Nurses put POC tests through their paces
Few would argue that point-of-care testing programs in hospitals
come a long way, but becoming better by continuing to smooth the
wrinkles has for most become a way of life.
At some hospitals,
such as New York University Medical Center, New York City, the number
of point-of-care tests has been stripped to a minimum. “We
do very limited point-of-care testing, and we have it restricted
to a few areas,” says Beth Duthie, RN, director of nursing
for patient care systems.
At others, such
as Sentara Healthcare, Norfolk, Va., multiple tests are performed
in the nursing units. “We’re looking for more tests
that we can do at the bedside,” says Mary Dahling, RN, MSN,
clinical nurse specialist in the cardiovascular thoracic intensive
care unit at Sentara Norfolk General Hospital. Dahling stresses
that all test methods are validated in the laboratory for precision,
accuracy, and linearity before testing is approved for a nursing
At 245-bed Holy
Family Hospital and Medical Center, Methuen, Mass., POC testing
program representatives decided to limit POC tests at the program’s
outset. “You’reworking with people’s lives,”
says Susanne Uzdavinis, RN, MS, nurse manager of the birthing center.
“You want the most precise and accurate results you can get.”
co-chairs the hospital’s point-of-care testing program, would
prefer that all tests be done by the laboratory. As it stands, blood
glucose is the only test performed in every nursing unit. Other
POC tests, including occult blood tests, urine dipsticks, and amino
sticks, are done in a limited number of areas.
The reason is
simple. “When you have many people doing the same thing, it’s
not as good as having a small number that continually do it over
and over again,” Uzdavinis says. In only a few areas does
nursing have the test volume necessary to ensure that it can perform
at the same level expected of a laboratory, she adds. But she admits
that the performance of Holy Family’s laboratory plays a role
in her hospital’s approach. “Our turnaround time is
extremely good,” she says.
NYU Medical Center
began limiting bedside testing when it became difficult to maintain
quality control. Pregnancy tests, for example, were pulled from
the emergency department last year because they “did not meet
the goal of more efficient, streamlined processes,” Duthie
levels are now measured throughout the hospital. Other tests, such
as activated clotting times, occult blood tests, and urine dipsticks,
are used in a handful of high-volume areas. Occult blood tests,
for example, are used in the neonatal intensive care unit to diagnose
necrotizing enterocolitis. “There is a definite need for rapid
intervention,” Duthie notes.
Duthie says the new generation of glucose meters, which she refers to as “error
proof,” are a model for other POC tests. If, for example, you don’t
have enough blood on the strip, the meter won’t provide an answer. Using
the old glucose meters, the result would have been falsely low. “The simpler
and more error proof it is, the easier it is to implement the technology,”
she says. “You want technology where competency becomes a nonissue.”
increasingly are realizing the need for laboratory oversight
and investing accordingly.
Shands Jacksonville, an academic medical center associated with
the University of Florida, uses beta-hemolytic streptococci, blood
glucose, urine dipstick, cholesterol, Nitrazine paper, occult blood,
and pregnancy tests. “Because there’s a mixture of simple
and complex testing, the laboratory is being pulled into the picture
a lot more,” says Cindy Westbrook, RN, a performance improvement
specialist in the quality management department.
recently decided, for example, to hire two POC specialists from
the laboratory to manage the POC program. “With the POC positions
in place, there will be a more thorough review,” says Westbrook.
“It creates a higher quality point-of-care program when you
involve the laboratory.”
nursing managed the POC program. “With the way the market
is heading, who knows what’s going to be available at the
bedside,” Westbrook says. “We wanted to put ourselves
in a good position for the future.”
The 542-bed VA
North Texas Health Care System, Dallas, has a full list of POC tests—blood
glucose, B-type natriuretic peptide, parathyroid hormone, cholesterol,
H. pylori, activated clotting time, hemoglobin, chemistries,
occult blood, visual urinalysis, and blood gases. Because the scope
of its program continues to grow, the hospital decided in January
to dedicate two full-time laboratory positions to overseeing POC
testing. When Jacquelyn Gray, BS, MT (ASCP), one of the two ancillary
testing coordinators, started working with POC testing about three
years ago, there were fewer than 50 glucose meters on the floors.
Today there are 74. “There’s a lot of added tests and
patients,” she says.
System has 7.8 full-time equivalents dedicated to POC testing. These
technologists monitor the POC testing program at five of the six
hospitals in the system. The health system finds that this level
of commitment works well, says Lou Ann Wyer, BS, MT (ASCP), clinical
specialist for point-of-care testing and quality management for
Sentara Laboratory Services.
