Feature Story

Nurses put POC tests through their paces

April 2003
Vida Foubister

Few would argue that point-of-care testing programs in hospitals
have come a long way, but becoming better by continuing to smooth the wrinkles has for most become a way of life.

At some hospitals, such as New York University Medical Center, New York City, the number of point-of-care tests has been stripped to a minimum. “We do very limited point-of-care testing, and we have it restricted to a few areas,” says Beth Duthie, RN, director of nursing for patient care systems.

At others, such as Sentara Healthcare, Norfolk, Va., multiple tests are performed in the nursing units. “We’re looking for more tests that we can do at the bedside,” says Mary Dahling, RN, MSN, clinical nurse specialist in the cardiovascular thoracic intensive care unit at Sentara Norfolk General Hospital. Dahling stresses that all test methods are validated in the laboratory for precision, accuracy, and linearity before testing is approved for a nursing unit.

At 245-bed Holy Family Hospital and Medical Center, Methuen, Mass., POC testing program representatives decided to limit POC tests at the program’s outset. “You’reworking with people’s lives,” says Susanne Uzdavinis, RN, MS, nurse manager of the birthing center. “You want the most precise and accurate results you can get.”

Uzdavinis, who co-chairs the hospital’s point-of-care testing program, would prefer that all tests be done by the laboratory. As it stands, blood glucose is the only test performed in every nursing unit. Other POC tests, including occult blood tests, urine dipsticks, and amino sticks, are done in a limited number of areas.

The reason is simple. “When you have many people doing the same thing, it’s not as good as having a small number that continually do it over and over again,” Uzdavinis says. In only a few areas does nursing have the test volume necessary to ensure that it can perform at the same level expected of a laboratory, she adds. But she admits that the performance of Holy Family’s laboratory plays a role in her hospital’s approach. “Our turnaround time is extremely good,” she says.

NYU Medical Center began limiting bedside testing when it became difficult to maintain quality control. Pregnancy tests, for example, were pulled from the emergency department last year because they “did not meet the goal of more efficient, streamlined processes,” Duthie says.

Blood glucose levels are now measured throughout the hospital. Other tests, such as activated clotting times, occult blood tests, and urine dipsticks, are used in a handful of high-volume areas. Occult blood tests, for example, are used in the neonatal intensive care unit to diagnose necrotizing enterocolitis. “There is a definite need for rapid intervention,” Duthie notes.

Duthie says the new generation of glucose meters, which she refers to as “error proof,” are a model for other POC tests. If, for example, you don’t have enough blood on the strip, the meter won’t provide an answer. Using the old glucose meters, the result would have been falsely low. “The simpler and more error proof it is, the easier it is to implement the technology,” she says. “You want technology where competency becomes a nonissue.”

Hospitals increasingly are realizing the need for laboratory oversight and investing accordingly. Shands Jacksonville, an academic medical center associated with the University of Florida, uses beta-hemolytic streptococci, blood glucose, urine dipstick, cholesterol, Nitrazine paper, occult blood, and pregnancy tests. “Because there’s a mixture of simple and complex testing, the laboratory is being pulled into the picture a lot more,” says Cindy Westbrook, RN, a performance improvement specialist in the quality management department.

Shands Jacksonville recently decided, for example, to hire two POC specialists from the laboratory to manage the POC program. “With the POC positions in place, there will be a more thorough review,” says Westbrook. “It creates a higher quality point-of-care program when you involve the laboratory.”

Until recently, nursing managed the POC program. “With the way the market is heading, who knows what’s going to be available at the bedside,” Westbrook says. “We wanted to put ourselves in a good position for the future.”

The 542-bed VA North Texas Health Care System, Dallas, has a full list of POC tests—blood glucose, B-type natriuretic peptide, parathyroid hormone, cholesterol, H. pylori, activated clotting time, hemoglobin, chemistries, occult blood, visual urinalysis, and blood gases. Because the scope of its program continues to grow, the hospital decided in January to dedicate two full-time laboratory positions to overseeing POC testing. When Jacquelyn Gray, BS, MT (ASCP), one of the two ancillary testing coordinators, started working with POC testing about three years ago, there were fewer than 50 glucose meters on the floors. Today there are 74. “There’s a lot of added tests and patients,” she says.

Sentara Health System has 7.8 full-time equivalents dedicated to POC testing. These technologists monitor the POC testing program at five of the six hospitals in the system. The health system finds that this level of commitment works well, says Lou Ann Wyer, BS, MT (ASCP), clinical specialist for point-of-care testing and quality management for Sentara Laboratory Services.

At other sites, nursing provides the oversight, but many know they can’t go it alone. Mary Jo Rose, BSN, RN, coordinator for nursing point-of-care testing at the Alfred I. duPont Hospital for Children, Wilmington, Del., leads an orientation once a month for new staff members. In it she emphasizes that point-of-care testing is a “laboratory test that nursing personnel have the privilege of doing at the bedside.”

