The good, the bad, the ugly A month in the life of a Point ...€¦ · The good, the bad, the ugly...

The good, the bad, the uglyA month in the life of a Point Of Care

Coordinator

Stefanie Van Heule

Ghent University Hospital23/10/2014

Ghent University Hospital

• ± 3000 patients / day

• ± 62 000 total admissions (2013)

• ± 450 000 consultations (2013)

• 6000 employees

• 45 wards

+ 16 day clinics + surgery rooms + recovery rooms

Introduction

Department of Laboratory Medicine

= Sample analysis

+ Phlebotomy

+ Distribution of the samples

+ Point of Care Testing

Average per workday

± 2 600 lab orders

± 700-800 bed side samples

Introduction

POCT = Medical testing at or near the site of patient care

• 4 Lab technicians Special Chemistry

2 Fulltime POC-Coordinators

1 POC Manager + 1 Clinical biologist

Elke

Tim

KarenBarbaraDorine

Stefanie

Heleen

Prof. J. Delanghe

Accuchek Inform II ® (Roche)

• What: Measurement of glucose in whole blood, near the patientwith only one drop of blood

• Important

* Scanning operator ID, patient ID

* Quality controls :

Low range (30 – 60 mg/dL)

High range (261 – 353 mg/dL)

Users: 1x / 24h REQUIRED 1 STAT

Introduction

Importance QC E-learning+ Visiting ward

Rapidlab 1265 / 1245® (Siemens) Rapidpoint 400, 405, 500® (Siemens)

• What?

Measurement in whole blood of

* pH

* Blood gases: pO2, pCO2

* Electrolytes: Na+, K+, Ca2+, Cl- (only RL1265®, RP®)

* Total haemoglobin & CO-oximetrie

* Metabolites : glucose, lactate (only RL1265®, RP500®)

• Use:

• Nurses, some physicians in the ward

• Super users: can replace cartridge, perform QC & calibration

Selected super users

1 month in the life of a POC Coordinator

Introduction

Trouble-shooting

(Re)Training operators

Lot validation

Management of reagents

Management of internal & external QC 25 %

10 % 15 %

35 %

10 %

Maintenance

25 %

10 % 15 %

35 %

10 %

Maintenance

1) POCT: Maintenance

• Daily: Glucose (10’)

* Checking status

* Checking QC

* Checking abnormal results (message)

* Management of data users

POCT - Maintenance

POCT: Maintenance

• Daily: Blood gases: (10’/ instrument )

* Checking status

* Checking QC & calibrations

* Checking reagent level

* Checking events log

* Cleaning

Rapidcomm® device link

POCT - Maintenance

Rapidcomm®

POCT - Maintenance

Rapidcomm®

POCT: Maintenance

• Weekly:

* Glucose: (10’)

* Checking data transfer to LIS

* Blood gases: (20’/instrument)

* Deproteinising (types RL®)

* Sample port

POCT - Maintenance

Problem with glucose data transfer Checking

Severe CO-oximetrie problems(types RL®)

Deproteinising more frequently (2-3x/week)

POCT: Maintenance

• Monthly: Blood gases: (45’/instrument)

* Filling electrode fluid (types RL®)

* Changing cartridges

* Checking filters

POCT - Maintenance

QC, calibration errors Monthly (re)filling electrode fluid+ Fixed schedule for changing

electrodes

1 month in the life of a POC Coordinator

Introduction

Maintenance

Trouble-shooting

(Re)Training operators

Lot validation

Management of reagents

Management of internal & external QC 25 %

10 % 15 %

35 %

10 %

2) POCT: Maintenance & troubleshooting

• 08:00 – 17:00: 1p/day:2 Fulltime POC-Coordinator

4 Lab technicians Special Chemistry

17:00 - 08:00 + weekend:

Glucose: 2 spare instruments

Blood gas: Back-up system

Emergency troubleshooting: Clinical chemists in training

POCT - Troubleshooting

1 spare 2 spare

/ Training troubleshooting: General training on tour+ 5 hands-on-training

POCT: troubleshooting

• Accuchek Inform II®:

* E.g. badges, disfunctional, software block, data transmission error, batteryerror, strip error

* Log book

* 2014: * Spare instruments were 18 times used

* 17 were phased out

POCT - Troubleshooting

Problems Emphasize in e-learning

POCT: troubleshooting

• Blood gases:

Clot, Failed QC & calibration,

electrode problems, cartridge

problems, CO-oximetrie, …

Log book

Interventions: 2-5/week

POCT - Troubleshooting

Problems ↑ MaintenanceEmphasize pre-analytical phasein e-learning + visiting ward