At other sites,
nursing provides the oversight, but many know they can’t go
it alone. Mary Jo Rose, BSN, RN, coordinator for nursing point-of-care
testing at the Alfred I. duPont Hospital for Children, Wilmington,
Del., leads an orientation once a month for new staff members. In
it she emphasizes that point-of-care testing is a “laboratory
test that nursing personnel have the privilege of doing at the bedside.”
do it without laboratory support and someone to oversee the compliance,”
Rose gives her
trainees a lecture and an opportunity to do hands-on testing. The
trainees dip urines and review and record results, prepare Hemoccult
slides and recognize positive and negative results, and are trained
on how to use glucose meters. Rose collaborates with the POC testing
coordinator for the laboratory to train the nursing staff and monitor
their competency. “Our hours are flexible, depending on who
we want to update and train,” she says. That means working
day, night, and weekend shifts.
Rose and her laboratory
counterpart also feature POC testing at the hospital’s educational
blitzes. This monthly event, which originally focused on cardiopulmonary
resuscitation, encompasses patient safety, POC testing, and more.
It’s a chance for employees to stop by and ask questions or
even to maintain their competency. “We’re visible to
all units. We’re visible to the lab,” Rose says. “We’ve
found this to be very effective.”
Two or three times
a week, Rose and her laboratory counterpart make rounds through
the hospital. “People from the nursing side get to see who
the point-of-care testing person is in the lab,” she says.
It gives nurses another chance to ask questions about POC testing
or other lab tests.
Rose also set
up what she calls “point-of-care resources.”
asked two people on every unit to be our resources for point-of-care
testing,” she says. “They help us get the word out to
people we can’t see every day or every week.”
Charlotte, NC, has taken a similar approach. Each unit designates
one person to attend regular meetings as the POC testing laboratory
liaison. “It’s that person’s responsibility to
go back to the nursing unit and pass on the information,”
says Susan Weiner, BA, RN, a nurse manager for hemodialysis.
Having at least
one or two nursing staff members who are well-versed in point-of-care
can help an institution overcome training challenges. “People
have heard the term point-of-care, but they don’t get the
full impact of what it means, the responsibility that goes behind
that,” says Lillian Falko, RN, a diabetes clinical nurse specialist
for inpatient care at Yale–New Haven (Conn.) Hospital. Falko,
who coordinates education for the glucose meters, adds that, “If
you use the [glucose meter], you’re to understand how it works,
how to do a control, and how to clean it.”
At Sentara Healthcare,
the POC testing department sends monthly quality summaries, which
include quality control compliance and operator performance levels,
to the nurse managers. This allows nursing staff members to get
feedback in a timely manner.
In the last six
months, Sentara has put its POC test procedures on the hospital
intranet and eliminated paper manuals. “The nurses can access
any test procedure or quality control log from their computers,”
Whatever the mode
of education, it’s wise to remind nurses that their backgrounds
are an asset to laboratory testing. “Nurses have been trained
to assess the patient’s clinical picture and the POC test
results,” says Diane Greiber, BS, MT (ASCP), MBA, senior laboratory
technologist for Sentara Laboratory Services. Collaborating with
the nursing units, the lab developed a process for bedside clinicians
to follow if POC results don’t match the patient’s clinical
Nurses’ expertise is also being tapped to select new glucose meters.
A pilot program is under way in which nurses are evaluating three types of glucose
monitors, each for a period of three weeks. “They like the idea of being
part of the group that gets to choose the [glucose meters] they use,”
says Edie Alley, RN, MSN, a clinical nurse specialist on the general surgery
floor at Sentara Norfolk General Hospital.
all their efforts, nurses have seen firsthand the payoff in patient
care. POC tests, for example,
have reduced the time necessary to remove patients from mechanical
ventilation in the cardiovascular thoracic intensive care unit at
the i-Stat came to the [cardiovascular thoracic intensive care unit],
we would have to draw an arterial blood gas and send it to the laboratory
on ice,” recalls Dahling. Then it would take 20 to 30 minutes
to get the result back from the laboratory.
can just run the ABG at the bedside, get the result in two minutes,
and proceed to make adjustments to the ventilator,” Dahling
says. “It’s affected how quickly we can wean patients
off mechanical ventilation.”
times were also a problem, she adds. Before potassium was tested
at the point of care, normal turnaround times were 30 to 60 minutes.
This was a drawback because the patients are often low in potassium,
which predisposes them to develop cardiac arrhythmias. Now the nurses
can treat the electrolyte imbalances within minutes and avoid negative
In addition, the
small sample sizes sufficient for POC testing are a plus, says Dahling,
because the patients have a drop in hemoglobin after surgery. Small
sample sizes are a benefit for other patients as well, including
diabetics, who have frequent blood draws.
Nurses like doing
their own blood glucoses, says Weiner, of Presbyterian Hospital,
because they’re able to treat patients quickly. “We’re
more in control of our practice,” she says. Similarly, the
results from occult blood tests allow them to treat patients with
gastrointestinal bleeds more efficiently. “We don’t
have to wait,” notes Weiner. “We get the result and
go on to treat the patient.”
Vida Foubister is a writer in Mamaroneck, NY.