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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