Never give in—fighting for POC patient safety
In grammar school, the “three Rs” still hold sway (or so we all hope). But in point-of-care testing, there’s just one R that matters: Relentless. It’s a word that comes up over and over again in conversation with hospital POC testing coordinators—yes, even more often than “specimen” or “CLIA.”
“People pretty much know I’m relentless about certain things,” says Tim Deen, MLT(ASCP), MT (HEW), POC testing manager at Medical City Hospital, Dallas. “My chief nursing officer has kindly referred to me as a ‘tough-love’ type of person.” In that regard he has a lot in common with Deb Phaup, BS (MT), MT(ASCP), CLS (NCA), POC coordinator at Mount Auburn Hospital, Cambridge, Mass. “I’m relentless,” she admits, laughing.
Personable as Deen and Phaup are, they know that POC testing safety is nothing to joke about. With thousands of POC tests performed in their hospitals each month, theirs is not exactly a sit-back-and-relax situation. With their colleague Joann Bauwens, BS(MT), MT(ASCP), MA(HSM), interim director of laboratory services and POC testing coordinator at SSM St. Mary’s Health Center, St. Louis, Mo., they provide insight into what keeps POC testing on the safe side.
Both Deen and Phaup assumed their POC responsibilities just over a decade ago, when bedside testing wasn’t as frequently conducted or as closely regulated as it is now. When Deen began, he says, Medical City Hospital’s point-of-care program was “a lax system, where the lab was not involved.” And at Mount Auburn Hospital, where the POC coordinator position was created for Phaup, “nobody even knew what POC testing was,” she says. “The first week I started the job, I came into work and the then-manager didn’t even know where to put me. I was just standing in the hall without a clue.”
At first, Phaup’s duties consisted of simply trying to compile and streamline information. “There were reams and reams of data that weren’t collected, or if they were, they weren’t looked at,” she says. “I had to start consolidating what people were doing and the methodologies they were using.” The need to earn her colleagues’ respect and compliance complicated that task. “There was some resistance from the nursing department as far as having a laboratory technologist, in essence, telling them what they had to do and how to do it,” she remembers. “Point-of-care coordinators usually have a ton of responsibility with little or no authority, and you’re dealing with operators who work in a different department.”
The difficulties posed by that interdepartmental culture clash persist to this day. “Lab work is very detailed, and they [nursing staff] look at it as a nuisance,” Phaup says. “Their focus is the patient. They’re short-staffed. Anything extra that we’re asking them to do is an interruption. A number to them is just a number. With lab people, a number is everything behind it and leading up to it.”
Bauwens agrees. One of her main responsibilities, she says, is to “make sure that a nonlaboratorian understands why the process is done this way, why the steps have to be performed, why you have to get enough blood—all the pieces that, to a laboratorian performing a test, are just intuitive.” That task was difficult enough in the early days, when “it was the urine dipsticks, the fingerstick glucoses,” she says. “Now we have 12 different point-of-care platforms we offer, from the flu tests to the pregnancy tests, iStats, even cardiac markers in the ER.”
To earn staff cooperation, there’s no substitute for shoe leather—that is, making yourself visible on the units, Phaup says: “I talk to people. I feel like Sybil sometimes, because I have to have different ways of dealing with different types of people. I make things personal. I e-mail, make phone calls, attend meetings, try to get on committees.”
Then, too, performing that kind of footwork is often the only way to play detective when baffling errors recur. When the bar codes on patients’ wristbands at Mount Auburn kept scanning incorrectly, Phaup was the one who tracked down the source of the problem. “It was the toner that we were using to print the wristband,” she says. “It turned out we were using recycled toner in the admitting department’s wristband printer. Even one little white dot on one of those bar codes will read as a different number. Luckily, it would not go into the LIS because it wouldn’t match with a real patient.”
