed their words of wisdom.

So listen up. Here’s what they have to say.

Quality control means very little to them.

(You suspected this all along, didn’t you?)

It’s not that they don’t understand the requirements. They just wish they didn’t have to deal with them.

Or, as Tommy Waggoner, RNC, puts it, "We waste a lot of time on QC documentation and procedures."

Case in point: As a labor and delivery nurse with 22 years’ experience, Waggoner "can’t remember a time when I didn’t do urine dipsticks. Nurses have been doing them forever. We’re taught how to do them in nursing school."

She and her colleagues still do them, but it’s no longer a simple matter now that the nursing staff maintains the POC testing manuals and tracks competencies. "Essentially what happened is the lab people came up and trained us to do something we’d been doing for 20 years," says Waggoner, nurse manager of obstetrical services at Hendrick Health System, Abilene, Tex. "It was redundant-a waste of time, effort, money, and salaries."

Waggoner acknowledges the value of some regulations, such as those requiring users to perform QC on test strips. "I’ll go with that. That was a good change, because we weren’t doing that before, and we should have been." But proving her competency to dip a urine and read the strip? Forget it. "It’s like saying, ’OK, all you nurses have to have a competency test every year to prove you know how to give an injection.’ That’s simply part of a nurse’s job, as far as I’m concerned."

Debra Case-Cromer, RN, MS, coordinator for nursing education at Johns Hopkins Hospital, Baltimore, says when urine dipsticks fell back under the laboratory’s purview at her institution, one of her nursing colleagues termed the new setup "Bizarro World." Says Case-Cromer: "We went from doing this really simple task to something that now had a 27-page procedure and two-page checklist."

Territorial feelings don’t help matters, says Mary Zugcic, MS, CS, a clinical nurse specialist at Henry Ford Hospital, Detroit. "Sometimes it’s hard to let go of the things that you’ve done for years. And nurses have done testing for a long time without having to worry about quality control," she says. When confronted with QC requirements, "Our response is, ’What do you mean, I have to do quality control? How come it was OK not to do it for 20 years, and now it’s not?’"

Moreover, nurses simply have a different view of what constitutes good QC, says Case-Cromer. "Where a lab might think an 82 percent rate for QC is terrible, for nursing that’s actually pretty good, because it has to take its place in the bigger scheme of patient care," she says.

Nurses are loath to let QC interfere with what they consider to be more important matters. "Most nurses went into nursing for the art of nursing, not just for the science of nursing," says Stephanie S. Poe, MScN, RN, coordinator for nursing clinical quality at Johns Hopkins. "To a nurse, the interpersonal relationship with your patient is extremely important. And although the technical aspects of your job are important and must be done well, the interpersonal piece can’t suffer because of the technical piece. We don’t nurse machines; we nurse patients."

"Nurses tend not to value the QC procedures," Case-Cromer agrees. "It’s hard to convince nurses that they make a difference in the quality and accuracy of the results. They do QC because they have to do it, not because they see an intrinsic value in doing it."

So how can the laboratory create QC buy-in?

Pointing to regulatory won’t cut it. "Ancillary services often throw up this smoke screen of ’It’s required by JCAHO, CLIA, CAP, blah, blah, blah,’" says Case-Cromer. While those requirements are real, "Nurses don’t care about that. They care because they have to-they know that without accreditation the doors of the hospital won’t stay open."

Showing that QC has a direct effect on care is more convincing. "Explain to us why the QC is an important method of determining test accuracy," suggests Pat Willie, RN, MSN, program manager for the cardiac cath laboratory and noninvasive cardiology program at Hendrick Health System. "Demonstrate its direct impact on improving patient care. Rationale has always been important to nurses."

And if that fails? "Buy-in is important, but we may never get it," says Case-Cromer. "We might have to settle for people doing QC because they have to, and leave it at that."

That being said, they understand
QC better than you think.

This is especially true for those who already are familiar with the process. As new POC tests have made their way onto the floors at Fletcher Allen Health Care, nurses have complied relatively quickly with QC requirements, reports Margaret M. Terrien, ANP, MSN, CDE, who oversees POC testing for nursing at the Burlington, Vt.-based institution. "Nursing was familiar with QC from having worked with the bedside glucometers over the years," Terrien says. "So it wasn’t as hard a fight with the nurses as it was with the physicians," some of whom were incubating cards from a new H. pylori test under their arms, she reports.

With time, QC can become more the norm, agrees Poe. "When we first started doing point-of-care testing, we just assumed the instruments were reliable. We figured since a device was supposed to give the correct reading, that it did give the correct reading. Initially we had no idea that quality control and proficiency testing need to happen-it just wasn’t within our cognition. But over the years we’ve certainly learned."

