Feature Story

How top-notch POC programs earn high marks

June 2002
Karen Southwick

When point-of-care testing first surfaced more than a decade ago, laboratories figured if they ignored it, it might go away.

How times have changed. Today, laboratories are not only learning to live with point-of-care testing but also taking charge of it. "We found that we need to be actively involved no matter where testing is performed," says Peter J. Howanitz, MD, director of laboratories and vice chair, Department of Pathology, State University of New York Health Science Center. He also chairs the CAP’s Point-of-Care Testing Committee.

POC testing has been good for labs, in fact, because its growth has forced them to build bridges with nursing and other units, says Kent Lewandrowski, MD, associate director of clinical laboratories at Massachusetts General Hospital and editor of Point of Care: The Journal of Near Patient Testing Technology. "We have to form interdepartmental teams and get to know each other," he says. In the process, "we’re beginning to get the hang of how to manage POC well." In fact, he says, the best labs now embrace point-of-care testing as an opportunity to improve patient care.

Other departments that do point-of-care testing have gained an appreciation for what the laboratory does, Dr. Howanitz says. "One of the most difficult aspects is to train the nursing staff or other operators to do all the things that will be required," he says. "It has made them realize just what is involved in doing a lab test."

CAP TODAY talked with a handful of hospital labs whose POC testing programs are considered to be a cut above the average. We wanted to know what they’re doing and what works and what doesn’t.

Capturing the data

At many hospitals, POC test results never make it to the lab information system. Nurses record them on the patient’s paper chart—that’s as far as they go. In some cases, the lab may get weekly reports, but there’s no way to verify whether all the results are there.

At the hospitals CAPTODAY surveyed, by and large results are automatically uploaded into the LIS and from there into the hospital information system for use in an electronic medical record and for billing. But even the most highly automated hospitals don’t yet capture all their test results electronically. The latest glucose monitors can be docked with a computer and their information can be transferred electronically, but other types of test results—such as activated clotting times or microscopy—are still recorded manually. Therefore, results typically remain within the unit where the test is performed.

"Without good data management, you can’t have good control over the POC program," says Christopher Fetters, president of Nextivity, a POC consulting firm in York, Pa.

And bar-coded patient armbands, which nurses use to scan patient information when they’re running the test, do a lot to shore up data handling, he notes. "Nurses are human and they’re going to make mistakes," Fetters says. "How can you be sure the results will make it onto the right chart if you depend on a nurse to correctly enter a long patient number every time?"

Mercy Health System in Philadelphia is a three-hospital complex with about 800 beds and a core laboratory that coordinates POC testing, including 21,000 bedside glucose tests each month. The automated glucose and coagulation results are transmitted into the LIS, which generates the permanent electronic medical record. Urinalysis results are documented manually on a POC report form, as is glucose even though it’s duplicative, says Bette Seamonds, PhD, clinical chemist and director of the point-of-care testing service. "The physician is not going to check two places for this information," the lab computer and the chart. "So the nurses are still putting them on paper because that’s where the doctors are going to look," Dr. Seamonds says.

At the same time, the electronic results are uploaded into the LIS so they become part of the permanent record. Urinalysis results will be available once that connectivity is added to the system. "We simply don’t have the manpower to put manual results into the computer retrospectively," Dr. Seamonds says.

Mercy uses bar-coded armbands. Compliance with scanning them has become a quality indicator tracked by the lab. (See "Making the case for QC.")

At Sentara Healthcare, a six-hospital system in Norfolk, Va., i-Stat results flow into the LIS and HIS. Other tests, such as the hemoccult, must be documented manually, although "report retrieval is available in the computer," says Lou Ann Wyer, MT, clinical specialist for POC testing and quality management.

Bar-coded armbands have been rolled out in all patient areas, and the nurses are supposed to scan the armbands and their own employee badges. The information is entered automatically into the record. Being able to identify the employee who did the scan helped boost compliance, Wyer says.

Similarly, at WellSpan Health, a two-hospital system in York, Pa., the results of glucose as well as tests performed on the i-Stat analyzer go directly into the LIS and HIS "with minimal or no review," says LuAnn Hildebrand, laboratory customer services/POC manager. The latest glucose meters can also scan bar codes, notes Hildebrand, so nurses have to use only one device to enter patient identification from the armband as well as test results. "The operator scans the armband, runs the test, and the results are captured in the meter. They then dock the meter, and results are sent directly into the LIS/HIS," Hildebrand says.

Other tests are entered manually; the POC team or "free hands" in the lab enter the data into the LIS. Nurses have been accustomed to entering manual results on a standardized report form; the forms are gathered periodically and taken to the lab for entry.

