How top-notch POC programs earn high marks
When point-of-care testing first surfaced more than a decade
ago, laboratories figured if they ignored it, it might go away.
How times have changed. Today, laboratories are not only learning
to live with point-of-care testing but also taking charge of it.
"We found that we need to be actively involved no matter where testing
is performed," says Peter J. Howanitz, MD, director of laboratories
and vice chair, Department of Pathology, State University of New
York Health Science Center. He also chairs the CAP’s Point-of-Care
POC testing has been good for labs, in fact, because its growth
has forced them to build bridges with nursing and other units, says
Kent Lewandrowski, MD, associate director of clinical laboratories
at Massachusetts General Hospital and editor of Point of Care:
The Journal of Near Patient Testing Technology. "We have to
form interdepartmental teams and get to know each other," he says.
In the process, "we’re beginning to get the hang of how to manage
POC well." In fact, he says, the best labs now embrace point-of-care
testing as an opportunity to improve patient care.
Other departments that do point-of-care testing have gained an
appreciation for what the laboratory does, Dr. Howanitz says. "One
of the most difficult aspects is to train the nursing staff or other
operators to do all the things that will be required," he says.
"It has made them realize just what is involved in doing a lab test."
CAP TODAY talked with a handful of hospital labs whose POC testing programs
are considered to be a cut above the average. We wanted to know what they’re
doing and what works and what doesn’t.
Capturing the data
At many hospitals, POC test results never make it to the lab information
system. Nurses record them on the patient’s paper chart—that’s
as far as they go. In some cases, the lab may get weekly reports,
but there’s no way to verify whether all the results are there.
At the hospitals CAPTODAY surveyed, by and large results are automatically
uploaded into the LIS and from there into the hospital information
system for use in an electronic medical record and for billing.
But even the most highly automated hospitals don’t yet capture all
their test results electronically. The latest glucose monitors can
be docked with a computer and their information can be transferred
electronically, but other types of test results—such as activated
clotting times or microscopy—are still recorded manually.
Therefore, results typically remain within the unit where the test
"Without good data management, you can’t have good control over
the POC program," says Christopher Fetters, president of Nextivity,
a POC consulting firm in York, Pa.
And bar-coded patient armbands, which nurses use to scan patient
information when they’re running the test, do a lot to shore up
data handling, he notes. "Nurses are human and they’re going to
make mistakes," Fetters says. "How can you be sure the results will
make it onto the right chart if you depend on a nurse to correctly
enter a long patient number every time?"
Mercy Health System in Philadelphia is a three-hospital complex
with about 800 beds and a core laboratory that coordinates POC testing,
including 21,000 bedside glucose tests each month. The automated
glucose and coagulation results are transmitted into the LIS, which
generates the permanent electronic medical record. Urinalysis results
are documented manually on a POC report form, as is glucose even
though it’s duplicative, says Bette Seamonds, PhD, clinical chemist
and director of the point-of-care testing service. "The physician
is not going to check two places for this information," the lab
computer and the chart. "So the nurses are still putting them on
paper because that’s where the doctors are going to look," Dr. Seamonds
At the same time, the electronic results are uploaded into the
LIS so they become part of the permanent record. Urinalysis results
will be available once that connectivity is added to the system.
"We simply don’t have the manpower to put manual results into the
computer retrospectively," Dr. Seamonds says.
Mercy uses bar-coded armbands. Compliance with scanning them has
become a quality indicator tracked by the lab. (See "Making
the case for QC.")
At Sentara Healthcare, a six-hospital system in Norfolk, Va.,
i-Stat results flow into the LIS and HIS. Other tests, such as the
hemoccult, must be documented manually, although "report retrieval
is available in the computer," says Lou Ann Wyer, MT, clinical specialist
for POC testing and quality management.
Bar-coded armbands have been rolled out in all patient areas,
and the nurses are supposed to scan the armbands and their own employee
badges. The information is entered automatically into the record.