"Nurses can get used to QC; they have to check off on everything anyway," says Janis Watts, BSN, RN, CCRN, manager of clinical operations, adult critical care, at Clarian Health Partners, Indianapolis. "They understand QC is a necessary evil."

But sometimes it’s just not worth it.

It might seem like an easy matter to test stool for occult blood at bedside-place the sample on the cards, record the results, and mark "OK" to indicate the control has been performed.

"It sounds like a very small thing," agrees Henry Ford’s Zugcic. "But to get everyone who’s doing the test to record it correctly, even something as simple as marking ’OK,’ is next to impossible."

Her unit no longer performs this particular bedside test, not so much because nurses lack the time to do it, but because even this straightforward QC system fails to accommodate the realities of life on a patient care unit.

"When I’ve got someone who’s GI bleeding and I’m hanging blood and I’m trying to get an IV started and keep the patient clean, and I’m talking to the patient to keep him calm and the phone is ringing and the doctor is giving me orders, to remember to write down that ’OK’-hey, they’re lucky I got the test done and wrote the results down. What’s this little game I have to play with ’OK’? Of course I did the control," Zugcic says.

POC testing requirements create "a great deal of conflict between the lab and nursing," says Case-Cromer. "That’s why some of our departments finally said, ’We’re not going to do this. We’ll just send the specimens back to the lab for regular testing. It’s just not worth it to us to do all this QC and worry about how the controls are stored and what temperature things are.’ They’re just not details that rise up to a level of importance for nurses."

At William Beaumont Hospital, Royal Oak, Mich., bedside testing on the inpatient and outpatient surgical units remains firmly in the hands of laboratory personnel, who work on the units as part of the pre-op teams.

"We toyed with the idea of having nurses do the testing, but decided that this would be biting off far more than we could chew," says Ellen B. Prince, BS, administrative manager. "So the lab is in charge of quality control and quality assurance, and everyone feels comfortable with that. The lab doesn’t have to worry whether the QC is being done properly, and we’re not constantly bird-dogging the nursing staff because they’re doing something incorrectly."

You don’t understand how busy they are.

Despite years of positive interactions between the laboratory and nursing, the latter remains a mystery to the former-or so nurses say.

"I still don’t think the lab understands the full scope of what nurses do. I don’t think they will ever understand that," Case-Cromer says.

"There is so much going on in any one patient’s care. And while point-of-care testing is a helpful portion of that, it’s only a very small portion," adds Poe.

Recent POC discussions at Johns Hopkins have focused on downloading data from the bedside blood glucose meters. The most efficient way to accomplish this task, suggested the laboratory, would be to have one nurse from each of the approximately 70 nursing units download the data once a day. "That seemed to them an easy thing to do," recalls Case-Cromer.

And from nursing’s perspective? "We thought it was an outrageous request," she says. "To have a nurse-who’s doing patient administration, monitoring vital signs, dealing with IV lines, teaching patients, sending them off to procedures, giving whatever other treatments are needed, dealing with questions from patients and family and doctors-to ask them to remember to download lab data so the lab could generate reports seemed like an excessive, unrealistic demand."

Having a laboratory staff person download the data would have required two days’ worth of work, she acknowledges, which would appear to bolster the lab’s argument that nursing was a more efficient route. After all, the task would take a mere two minutes of a nurse’s time.

But time is relative, as nurses are quick to point out. While the actual download might take two minutes, that doesn’t account for the time it would take for nurses to track down the multiple glucose meters, wait for their colleagues to finish using the devices, and find an available computer to download the results. "The lab’s two minutes are actually 20 to 30 minutes," Case-Cromer calculates.

You still don’t get it, do you?
Nurses are busy people.

Poe says she’s well aware of one frequent laboratory complaint-that nurses don’t take the time to perform simple troubleshooting on POC devices. "We send down a meter that doesn’t work, and it turns out to be something like missing batteries or whatever. Then the lab gets mad because they think we should take the time to figure that out.

"Well, we don’t have that time," she says. "And if we did, we don’t want to use our nursing expertise to figure out what’s wrong with the glucometer-we’d rather be with our patients."

Not convinced yet?

"As a nurse, I literally deal with life and death in a matter of minutes," says Charlotte Cabello, MSN, RN, CNA, clinical nurse manager of the adult solid organ transplant unit at Mt. Sinai Medical Center, NY. "There are times when I have to be able to respond instantaneously. I don’t have 10 minutes. I don’t have five minutes. It sounds like an exaggeration, but it’s true."