1 month in the life of a POC Coordinator

Maintenance

Trouble-shooting

(Re)Training operators

Lot validation

Management of reagents

Management of internal & external QC 25 %

10 %15 %

35 %

10 %

3) POCT: Operator training: Glucose

• Glucose:

1. E-Learning

2. Theoretical test

3. Practical test:

~ Number of QC, patient

With POCT coordinator

4. Visiting ward 1x / year

Unclear how to get a certification Flowchart

Misunderstandings, frustrations Visiting ward 1x / year

EXAMPLE E-LEARNING GLUCOSE

POCT: Operator training: Glucose certification

Questions are devided into 3 categories:

Essential, Important, Useful to know

Example category 3 (essential)

“You see the message Quality control is necessary …”

1. You ignore this message

2. You can do more than 1 patient measurement

3. You first perform a correct QC before you do a patient measurement

4. You can do 1 “CITO” (urgent) -measurement

POCT – Training operators

POCT: Operator training: Glucose certification

Example category 3 (essential)

“You see the message Quality control is necessary …”

1. You ignore this message

2. You can do more than 1 patient measurement

3. You first perform a correct QC before you do a patient measurement

4. You can do 1 “CITO” (urgent) -measurement

POCT – Training operators

POCT: Operator training: Glucose certification

Example category 2 (important)

“What is the influence of squeezing the finger of the patient to get blood?”

1. The concentration of glucose is higher because you add interstitial fluid

2. The concentration of glucose is lower because you add interstitial fluid

POCT – Training operators

POCT: Operator training: Glucose certification

Example category 2 (important)

“What is the influence of squeezing the finger of the patient to get blood?”

1. The concentration of glucose is higher because you add interstitial fluid

2. The concentration of glucose is lower because you add interstitial fluid

POCT – Training operators

POCT: Glucose e-learning & certification

Home developed Commercial

• E-learning:* Tailored according to experience* Developed for nurses

• Certification expiry:Warning by EPR

• Passport authentification(no e-mail / individual)

• Scanning badge as operator ID• Automatic synchronisation forbadgenumber (high turn-over)

• Integrated tools for handlingrecertification data

• E-learning:* General, rigid* Technical, not targeted for nurses

• Certification expiry:Warning by e-mail

• No integration for authentification

• No automatic link with hospital ID• No account with QC & Patientresults

• Seperate tools

POCT: Training operators: Blood gases

• E-learning: Specific / wardFor users & super users

• Daily visit: Possibility to ask questions• 1x / year: At ward: training

POCT – Training operators

EXAMPLE E-LEARNING BLOOD GASES

EXAMPLE E-LEARNING BLOOD GASES

1 month in the life of a POC Coordinator

Introduction

Maintenance

Trouble-shooting

(Re)Training operators

Lot validation

Management of reagents

Management of internal & external QC 25 %

10 % 15 %

35 %

10 %

4) POCT: Validation

• Glucose:

* New instrument

* New teststrips lot

* New QC lot

• Bloodgas:

* New instrument

POCT – Training operators

1 month in the life of a POC Coordinator

Introduction

Maintenance

Trouble-shooting

(Re)Training operators

Lot validation

Management of reagents

Management of internal & external QC 25 %

10 % 15 %

35 %

10 %

5) POCT: Management of reagents

• Glucose: * Stock

* Managing QC, teststrips (lot reservation)

• Blood gas: * Reagent level

* Stock reagent

POCT – Training operators

Period changing teststrips

=> Miscalculation in reports

* 2 spare* Schedule changing teststrips* In house developed tool LIS

/ First in, first out

1 month in the life of a POC Coordinator

Introduction

Maintenance

Trouble-shooting

(Re)Training operators

Lot validation

Management of reagents

Management of internal & external QC 25 %

10 % 15 %

35 %

10 %

6a) POCT: Management of internal QC

• Glucose: Daily QC follow-up

•Blood gases: Daily QC follow-up Rapidcomm® + LIS

POCT – Management internal QC

6b) POCT: External quality assessment

• Glucose: EQA (Institute for Public Health)

• Blood gases: QC Reports : QC Online / RTQC Web

POCT – External quality assessment

POCT – External quality assessment

POC Experiences

• PRE ANALYTICAL PHASE: Start of a good measurement

• When nurses are observed: they follow the rules

Still, we detect of user errors ( > 1/week)

• BAD - UGLY

Improve processes GOOD

E.g. * Frustration, misunderstanding Visiting ward

* CO-oximetrie problemsMore deproteinising

The good, The bad, The Ugly

Bad Good

POC Future

• Still learning and growing …

• Video e-learning

• Online logging

• Integration of documents in an electronic education portal

The good, The bad, The Ugly

Conclusion

• Variable, interesting, challenging

• Certification, QC very important

• Communication

The good, The bad, The Ugly