Being able to identify the employee who did the scan helped boost
compliance, Wyer says.
Similarly, at WellSpan Health, a two-hospital system in York,
Pa., the results of glucose as well as tests performed on the i-Stat
analyzer go directly into the LIS and HIS "with minimal or no review,"
says LuAnn Hildebrand, laboratory customer services/POC manager.
The latest glucose meters can also scan bar codes, notes Hildebrand,
so nurses have to use only one device to enter patient identification
from the armband as well as test results. "The operator scans the
armband, runs the test, and the results are captured in the meter.
They then dock the meter, and results are sent directly into the
LIS/HIS," Hildebrand says.
Other tests are entered manually; the POC team or "free hands"
in the lab enter the data into the LIS. Nurses have been accustomed
to entering manual results on a standardized report form; the forms
are gathered periodically and taken to the lab for entry.
University of Missouri Healthcare in Columbia, an academic system
with four hospitals, expects to have the nursing units interconnected
to its LIS and HIS within the next several months. When it began
to hook up the nursing units, it was obvious it would be a major
project, says laboratory director Alan Luger, MD. "We put together
an ad hoc committee to oversee it," including nurse managers, the
lab manager, POC coordinator, information technology staff, and
Dr. Luger himself. "We’re still in the midst of doing that change."
Once the project is completed, nurses will be able to obtain patient
demographics from the HIS and transmit glucose results to the LIS.
Blood gas results are also going online, but "everything else is
manual," says Dr. Luger. In addition, "Our institution hasn’t decided
whether to buy armbands yet, so nurses must enter the patient number
manually," he says.
El Camino Hospital in Mountain View, Calif., which performs about 100,000
POC tests annually, still manually documents all the results. The nurses are
supposed to record results in two places, one for the laboratory and another
for their nursing flowcharts. They look at the digital readout on the instrument
and write the result onto a chart, says Robyn Medeiros, quality assurance, POC,
and education manager. "We’re hoping to get connected electronically this year,"
she says, which should eliminate a lot of that tedium. Medeiros is also pushing
for bar-coded armbands.
Many institutions are leaving money on the table by not billing
for POC testing, Fetters notes. That’s because it often sprang up
haphazardly and documentation was manual. Electronic results make
it easier to bill, but, even then, POC testing still falls into
the gap between laboratory and nursing. Typically, the lab has to
take responsibility for getting the right information to the finance
"If we’re able to capture the results in our LIS, lab does the
billing for POC," says WellSpan Health’s Hildebrand. That includes
glucose billing, which is in dispute at some hospitals. She acknowledges
that billing for POC testing has been a "giant mountain" to climb,
but it has been made easier, she says, "since we have developed
a mechanism to attach billing to the lab result." Because WellSpan
has set up POC testing as a cost center, "we want to make sure we
don’t lose money," she adds. "We try to balance incoming and outgoing
Mercy Health System also bills only for results that are available
electronically, and it took some time to convince the finance department
that, in the case of glucose, it was not duplicative testing according
to Medicare. "We don’t have the manpower to bill for any of the
manual tests, so we are anxious to get the urinalysis results online,"
Dr. Seamonds says.
Wyer is fighting the glucose battle at Sentara Healthcare. "We
used to bill for glucoses but we don’t anymore," she says. "I’ve
been working with finance to get glucose billing reinstated." But
everything else is billed for, with the information systems providing
the documentation to the finance department.
At El Camino Hospital, which hasn’t yet connected the laboratory
and other units electronically, "we’re not billing for POC testing,"
reports Medeiros. Once everyone is linked, "we’ll start to do that.
It will be a joint effort between lab and finance."