“We can’t do it without laboratory support and someone to oversee the compliance,” she says.

Rose gives her trainees a lecture and an opportunity to do hands-on testing. The trainees dip urines and review and record results, prepare Hemoccult slides and recognize positive and negative results, and are trained on how to use glucose meters. Rose collaborates with the POC testing coordinator for the laboratory to train the nursing staff and monitor their competency. “Our hours are flexible, depending on who we want to update and train,” she says. That means working day, night, and weekend shifts.

Rose and her laboratory counterpart also feature POC testing at the hospital’s educational blitzes. This monthly event, which originally focused on cardiopulmonary resuscitation, encompasses patient safety, POC testing, and more. It’s a chance for employees to stop by and ask questions or even to maintain their competency. “We’re visible to all units. We’re visible to the lab,” Rose says. “We’ve found this to be very effective.”

Two or three times a week, Rose and her laboratory counterpart make rounds through the hospital. “People from the nursing side get to see who the point-of-care testing person is in the lab,” she says. It gives nurses another chance to ask questions about POC testing or other lab tests.

Rose also set up what she calls “point-of-care resources.”

“We’ve asked two people on every unit to be our resources for point-of-care testing,” she says. “They help us get the word out to people we can’t see every day or every week.”

Presbyterian Hospital, Charlotte, NC, has taken a similar approach. Each unit designates one person to attend regular meetings as the POC testing laboratory liaison. “It’s that person’s responsibility to go back to the nursing unit and pass on the information,” says Susan Weiner, BA, RN, a nurse manager for hemodialysis.

Having at least one or two nursing staff members who are well-versed in point-of-care can help an institution overcome training challenges. “People have heard the term point-of-care, but they don’t get the full impact of what it means, the responsibility that goes behind that,” says Lillian Falko, RN, a diabetes clinical nurse specialist for inpatient care at Yale–New Haven (Conn.) Hospital. Falko, who coordinates education for the glucose meters, adds that, “If you use the [glucose meter], you’re to understand how it works, how to do a control, and how to clean it.”

At Sentara Healthcare, the POC testing department sends monthly quality summaries, which include quality control compliance and operator performance levels, to the nurse managers. This allows nursing staff members to get feedback in a timely manner.

In the last six months, Sentara has put its POC test procedures on the hospital intranet and eliminated paper manuals. “The nurses can access any test procedure or quality control log from their computers,” Wyer says.

Whatever the mode of education, it’s wise to remind nurses that their backgrounds are an asset to laboratory testing. “Nurses have been trained to assess the patient’s clinical picture and the POC test results,” says Diane Greiber, BS, MT (ASCP), MBA, senior laboratory technologist for Sentara Laboratory Services. Collaborating with the nursing units, the lab developed a process for bedside clinicians to follow if POC results don’t match the patient’s clinical condition.

Nurses’ expertise is also being tapped to select new glucose meters. A pilot program is under way in which nurses are evaluating three types of glucose monitors, each for a period of three weeks. “They like the idea of being part of the group that gets to choose the [glucose meters] they use,” says Edie Alley, RN, MSN, a clinical nurse specialist on the general surgery floor at Sentara Norfolk General Hospital.

For all their efforts, nurses have seen firsthand the payoff in patient care. POC tests, for example, have reduced the time necessary to remove patients from mechanical ventilation in the cardiovascular thoracic intensive care unit at Sentara Norfolk.

“Before the i-Stat came to the [cardiovascular thoracic intensive care unit], we would have to draw an arterial blood gas and send it to the laboratory on ice,” recalls Dahling. Then it would take 20 to 30 minutes to get the result back from the laboratory.

“Now we can just run the ABG at the bedside, get the result in two minutes, and proceed to make adjustments to the ventilator,” Dahling says. “It’s affected how quickly we can wean patients off mechanical ventilation.”

Potassium turnaround times were also a problem, she adds. Before potassium was tested at the point of care, normal turnaround times were 30 to 60 minutes. This was a drawback because the patients are often low in potassium, which predisposes them to develop cardiac arrhythmias. Now the nurses can treat the electrolyte imbalances within minutes and avoid negative outcomes.

In addition, the small sample sizes sufficient for POC testing are a plus, says Dahling, because the patients have a drop in hemoglobin after surgery. Small sample sizes are a benefit for other patients as well, including diabetics, who have frequent blood draws.

Nurses like doing their own blood glucoses, says Weiner, of Presbyterian Hospital, because they’re able to treat patients quickly. “We’re more in control of our practice,” she says. Similarly, the results from occult blood tests allow them to treat patients with gastrointestinal bleeds more efficiently. “We don’t have to wait,” notes Weiner. “We get the result and go on to treat the patient.”

Vida Foubister is a writer in Mamaroneck, NY.