University of Missouri Healthcare in Columbia, an academic system with four hospitals, expects to have the nursing units interconnected to its LIS and HIS within the next several months. When it began to hook up the nursing units, it was obvious it would be a major project, says laboratory director Alan Luger, MD. "We put together an ad hoc committee to oversee it," including nurse managers, the lab manager, POC coordinator, information technology staff, and Dr. Luger himself. "We’re still in the midst of doing that change."

Once the project is completed, nurses will be able to obtain patient demographics from the HIS and transmit glucose results to the LIS. Blood gas results are also going online, but "everything else is manual," says Dr. Luger. In addition, "Our institution hasn’t decided whether to buy armbands yet, so nurses must enter the patient number manually," he says.

El Camino Hospital in Mountain View, Calif., which performs about 100,000 POC tests annually, still manually documents all the results. The nurses are supposed to record results in two places, one for the laboratory and another for their nursing flowcharts. They look at the digital readout on the instrument and write the result onto a chart, says Robyn Medeiros, quality assurance, POC, and education manager. "We’re hoping to get connected electronically this year," she says, which should eliminate a lot of that tedium. Medeiros is also pushing for bar-coded armbands.

Getting paid

Many institutions are leaving money on the table by not billing for POC testing, Fetters notes. That’s because it often sprang up haphazardly and documentation was manual. Electronic results make it easier to bill, but, even then, POC testing still falls into the gap between laboratory and nursing. Typically, the lab has to take responsibility for getting the right information to the finance department.

"If we’re able to capture the results in our LIS, lab does the billing for POC," says WellSpan Health’s Hildebrand. That includes glucose billing, which is in dispute at some hospitals. She acknowledges that billing for POC testing has been a "giant mountain" to climb, but it has been made easier, she says, "since we have developed a mechanism to attach billing to the lab result." Because WellSpan has set up POC testing as a cost center, "we want to make sure we don’t lose money," she adds. "We try to balance incoming and outgoing funds."

Mercy Health System also bills only for results that are available electronically, and it took some time to convince the finance department that, in the case of glucose, it was not duplicative testing according to Medicare. "We don’t have the manpower to bill for any of the manual tests, so we are anxious to get the urinalysis results online," Dr. Seamonds says.

Wyer is fighting the glucose battle at Sentara Healthcare. "We used to bill for glucoses but we don’t anymore," she says. "I’ve been working with finance to get glucose billing reinstated." But everything else is billed for, with the information systems providing the documentation to the finance department.

At El Camino Hospital, which hasn’t yet connected the laboratory and other units electronically, "we’re not billing for POC testing," reports Medeiros. Once everyone is linked, "we’ll start to do that. It will be a joint effort between lab and finance."

Dr. Luger estimates that the University of Missouri, which like El Camino Hospital isn’t billing for POC testing, is losing $750,000 a year in uncollected revenue from glucose tests alone. "We know how to bill for the tests; we just don’t have the tools in place yet to do it," he says. The LIS has software that can generate a bill for electronic results, but it’s still unclear how to get that information into the billing system. "As soon as we have that connectivity, we’ll do the billing," Dr. Luger says.

The people factor

"The labs that do this testing the best have taken the bull by the horns and designated a point-of-care coordinator," says consultant Fetters. Typically a medical technologist, the POC coordinator sits on and perhaps chairs the POC committee, makes sure educational programs are in place for POC operators, maintains relationships with nurses and other departments, verifies that test results are entered into the appropriate systems, and tracks QC.

No one has enough people to do the job right, but most POC coordinators are adept at exploiting the resources they have. Generally, rather than provide all the training themselves, they will train trainers in the nursing units or make sure that POC proficiency is a part of new employee orientation. Most of the hospitals use devices, especially for glucose testing, that lock out operators whose identification they don’t recognize. With manual tests, of course, this control is not possible.

Mercy’s Dr. Seamonds voices a familiar complaint: "The whole lab needs more people." In addition to her full-time POC coordinator, she has occasional part-time help with proficiency testing. "We’ve trained nurse educators to handle the in-servicing of their staff," she says. For annual recertification, each nurse operator takes a written test. After the nurses have completed the test, the supervisor notifies the POC coordinator, who then revalidates the operator in the RALS system so he or she is not locked out.

Nurses who are sent by an agency or work only a few shifts per month are a particular challenge. Mercy does not allow agency nurses to be trained in POC testing unless "we’re guaranteed they will be here for at least three months," Dr. Seamonds says. Pool nurses must work one shift a week to qualify for POC testing. But since the laboratory isn’t there for the nurses’ shifts, "we have to rely on the nursing managers to oversee this and provide us with the appropriate information."