You’re not the only ones being squeezed by
staffing shortages and tight budgets.

Nonlaboratory personnel have to be quite savvy about POC costs. "We have to look at more than the cost of the device and the savings in reagents," Case-Cromer says. "If we bring on a new instrument, we have to look at all the invisible costs, which include staff training time, QC time, the nurse manager’s time, reviewing lab reports. POC can be a very expensive venture for nursing. But it doesn’t show up as a line item-’training for blood glucose meters, $35,000,’ which is what it cost us last time."

Whether the laboratory is cognizant of those costs is unclear to Case-Cromer. "It’s a cost for nursing; it’s not a cost for them. But we still bring it up anyway," she says.

When the stat laboratory at Clarian Health Partners closed in the early 1990s, most critical care testing wound up on the critical care units and a handful of other sites. Much of the responsibility for the new bedside tests fell to nurses, who simultaneously were undergoing a major phlebotomy/IV training initiative.

"Everything was shifting to nursing," Watts says. That’s a typical scenario, from nursing’s perspective. "Whenever an organization goes through a downsizing, rightsizing, whatever, a lot of things that had been part of other departments are, all of a sudden, something that nurses can somehow do," she says.

You do not see eye-to-eye on quality of care.

Direct care providers have no doubt the laboratory is committed to quality care. "It’s just their definition of quality and our definition of quality are very different," says Case-Cromer.

Laboratory quality, in the view of many nonlab personnel, means accurate lab results. "Which is important," Case-Cromer acknowledges.

For nursing, quality of care is much broader in scope. "Our definition of quality is, The lab results are accurate, patients get to their procedures on time, patients get their discharge instructions, patients get the correct meds at the correct time, someone is there to talk to and console the patient and family," she says.

Quality of care is a more personal matter for bedside providers than for laboratory professionals, Poe suggests. When a patient needs to have another sample drawn, "I don’t believe the lab people don’t care that the patient has to get stuck again. It’s just that they don’t have to come face-to-face with it. The nurse has an intimate relationship with the patient, while the lab personnel, for the most part, have never met the patient. The lab people care, but it’s not personal."

But they appreciate good technology almost as much as you do.

This month, new bedside glucose meters are slated to make their debut on Cabello’s unit at Mt. Sinai. "The staff is so excited they can’t wait," Cabello says.

The reason for the enthusiasm is simple: The new meters will download data automatically, eliminating the need for nurses to chart the finger-stick results online. Other improvements have come with the advent of computerized order entry and a more computerized patient record. Before that, Cabello recalls, "Staffers did a finger-stick and had to write down the results in the logbook and in the patient’s record and at the bedside."

Any technology that lessens the time bedside caregivers devote to documentation is welcome, Cabello says."That’s more time we can spend with the patients."

In fact, they’d like some say in deciding what you bring onboard.

Having a user-friendly instrument has meant a smoother transition to blood gas POC testing in the neonatal intensive care unit at William Beaumont Hospital. "We like the instrument the lab chose," says Kim Terzian, BS, co-director of respiratory care at the hospital. A sample reference cassette system makes it easy for staff to perform QC, and the machine does not depend heavily on operator technique. "Since it’s easy to use, it’s been easy for us to adjust and to use it properly," she says.

Such was not always the case. The laboratory first chose an instrument users found difficult to master. Eventually, Terzian says, it was replaced because of new technologic advances and the number of problems "related to technique. And because we’re a large institution with many people to train, getting proper technique down was a real issue."

Remember, Terzian says, ease of use may mean one thing to laboratory professionals and something completely different to nonlaboratory personnel. "It’s absolutely beneficial for a nonlab individual to be trained on the equipment when the lab is trialing it, to see how easy it will be for nonlab staff to use it."

Same goes for implementation and training.
Why, you could even let them lead the way.

POC testing has succeeded at Henry Ford in part because "The lab people were clever enough to know they just couldn’t come down from their mountain and mandate what had to be done," Zugcic says. "And they knew not to threaten to take it away from us if we didn’t do it right."

Instead, she reports, lab leaders explained the regulations and made the end-users feel as if the two groups were working in tandem to adopt the new requirements.

Laboratories would also do well to step back at times. "Nurses accept things better from other nurses," says Case-Cromer. "A nurse educator has a way of framing information, even unconsciously, in a way that will give nurses more of a buy-in." When training a nurse on a new device, for example, "A lab-based trainer might say, ’Do it this way because CLIA requires it,’ whereas a nurse might say, ’Do it because the results are more accurate, which means we can treat the patient better.’" While that may not sound like a big deal, she says, "It is."