And, of course, ongoing staff education is indispensable to patient safety. “We’ve had a pretty stringent training program here for the last five or six years,” Deen says. “I still have some issues with some people who think they can waltz in and start testing without going through our training program, but that isn’t going to happen. If somebody comes to our facility and says, ‘Well, I know how to perform Accu-Chek testing,’ I say, ‘But you don’t know how we do it.’ I won’t give them access till they come to class.”
The assumption that anyone can perform POC testing without training stems in part from a misperception of the term “CLIA-waived,” Deen says. “Some people think ‘waived’ means you don’t have to meet any regulatory requirements for Joint Commission or CAP. ‘It’s easy, it’s a dipstick.’ They don’t see all the possibilities with interferences and the impact on patient care.”
But when Deen’s through with them, they do. “Just for glucose, we spend an hour with them,” he says. “We go over all of the policies and procedures, and cover things such as fingersticks, capillary sticks, venous sticks, proper use of the meter. We run QCs, we show them how to bar-code-scan patient IDs, and they take an online competency assessment. Another big area for POC testing is the ED. We’ll spend another two hours one-on-one with that person. For patient safety, you can’t scrimp on training.”
Whereas some staff have to be taught to take POC testing seriously, others misperceive it as a kind of magic bullet. When Bauwens receives a request to introduce a new type of POC testing at SSM St. Mary’s, the first thing she asks is: “Is it convenient, or is it a real need?” “You don’t put POC at a problem just to solve a problem,” she says. “There has to be a definite reason why POC is going to improve the situation.” It takes a real gain in patient safety and care to justify the expense and added monitoring needs that accompany a new point-of-care test.
Another major component of POC testing safety: the use of bar codes on patient armbands. Deen, Bauwens, and Phaup all use them in their hospitals, albeit to varying degrees. With bar codes, “the whole audit trail becomes much smoother,” Bauwens says. “We have bar codes on the back of our employee badges, and our patients have bar codes on their armbands. Both of those are used whenever we have a POC test that gives us the ability to bar code. We also use it for reagents.”
If bar coding were a religion, meanwhile, Deen might be its prophet. “We are pretty much bar-code-scan only,” he says, with the exceptions of the nursery, NICU, and ED. “Back when we did not have bar codes and we were just on manual patient ID entry, we were running anywhere from eight to 10 percent entry errors. Once we converted to where we did have the bar code but it wasn’t mandatory, we were still struggling with a one to three percent error rate. And now that we’re bar-code-only, we’ve pretty much erased that.”
But just requiring bar codes isn’t enough, of course. “You could have mandatory bar code scanning, and they [the operator] could scan a can of soup,” Deen points out. That’s why Medical City instituted bar-code masking last year. With masking, an institution can define what letters and numbers are and are not allowed in a bar code. This is especially useful on Medical City’s hospital campus, which consists of the main hospital, a children’s hospital, and a behavioral health facility, all with identical-looking wristbands. Defining which alphanumeric attributes are allowable at which location helps prevent patient identification error. It also prevents operators from mistakenly scanning a reagent strip when they mean to scan a patient’s wristband.
Deen is also a fan of enhanced patient identification, a feature available on Roche’s Accu-Chek Inform glucose meter. “When you bar-code scan an account number, the meter actually displays the patient’s name and asks, ‘Are you testing Susie Jones?’ Then you have to take an active role in saying, ‘Yes, this is Susie Jones,’ or ‘No, it’s not,’” he explains.
Bauwens, Deen, and Phaup continue to seek new ways to stamp out error and improve patient safety—a process that, as they’ve illustrated, entails maintaining excellent relationships with staff as much as it does staying abreast of POC technology. One barrier Bauwens still faces: occasional resistance from laboratory staff. “The biggest challenge from laboratory colleagues is that they don’t always acknowledge that it [the POC test] is a laboratory test,” she says. “The threat is that ‘Oh, you’re taking this work away from the main laboratory.’ Well, only if there’s a compelling enough reason that it should be done point of care. I am a laboratorian by training. I am a laboratorian by heart. My goal is that a laboratory test be done properly no matter where it is performed.”
Anne Ford is a writer in Chicago.