At WellSpan Health, it’s up to the manager of the testing area to determine who will be doing POC tests. "The agency nurses are treated exactly like any other operator," says Hildebrand. "If they’re going to be here on a regular basis and want to do POC, they have to go through the same training and competency testing." Most of the time, nurses do want to learn POC testing because it broadens their skills and makes them more valuable.

Sentara’s core lab, which serves six hospitals, is better staffed for POC testing than most. Wyer has 7.5 FTEs involved with the program, four at the largest facility and the rest at other sites. But she is also responsible for managing quality at all the outlying labs as well as performance improvement monitors for laboratory services. Monitoring POCtesting is a huge job, she says. "We probably have well over 3,000 people doing the testing," and the POC staff has to make sure each one is competent.

A technologist from education and research and the POC staff help train incoming nurses on POC testing and devices. The POC staff also does all the competency testing and provides periodic skills updates on product lines. "Anybody from any of our hospitals can attend these sessions and get the competency they need to do testing," Wyer says. For people who work unusual shifts, "we have ’night owls’" who get all the people together for competency testing and product demonstrations, she adds.

The lab has also developed materials for contract nurses who don’t go through new employee orientation. "Experienced nurses can challenge each requirement by completing a test and doing a return demonstration," Wyer says. Sentara uses operator lockout to prevent untrained people from using the devices and to make sure QC has been done.

University of Missouri Healthcare has one FTE and two part-time people assigned to POC testing in the lab, and they’re loaded with work, according to Dr. Luger. The POC coordinator is involved with new employee training but "doesn’t have to train everyone herself." Nurses learn and then train each other.

El Camino has only one full-time position budgeted for POC testing, which is split between Medeiros, who devotes half her time to POC testing, and three other medical technologists. "Even with an allocated full-time position," Medeiros says, "we still find we are at least half a person short, so one solution for us has been to train the trainer." She also enlists the help of the diabetic educator. "She’s a great spokesperson for the lab," Medeiros says.

El Camino doesn’t have operator lockout yet, so they are looking forward to the upgrade, which will have this feature. "Extended-stay registry nurses are allowed to run POC tests after they’ve completed competency by their units’ designated trainer," Medeiros says, "but we don’t allow short-term registry RNs or registry certified nurse assistants to perform testing. That’s the hardest part to control."

The nurse connection

Since the POC coordinator typically is a technologist or technician with no direct control over the tests nurses perform, a good relationship, fostered by communication, is all-important.

"We have been very dedicated to building a bridge between the lab and nursing," says Dr. Seamonds of Mercy Health System. When it came time to hire a POC coordinator, "we invited the nurse educators to interview the top two candidates and help us make the decision. That gave us a rock-solid foundation," she says. That POC coordinator, Bhupen Desai, travels from site to site and visits all the nursing units to have a point of connection.

She and Desai are members of the hospital POC committee, which meets bimonthly and tries to stay on top of where POC testing is springing up and how it can standardize equipment and reporting. Nursing units or departments are supposed to present their needs to the committee before adding a new test. Dr. Seamonds, who is chair, makes sure the committee gets the information it needs to decide whether to add or change a POC test.

One of the first things she did upon coming onboard four years ago was to stop urine dipstick testing. "We waited to see who screamed. Immediately the ER screamed," she recalls. So she invited representatives to come to a committee meeting and present ER’s need for dipstick testing. "They wanted urine hCG, and we couldn’t fight it," says Dr. Seamonds, because the lab couldn’t turn around blood hCG fast enough. "You learn to make allowances that meet other people’s needs," she notes.

WellSpan Health organizes its POC committee by service lines, including representatives from cardiac care, trauma, nursing, pharmacy, and labs, and a pathologist chairs the committee. It rarely meets formally these days, however. "Now that our program is pretty much in control, we communicate by e-mail," Hildebrand says.

Establishing POCtesting as a separate cost center has helped break down the turf barriers at WellSpan. That cost center, operated by the lab, pays for all the supplies and equipment, handles training and procedures, and reviews QC, she says. Any unit that wants to add a POC test will be considered for approval "after petitioning the committee with a request that includes medical and financial justifications," Hildebrand says.

Even a smaller hospital, El Camino, finds a multidisciplinary committee useful. "We meet on an as-needed basis, if we get a request or have an issue crop up," Medeiros says.

The committee provides the support they need to push through JCAHO-mandated protocols or "put the brakes on new testing," she says, while a performance improvement committee researches turnaround time alternatives—such as a pneumatic tube to shorten TATs for emergency and critical care departments.

University of Missouri Healthcare doesn’t need a committee. "I set the policy," lab director Dr. Luger says. He and the lab manager "talk about POC issues on a regular basis. When somebody has a request, we let them make their case, and decide whether to allow it."

