When point-of-care coordinator Edwina Szelag’s director was reviewing her performance, he asked her what he could do to make her job more challenging. She laughed and said, “Not a thing.”
“Each day I walk in with a game plan, and as the day unfolds, the plan doesn’t happen,” says the POC coordinator for Health First, an integrated delivery system on Florida’s Space Coast. “There is no boredom in this position. Sometimes you have to blaze your own trails in terms of finding a solution to a situation that’s unique to point-of-care testing, and I enjoy the challenge of doing that.”
POC coordinators everywhere have blazed trails and still are doing so. Today, many years after point-of-care testing took off, strong programs are in place and setting examples for others. The American Association for Clinical Chemistry considers Szelag’s POC program one of them: Its Critical and POC Testing Division named her 2006 Point-of-Care Coordinator of the Year for her outstanding achievements in the POC field. She received the award last month at the AACC annual meeting in Chicago.
“A big part of my job is making sure everything is working everywhere, every day, but it takes the whole point-of-care testing team to make that happen,” says Szelag, who views POC testing as “running a virtual laboratory outside of the walls of the laboratory itself.”
When three of Florida’s not-for-profit hospitals joined in 1995 to form the core of Health First, Szelag had no idea what the future held. She was working at the time as a quality assurance assistant at Holmes Regional Medical Center in Melbourne. Today, she is responsible for a POC program that covers 724 beds in three hospitals (Holmes and Cape Canaveral and Palm Bay Community hospitals), an endoscopy center, a surgical center, a pain clinic, a wound clinic, and a hospice house. More than 1,600 of the system’s health care professionals now use point-of-care test systems, and it’s Szelag’s job to make sure all of them comply with federal and state law, and with CAP and JCAHO accreditation requirements.
“I spent the first 20 years of my career working in the laboratory, mainly in chemistry and hematology. When the quality assurance assistant position at Holmes opened up, it seemed like an opportunity to do something new,” Szelag says. Shortly after taking the position, she learned just how much of an opportunity she would have. Plans were in the works for the health care system to have a comprehensive, accredited POC program in place by the end of its first year as an integrated delivery system. Since then, Szelag has never stopped working to improve the POC program at Health First.
When she first was instructed in 1995 to help continue assembling a POC testing program at Health First, she studied the policies and procedures already in place. “The Joint Commission was coming to inspect us, and between the lab and nursing we had parts and pieces of a point-of-care testing program, but it was not yet pulled together.”
Her first task was to ensure that policies and procedures were written for every POC test being performed. “We had to document the training and competency of the entire nursing staff almost overnight,” she recalls. “We had to do all of the color blind testing and observations that were required, and we managed to do it before our inspection.”
Though Szelag has only one full-time senior technologist to assist, the POC testing program is set up such that it distributes oversight responsibilities to other key laboratory and nursing staff at each of the sites, making the program a true team effort. “We have point-of-care unit-based trainers or nursing staff who are part of their own departments but act as liaisons between the nurses and the laboratory. We think of them as ‘super users’ of point-of-care testing. They get extra training from us, are required to attend the point-of-care committee meetings we have, and we make sure they understand why we are doing things in a certain way so they have ownership in the process,” she says. Every year, Szelag holds a special program for the super users, who are trained to answer general questions their staff might have about the POC testing performed in their units. At each hospital, there is also a technologist in the laboratory who oversees the day-to-day POC issues that arise. This program has its own logo, and super users are given pins for “visibility and special recognition,” Szelag says.
Constant education is the key to keeping the team running smoothly. “We have to make sure those who are using the systems are trained and maintain competency,” she says. “We review their annual competency and use this as one of three performance indicators tracked and reported to nursing each month.” There are training programs for patients or consumers, too, to ensure they know how to use their home-testing instruments.
For new staff, training on POC instruments takes place the first week of employment. “When new employees who will be involved in point-of-care testing walk in the door, we give them an overview of our entire program so they know what our expectations are. We also do hands-on training with them up front,” Szelag says. Mock inspections are performed almost monthly, and the POC program participates in six to eight annual skills fairs, which are all-day events during which nurses and others have the opportunity to perform their annual competency assessments. Szelag and her colleagues hold special classes for the health system’s skilled nursing assistants.
They adapted once paper-driven annual test modules into online test modules called e-learning. E-learning helps users of POC testing meet knowledge-based competency requirements that supplement direct observation annually. A special newsletter was created to keep the team informed.
About 98 LifeScan SureStep Flexx glucose meters are in use throughout Health First’s system. In its cardiac catheterization laboratories, Health First uses 17 ITC Hemochron Responses and four Avoximeter 1000Es. Health First’s home health care providers use about 20 HemoSense INRatio systems, and the health system is now considering replacing visual urine dipstick testing with the Bayer Clinitek Status system. In its open heart/cardiology program, Health First uses Nova pHOX Plus analyzers. “Although our Nova pHOX Plus system does have an interface, we don’t yet have point-of-care connectivity for all of our systems at this time. We’re working on replacing our LIS, and when that happens, we will then be bringing our glucose interface live,” she says. Health First does have electronic medical records in all of its settings, and the POC program is able to audit charts and review results electronically.
For Szelag, positive patient identification is a top priority. “We have moved into the realm of bar coding patient identification, and bar coding the patient’s armband is a push that came from the point-of-care testing program,” she says. The POC program was the driving force, too, for bar-coding operator ID badges. “In fact,” Szelag says, “we have yet another monthly performance indicator to monitor compliance with proper identification.”
The third indicator that is reported monthly measures total testing compliance, which looks at—via site visit or audit—reagent dating, equipment care, documentation of QC and chart audits, and more. “This indicator is in essense a monthly report card for each department,” Szelag says.
When it comes to quality control, Health First is old school, Szelag says. “We take pride in being sticklers on our quality control. We still do wet quality control daily even though a lot of places have switched to using equivalent QC. I think a lot of point-of-care programs struggle with what to do these days, then look to the regulations coupled with their environment and the test systems they have in place to try to decide what the best fit is,” she says. Despite the higher cost for the wet QC, she and her team prefer it. “We feel comfortable that we’re testing the system completely, not only the system’s electronics but also the test vessel in which the specimen is going to be analyzed.”
Fortunately for other POC coordinators, and for patients everywhere, Szelag works as hard outside of the hospitals as she does inside. She established a regional POC coordinators group and has been instrumental in organizing the Florida East Coast Point-of-Care Testing Coordinators Conference, held each fall in Cocoa Beach since 2000. This conference merged in 2003 into the Central Florida POC Network, which, with the Florida Coalition for Professional Laboratory Organizations, co-hosted an event at last year’s AACC meeting that made it possible for POC coordinators from all over the country and world to meet. Szelag is co-chair of the network and speaks at local, state, and national seminars on POC topics, including implementing POC critical care programs. She clearly likes what she does, and it shows.
“The nice thing about my job is that as a laboratorian, I get to help bridge the imaginary gap between the laboratory and the rest of the medical center.”
Little wonder, then, that more challenge isn’t what Szelag needs.
Sue Parham is a writer in Edgewater, Md.