Everyday, nurses contend with fast-paced, crisis care, dealing with patients, physicians, coworkers, and patient's family members. A point-of-care testing (POCT) program can assist with the rapid decision-making required of today's nursing staff. However, it is tough for nurses to establish a POCT program without the assistance of the central laboratory. Like all laboratory testing, POCT must comply with the rules and regulations of the accrediting agencies. By meshing the backgrounds of nursing and the central laboratory into one workable philosophy, point of care testing can ensure optimal patient care.
Utilizing experiences gained by working together, nursing and laboratory point-of-care coordinators have discovered opportunities for improvement when the two disciplines work together to coordinate a POCT program. In this first article and our future articles, we will share our point-of-care (POC) experiences here at St. Alexius.
St. Alexius Medical Center, Bismarck & Mandan, North Dakota, was established in 1885 and is sponsored by the Benedictine Sisters of Annunciation Monastery. The Medical Center is fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). St. Alexius features a 308-bed acute care hospital, a full-service homecare/hospice agency, a regional medical equipment company, a state-of-the-art fitness center, and dozens of other health services. In addition, St. Alexius is a founding member of the PrimeCare health group, an organization representing over 150 affiliated area physicians.
The initial joint actions for POCT began at St. Alexius in May 1991, when a combined nursing and laboratory task force worked together to redesign glucose monitoring. The task force spent 4 months evaluating, selecting equipment, and working out issues related to test performance, charting, proficiency testing, quality control, and maintenance. Before this time, employee competency, test volume, and reimbursement were not accounted for at St. Alexius. Kidney dialysis unit and central laboratory examined activated clotting times in 1992. After considering the cost and time involved, it was determined the central laboratory should perform a partial thromboplastin time instead. Critical care areas were also performing activated clotting times, but the complicated compliance issues led to deferring action to a later time. Examination of activated clotting time (ACT) testing in the critical care areas occurred in 1994. The areas were in need of new instrumentation and supplies to comply with regulations; however, there was no money budgeted.
Compounding the issues were the two unique backgrounds that became apparent within the task force. Nursing personnel focus primarily on patient care, while laboratorians concentrate on ensuring proper instrument function prior to patient testing, thereby ensuring high quality results. In 1993, regulating agencies began requiring the same quality of care regardless of the site of test performance. The central laboratory was charged with the oversight and responsibility for maintaining quality POCT. The considerable amount of time and resources already spent in addressing POC issues, and the prediction that POCT would proliferate with the changing health care environment, led the laboratory administrative director and pathologists to propose a multidisciplinary POCT program to hospital administration. The proposal included resources for POC coordinators and supplies and materials, as well as establishing a POC committee.
The POCT Program objectives included:
* Gaining awareness of every bedside laboratory test being done within the institution.
* Enhancing the quality of patient care.
* Increasing staff knowledge regarding test performance.
*Improving physician satisfaction.
* Increasing laboratorians confidence in nonlaboratorians performing testing.
The initiation of the program required an extensive collaborative effort. The laboratory director recruited a registered nurse and a medical technologist to serve as POC coordinators part-time, 20 hours per week each. Administration addressed the budgetary items by designating a cost center specifically for POCT. Nursing unit planning committees, along with the department managers were educated on POCT and relayed the information to physicians and employees for input. Each unit decided which POC tests they would continue to perform. Department managers identified the personnel necessary to perform the testing. Each individual attended an orientation session to gain competency in the test performance. Nurse educators became involved in staff orientation. Laboratory technologists researched specific instruments and worked with nurses to implement changes. Personnel from all areas involved worked together to determine action plans that would achieve the objectives.
Role of the Point-of-Care Nursing Coordinator:
* To act as liaison of the POCT program and laboratory, to and from all nursing areas and all nonlaboratory personnel.
* Establish and maintain the educational and training programs as determined by the POC program.
* Educate all patient care areas regarding the role of the POC committee and its authority to oversee all POC tests.
* Make weekly rounds to POCT areas to review quality and consistency of testing, answer questions, and receive input and feedback from certified operators.
As the nursing POC coordinator, my goal is to make each POC test as simple and expedient as possible. The nurses that perform the test are not familiar with the regulatory requirements until we educate. They respect the accrediting agencies; however, any extra steps or duplication is resented as a waste of time. It is crucial that in every process for every POC test, we identify if the process is necessary, and if it is, we must identify why it is necessary. Then we must relay this information to the operators of each test to get their buy-in and cooperation. When the operators understand why policies and procedures are necessary, they are more likely to comply. Coordinators must expect to be challenged along the way.
Role of the POC Laboratory Coordinator:
* Provide technical oversight for all POCT such as evaluation of new instrumentation, proper instrument operation, and quality control requirements.
* Develop policies and procedures necessary for each POC test.
* Maintain the master documentation system for the POCT program.
* Serve as a resource for troubleshooting instrument problems.
* Assist the POC nursing coordinator as needed.
The biggest obstacle faced at St. Alexius prior to the formation of the POC committee was the lack of willingness to accept responsibility for the testing and related expenses. The central laboratory kept bringing the issues to the forefront, but nursing kept pushing it to the back burner because they had been doing the testing for many years and saw no need to change. When problems with regulatory compliance issues arose, we tried a variety of quick-fix, temporary, band-aid approaches that did not work. The central laboratory lacked the resources to bring all the testing into compliance, and the nursing areas lacked the laboratory background to know what to do to bring the testing into compliance. To have a successful POCT program, administration designated the responsibility, accountability, and authority to coordinate the daily, weekly, and monthly activities required for a successful POC program to the POC coordinators, under the direction of a POC committee. The POCT committee consists of a pathologist, a medical staff representative/physician, the nurse manager, a central laboratory director, the POC nursing coordinator, and the POC laboratory coordinator. The committee meets on a need basis, with the committee members having daily and weekly dialogue regarding POCT issues.
The importance of having at least one champion for the cause cannot be stressed enough. Nurses need to have a consistent person to whom they can communicate with and relate to. Having a nurse in the laboratory has also improved the dialogue between nursing and the laboratory and the laboratory staff's understanding of nursing practice. Conversely, nursing needs the expertise of the laboratory staff. Accrediting agency standards and operating complicated analyzers is something laboratorians deal with on a daily basis.
Key concerns that may be discussed in upcoming issues of POC Corner include the ongoing orientation and competency process, data management and connectivity, and POCT role in home care, rural health care, and community health screenings.