For the most part, says Dr. Luger, "we prefer to have the testing legitimized and supervised," so he will generally grant permission and send the POC coordinator to oversee the process. One recent addition was activated clotting times for radiology. "It’s better to bring people into the tent than put the institution at risk by performing unsupervised testing," he says.

Sentara doesn’t have a systemwide POC committee. With six hospitals owned or affiliated, it’s just too big. "We do 750,000 tests a year," says Wyer, "and it’s constantly growing." Instead of a centralized committee, Sentara sets up ad hoc groups to review requests for new POC tests or to oversee implementation.

For instance, when the system adopted the i-Stat analyzer, Wyer convened nurses, physicians, respiratory therapists, and lab staff to develop procedures for the new device. "Once we rolled it out we continued to meet to do followup and make sure everyone was comfortable." Then that committee was disbanded. "We do three or four projects a year that require getting together a core group of people like this," she says.

Wyer, who administers POC from a central lab, has four technologists who make weekly visits to all the units, checking on QC and inventory, answering questions, and taking reports. "The nurses now know that we are a valuable resource for them and will follow through on problems," she says.

Making the case for QC

Getting nurses to comply with the request to scan bar-coded armbands is tricky for many hospitals, including those in the Mercy Health System. About two years ago, after it got the armbands, "none of the emergency room nurses were using them," recalls Dr. Seamonds, because they were busy and unaccustomed to the new technology.

Dr. Seamonds met with the nurse managers and medical directors in the ER and listed the reasons for the armbands. "They promised to make an effort," she says, and compliance is now about 80 percent. One remaining problem is that glucose testing is often done before an armband is put on the patient. "I told them: ’At least make sure you put the patient’s name into the glucose,’" says Dr. Seamonds.

For nurses overall, armband compliance is at 91 percent, she reports. Mercy has an awards program: Any nursing unit that shows 98 percent compliance or better on a monthly basis earns a certificate. The stats are distributed to the nurse managers so they can see how they’re doing relative to their peers.

Because operators of automated devices must scan in their ID, Mercy is able to track "problem children," Dr. Seamonds says. If someone consistently fails to scan the armband or to perform QC properly, POC coordinator Desai can go "one-on-one with these people," she says. "The nurse manager is notified and, if a problem persists, the operator can be locked out. This extreme has yet to happen."

At Sentara, Wyer sends weekly and monthly reports of unit testing activities. "If we have a unit with 100 percent compliance for all the QC rates, we acknowledge their success," she says. If there’s a problem, "we’ll let them know and help them work through it. We send them only what they need to see and only what they need to act on."

For example, in one unit doing POC testing, the operators weren’t scanning their badges, contributing to reports of nonvalid operators, Wyer recalls. She met with the clinical nurse specialist and discussed why this needed to be done. "They turned it around in less than two months," she says. "We usually find that our strong nursing staff wants to do a good job and all we have to do is show them what it takes."

Other quality indicators at Sentara include compliance rates with patient identification, adherence to testing policies, operator performance, doing proficiency testing, and transmitting data according to schedule. Monthly reports are sent to the units to show them how they’re doing.

WellSpan’s Hildebrand agrees that most nurses just need to be shown how to do a good job and they’ll do it. Although she is prepared to talk to a nurse supervisor if someone isn’t performing POC testing or QC up to par, "in the 10 years I’ve been doing this there was maybe one time I had to go beyond the operator herself," she says. "Most of these issues are simply a matter of education."

At El Camino, Medeiros finds that sending a monthly report card on performance is an effective motivator. The report cards list department-specific compliance as well as hospitalwide performance indicators. "This has been one of the best ways to stimulate compliance," she says.

On occasion, she will meet with supervisors to spur improvements. Early on in the POC testing rollout, there was only 59 percent compliance with entering patient and operator identifications and running QC at the appropriate times. Medeiros reminded the vice president of nursing that the Joint Commission would be visiting the next year and these items would be part of the inspection. "She assigned a clinical nurse specialist to the matter, and our compliance is now up over 90 percent," Medeiros reports.

Medeiros and her team take weekly walks on the nursing floors and are ready to listen to what nurses have to say. One change stemming from their walks was that the lab now handles instrument troubleshooting rather than have the nurses do it. "They just don’t have time or the expertise, so it was very frustrating for them," she says. The operators do the routine QC, but the lab does everything else. "If there’s a problem, they call us and we’ll just swap out the instrument."

Says Medeiros: "POC has made the lab much more visible to nursing and has changed our perspective on nursing as well. We try to be a resource and support for nurses instead of getting upset if they’re not completing everything we want."

Karen Southwick is a writer in San Francisco.