Whenever the laboratory at West Tennessee Healthcare wants to address a blood glucose POC issue with nursing, they turn to Kathy Woolfork, RN, BSN, CDE. "The lab relates the issue to me, and I address it with nursing. I think that makes the nurses feel like they have more ownership of the testing-the fact that I’m a nurse, too, and I’m the one coming to them with this issue," says Woolfork, diabetes education coordinator at the Jackson, Tenn., institution. "It’s better than someone from the lab calling up and telling them, ’This is not the way it should be done.’"

But the laboratory also scores points with Woolfork by being willing, if she asks them, to join her in meeting with the nurses and explaining the problem from the lab’s viewpoint. "The lab is incredibly supportive," she says.

Face it, your timing could be better.

Poe knows that the POC testing office at Hopkins is dying to bring in a new glucose meter, one that would lock out users when QC is not performed. Voila!-good-bye, QC problems. "They see it as a quick fix," she says.

There’s nothing quick about it, she counters. "Even if the new device were able to flag us, that is not sufficient reason to retrain 2,500 nurses on a new machine. We just did it two years ago. In fact, since it takes us six to eight months to do the training, we’ve only really been using our current device for about a year and half."

If the new meter "could truly affect patient care, very visibly, and our ability to deliver that care, then it might be a different story," she says. But unless that’s the case, such a major educational effort should only be undertaken every four or five years, Poe maintains.

"We don’t deny the QC is a problem," she says. "But nursing is looking at that problem from a broader perspective. Given our training time, work overload, and staffing shortage, this is not the time to be making a change. It may be the lab’s priority, but it’s not our priority."

They know you dropped that tube of blood.

"One thing that makes us crazy is when the lab calls to tell us we need to have another blood specimen drawn because it’s QNS-quantity not sufficient," says Cabello. This immediately prompts the question, "Did somebody drop the tube of blood?"

"Hey, it happens," Cabello says. "God knows, we’ve done it too. But just tell us, because it drives us nuts when you tell us that, and we know we sent down a tube that was filled to the brim." The same goes for requesting another tube to replace a missing specimen. "If the lab tells us they never received a specimen, we will move heaven and earth to get ahold of the lab supervisor and to route through every single specimen that was sent. We want to make sure that missing specimen isn’t maybe hiding at the bottom of a pile, or that someone didn’t get interrupted and set it down someplace, and that it just never got to the machine for processing. We want to do everything we can to avoid having to stick the patient an additional time."

Having to redraw specimens is no minor matter for bedside caregivers, who may be sending down samples to confirm POC results. Indeed, it reflects larger issues of patient care. Every new stick represents an opportunity for infection and may limit the number of IV access sites. "It also makes the patients feel like a human pincushion," Cabello notes.

Furthermore, repeated needle-sticks can reflect poorly on the caregivers. "There’s nothing more upsetting to patients than being told, ’We have to stick you again.’ They get extremely upset with you and lose confidence in you-their view is that the staff person who drew their blood is incompetent, that they didn’t do it right the first time," Cabello says.

And lest you think this is a problem only for the bedside practitioners, consider this observation: "If the staff’s response, in order to ’defend’ themselves, is to say, ’It’s not our fault-the lab said they needed another specimen,’ the patient will lose confidence in the lab and the rest of the hospital, not just the care providers in the unit," Cabello points out.

They like seeing your face from time to time.

Yes, we know you’ve been told-umpteen times-to leave the lab, but it never hurts to hear it a few more times.

"If the lab folks were to come up and see what we do on the floors, that would be a nice gesture," says Case-Cromer. "It would show a real effort on their part to understand the multiple, multiple, multiple priorities nurses face."

Caregivers who see their laboratory colleagues on a regular basis definitely appreciate it.

At Clarian Health Partners, the laboratory’s POC manager and staff "are highly visible to nurse managers and their staff," Watts says. "It has a huge impact on us."

POC personnel at Henry Ford hold their meetings on the patient care units, rather than in the laboratory. "That may not seem like much, but it gets the lab people out of their inner sanctum," Zugcic says.

Lab professionals haven’t always been welcome on the floors with unbridled enthusiasm, Zugcic admits. "We used to cringe when we saw them on the units-we figured they were just coming up to give us grief about QC. But now we see them as people who are coming up here to help us." She also concedes laboratory personnel may have reasons for shying away from the patient care units. "Look at it from their point of view," she says. "Usually the only time they talk to a nurse is when there’s one screaming at them over the phone. Would you want to go up and face that? Lab people aren’t stupid-they’re not going to go where they get yelled at."

And they wouldn’t mind seeing just what it is you do.