Dr. Luger estimates that the University of Missouri, which like El Camino
Hospital isn’t billing for POC testing, is losing $750,000 a year in uncollected
revenue from glucose tests alone. "We know how to bill for the tests; we just
don’t have the tools in place yet to do it," he says. The LIS has software that
can generate a bill for electronic results, but it’s still unclear how to get
that information into the billing system. "As soon as we have that connectivity,
we’ll do the billing," Dr. Luger says.
The people factor
"The labs that do this testing the best have taken the bull by
the horns and designated a point-of-care coordinator," says consultant
Fetters. Typically a medical technologist, the POC coordinator sits
on and perhaps chairs the POC committee, makes sure educational
programs are in place for POC operators, maintains relationships
with nurses and other departments, verifies that test results are
entered into the appropriate systems, and tracks QC.
No one has enough people to do the job right, but most POC coordinators
are adept at exploiting the resources they have. Generally, rather
than provide all the training themselves, they will train trainers
in the nursing units or make sure that POC proficiency is a part
of new employee orientation. Most of the hospitals use devices,
especially for glucose testing, that lock out operators whose identification
they don’t recognize. With manual tests, of course, this control
is not possible.
Mercy’s Dr. Seamonds voices a familiar complaint: "The whole lab
needs more people." In addition to her full-time POC coordinator,
she has occasional part-time help with proficiency testing. "We’ve
trained nurse educators to handle the in-servicing of their staff,"
she says. For annual recertification, each nurse operator takes
a written test. After the nurses have completed the test, the supervisor
notifies the POC coordinator, who then revalidates the operator
in the RALS system so he or she is not locked out.
Nurses who are sent by an agency or work only a few shifts per
month are a particular challenge. Mercy does not allow agency nurses
to be trained in POC testing unless "we’re guaranteed they will
be here for at least three months," Dr. Seamonds says. Pool nurses
must work one shift a week to qualify for POC testing. But since
the laboratory isn’t there for the nurses’ shifts, "we have to rely
on the nursing managers to oversee this and provide us with the
At WellSpan Health, it’s up to the manager of the testing area
to determine who will be doing POC tests. "The agency nurses are
treated exactly like any other operator," says Hildebrand. "If they’re
going to be here on a regular basis and want to do POC, they have
to go through the same training and competency testing." Most of
the time, nurses do want to learn POC testing because it broadens
their skills and makes them more valuable.
Sentara’s core lab, which serves six hospitals, is better staffed
for POC testing than most. Wyer has 7.5 FTEs involved with the program,
four at the largest facility and the rest at other sites. But she
is also responsible for managing quality at all the outlying labs
as well as performance improvement monitors for laboratory services.
Monitoring POCtesting is a huge job, she says. "We probably have
well over 3,000 people doing the testing," and the POC staff has
to make sure each one is competent.
A technologist from education and research and the POC staff help
train incoming nurses on POC testing and devices. The POC staff
also does all the competency testing and provides periodic skills
updates on product lines. "Anybody from any of our hospitals can
attend these sessions and get the competency they need to do testing,"
Wyer says. For people who work unusual shifts, "we have ’night owls’"
who get all the people together for competency testing and product
demonstrations, she adds.
The lab has also developed materials for contract nurses who don’t
go through new employee orientation. "Experienced nurses can challenge
each requirement by completing a test and doing a return demonstration,"
Wyer says. Sentara uses operator lockout to prevent untrained people
from using the devices and to make sure QC has been done.
University of Missouri Healthcare has one FTE and two part-time
people assigned to POC testing in the lab, and they’re loaded with
work, according to Dr. Luger. The POC coordinator is involved with
new employee training but "doesn’t have to train everyone herself."
Nurses learn and then train each other.
El Camino has only one full-time position budgeted for POC testing,
which is split between Medeiros, who devotes half her time to POC
testing, and three other medical technologists. "Even with an allocated
full-time position," Medeiros says, "we still find we are at least
half a person short, so one solution for us has been to train the
trainer." She also enlists the help of the diabetic educator. "She’s
a great spokesperson for the lab," Medeiros says.