Zugcic says she makes it a point to stop by the laboratory occasionally to chat with her lab colleagues. Though she now enjoys making these visits, her first foray to the lab gave her pause.

"I was not comfortable doing it," she recalls. "It was much easier to sit up on the unit and call them and yell at them than actually go and deal with them."

Nor was she sure that she would be welcome in the laboratory. "There’s that sign on the door, ’Authorized personnel only,’ which makes you feel like you don’t belong. When I went in, I wasn’t sure if they’d call security on me, or if I’d be shot," she jokes.

Not that everyone is sold on this concept of calling on the lab.

"I can see where it might be helpful to go to the lab and see what they do," says Case-Cromer, a bit doubtfully. "Some people might find it interesting. But most nurses probably would not."

Your support makes the difference.

Terzian, of William Beaumont, says she and her respiratory therapist colleagues do not hesitate to ask the laboratory for help whenever they need it. "We expect them to assist us, because it does fall under their department to oversee [POC testing]."

Because the lab meets those expectations, bedside testing has worked well, she says. "They’re there for us when we ask questions, and they helped with the initial training. They even follow up and report to me without my having to ask them." This support "has given us a very good comfort level with using the equipment and doing the testing," she says.

"One of the reasons for our success is that the lab is customer-oriented," says Fletcher Allen’s Terrien. "They never said to us, ’You have to do this test this way.’ Instead, they sat down with everyone involved and said, ’What do you need to do and how can we help you?’

"That makes a world of difference, believe me."

Your role in POC testing is murky.
Actually, your role in general can be a little dim.
But POC is helping your cause.

As POC testing has gained a foothold at Johns Hopkins, so has the idea, slowly but surely, that the laboratory is somehow involved in the matter.

"The understanding that the lab is responsible for point-of-care testing has been new," says Case-Cromer. "Before, it was not something that we saw as the purview of the lab at all. The lab was a place where we sent specimens to, and what they did there was their business."

Observes Woolfork: "Sometimes the nurses do feel like they have ownership of bedside glucose testing. Nurses say to me, ’What does the lab have to do with it?’"

The laboratory-direct caregiver relationship is still clouded by ancient boundaries.

At Henry Ford, some of the recalcitrance nurses felt toward POC testing initially was based not so much on the lab’s attitudes, "but the attitudes we believed they had," says Zugcic. With interactions largely limited to phone calls asking for test results, it was easy for nurses to be chary regarding their laboratory colleagues. Opinion tended to fall toward the I-know-they-ignore-the-stat-work, I-know-the-lab-stuff-is-up-there-they’re-just-not-looking-for-it end of the spectrum, she says. "There was a lot of baggage that had come from years of the traditional lab-nursing dynamic. But POC has helped change that."

Before POC began making its mark at Hendrick Health Center, Willie says she saw the laboratory as merely an ancillary department. "And you know how ancillary departments can be-it’s usually a matter of, ’I want this result when I need it, and the department should have it.’"

Now that she’s elbow-deep in reagent parameters, CAP inspections, and the like, her empathy has grown. "Boy, do I have a greater appreciation for what the lab goes through to get those results."

However, they are calling some of the shots,
whether you like it or not.

Direct care staff at William Beaumont initially resisted training to perform blood gas POC tests "due to previous experience," says Terzian. "At first we were concerned about the time commitment for training, but the laboratory and respiratory care pulled together to accomplish a good training program," she says.

Eventually, she says, "We decided that because we are doing the testing and want to do it well and efficiently, we took on the responsibility to do the training and follow-through. And we decided to work with the lab and not against them."

Fortunately, they recognize
that you’re calling some shots, too.

"We know that the lab is the final authority," says Woolfork.

"Even though I have the equipment in my department, I run the test, and I handle the QC, the lab personnel remain the experts," says Willie. "They are a valuable resource, and I rely on their knowledge. Frankly, I don’t think that point-of-care should happen outside a collegial relationship with the lab."

Do they like POC?
You betcha.

Despite QC hassles, lack of time, the burden of training, and Byzantine regulatory requirements, the majority of direct care providers say they welcome the opportunity to do bedside testing when it benefits patients.

"We would love to expand our role with point-of-care blood gases in the hospital," says Terzian.

Willie says she has yet to hear a negative remark from her colleagues about POC testing. "We love having immediate results."

"We know the lab does a good job, and we know they run tests better than we do,’" says Zugcic. "But there is an advantage in us doing it, and whenever the lab can let us do it, they shouldn’t deny us that opportunity. Because having that result immediately allows us to do what’s best for the patient."

Karen Titus is CAP TODAY contributing editor and co-managing editor.