El Camino doesn’t have operator lockout yet, so they are looking forward to
the upgrade, which will have this feature. "Extended-stay registry nurses are
allowed to run POC tests after they’ve completed competency by their units’
designated trainer," Medeiros says, "but we don’t allow short-term registry
RNs or registry certified nurse assistants to perform testing. That’s the hardest
part to control."
The nurse connection
Since the POC coordinator typically is a technologist or technician
with no direct control over the tests nurses perform, a good relationship,
fostered by communication, is all-important.
"We have been very dedicated to building a bridge between the
lab and nursing," says Dr. Seamonds of Mercy Health System. When
it came time to hire a POC coordinator, "we invited the nurse educators
to interview the top two candidates and help us make the decision.
That gave us a rock-solid foundation," she says. That POC coordinator,
Bhupen Desai, travels from site to site and visits all the nursing
units to have a point of connection.
She and Desai are members of the hospital POC committee, which
meets bimonthly and tries to stay on top of where POC testing is
springing up and how it can standardize equipment and reporting.
Nursing units or departments are supposed to present their needs
to the committee before adding a new test. Dr. Seamonds, who is
chair, makes sure the committee gets the information it needs to
decide whether to add or change a POC test.
One of the first things she did upon coming onboard four years
ago was to stop urine dipstick testing. "We waited to see who screamed.
Immediately the ER screamed," she recalls. So she invited representatives
to come to a committee meeting and present ER’s need for dipstick
testing. "They wanted urine hCG, and we couldn’t fight it," says
Dr. Seamonds, because the lab couldn’t turn around blood hCG fast
enough. "You learn to make allowances that meet other people’s needs,"
WellSpan Health organizes its POC committee by service lines,
including representatives from cardiac care, trauma, nursing, pharmacy,
and labs, and a pathologist chairs the committee. It rarely meets
formally these days, however. "Now that our program is pretty much
in control, we communicate by e-mail," Hildebrand says.
Establishing POCtesting as a separate cost center has helped break
down the turf barriers at WellSpan. That cost center, operated by
the lab, pays for all the supplies and equipment, handles training
and procedures, and reviews QC, she says. Any unit that wants to
add a POC test will be considered for approval "after petitioning
the committee with a request that includes medical and financial
justifications," Hildebrand says.
Even a smaller hospital, El Camino, finds a multidisciplinary
committee useful. "We meet on an as-needed basis, if we get a request
or have an issue crop up," Medeiros says.
The committee provides the support they need to push through JCAHO-mandated
protocols or "put the brakes on new testing," she says, while a
performance improvement committee researches turnaround time alternatives—such
as a pneumatic tube to shorten TATs for emergency and critical care
University of Missouri Healthcare doesn’t need a committee. "I
set the policy," lab director Dr. Luger says. He and the lab manager
"talk about POC issues on a regular basis. When somebody has a request,
we let them make their case, and decide whether to allow it."
For the most part, says Dr. Luger, "we prefer to have the testing
legitimized and supervised," so he will generally grant permission
and send the POC coordinator to oversee the process. One recent
addition was activated clotting times for radiology. "It’s better
to bring people into the tent than put the institution at risk by
performing unsupervised testing," he says.
Sentara doesn’t have a systemwide POC committee. With six hospitals
owned or affiliated, it’s just too big. "We do 750,000 tests a year,"
says Wyer, "and it’s constantly growing." Instead of a centralized
committee, Sentara sets up ad hoc groups to review requests for
new POC tests or to oversee implementation.
For instance, when the system adopted the i-Stat analyzer, Wyer
convened nurses, physicians, respiratory therapists, and lab staff
to develop procedures for the new device. "Once we rolled it out
we continued to meet to do followup and make sure everyone was comfortable."
Then that committee was disbanded. "We do three or four projects
a year that require getting together a core group of people like
this," she says.
Wyer, who administers POC from a central lab, has four technologists who make
weekly visits to all the units, checking on QC and inventory, answering questions,
and taking reports. "The nurses now know that we are a valuable resource for
them and will follow through on problems," she says.
Making the case for QC
Getting nurses to comply with the request to scan bar-coded armbands
is tricky for many hospitals, including those in the Mercy Health
System. About two years ago, after it got the armbands, "none of
the emergency room nurses were using them," recalls Dr. Seamonds,
because they were busy and unaccustomed to the new technology.
Dr. Seamonds met with the nurse managers and medical directors
in the ER and listed the reasons for the armbands. "They promised
to make an effort," she says, and compliance is now about 80 percent.
One remaining problem is that glucose testing is often done before
an armband is put on the patient. "I told them: ’At least make sure
you put the patient’s name into the glucose,’" says Dr. Seamonds.
For nurses overall, armband compliance is at 91 percent, she reports.
Mercy has an awards program: Any nursing unit that shows 98 percent
compliance or better on a monthly basis earns a certificate. The
stats are distributed to the nurse managers so they can see how
they’re doing relative to their peers.
Because operators of automated devices must scan in their ID,
Mercy is able to track "problem children," Dr. Seamonds says. If
someone consistently fails to scan the armband or to perform QC
properly, POC coordinator Desai can go "one-on-one with these people,"
she says. "The nurse manager is notified and, if a problem persists,
the operator can be locked out. This extreme has yet to happen."
At Sentara, Wyer sends weekly and monthly reports of unit testing
activities. "If we have a unit with 100 percent compliance for all
the QC rates, we acknowledge their success," she says. If there’s
a problem, "we’ll let them know and help them work through it. We
send them only what they need to see and only what they need to
For example, in one unit doing POC testing, the operators weren’t
scanning their badges, contributing to reports of nonvalid operators,
Wyer recalls. She met with the clinical nurse specialist and discussed
why this needed to be done. "They turned it around in less than
two months," she says. "We usually find that our strong nursing
staff wants to do a good job and all we have to do is show them
what it takes."
Other quality indicators at Sentara include compliance rates with
patient identification, adherence to testing policies, operator
performance, doing proficiency testing, and transmitting data according
to schedule. Monthly reports are sent to the units to show them
how they’re doing.
WellSpan’s Hildebrand agrees that most nurses just need to be
shown how to do a good job and they’ll do it. Although she is prepared
to talk to a nurse supervisor if someone isn’t performing POC testing
or QC up to par, "in the 10 years I’ve been doing this there was
maybe one time I had to go beyond the operator herself," she says.
"Most of these issues are simply a matter of education."
At El Camino, Medeiros finds that sending a monthly report card
on performance is an effective motivator. The report cards list
department-specific compliance as well as hospitalwide performance
indicators. "This has been one of the best ways to stimulate compliance,"
On occasion, she will meet with supervisors to spur improvements.
Early on in the POC testing rollout, there was only 59 percent compliance
with entering patient and operator identifications and running QC
at the appropriate times. Medeiros reminded the vice president of
nursing that the Joint Commission would be visiting the next year
and these items would be part of the inspection. "She assigned a
clinical nurse specialist to the matter, and our compliance is now
up over 90 percent," Medeiros reports.
Medeiros and her team take weekly walks on the nursing floors
and are ready to listen to what nurses have to say. One change stemming
from their walks was that the lab now handles instrument troubleshooting
rather than have the nurses do it. "They just don’t have time or
the expertise, so it was very frustrating for them," she says. The
operators do the routine QC, but the lab does everything else. "If
there’s a problem, they call us and we’ll just swap out the instrument."
Says Medeiros: "POC has made the lab much more visible to nursing
and has changed our perspective on nursing as well. We try to be
a resource and support for nurses instead of getting upset if they’re
not completing everything we want."
Karen Southwick is a writer in San Francisco.