Personnel paradox and more: POC pitfalls

GEN.54400 Personnel Records says if a diploma or PSV report does not specify one of the required areas of study or is for training obtained outside the U.S., there must be records showing that qualifications are met using other acceptable means—transcripts, equivalency evaluation. And the training and qualifications of all personnel trained outside the U.S. must be evaluated by a recognized organization to determine equivalency to an education obtained in the U.S., with records of the evaluation available in the personnel file. “You can’t just translate your degree,” Dr. Karon said. “That’s why at Mayo Clinic we still have to bug about 100 of our nonwaived testing personnel for their diplomas and transcripts.”

This is where we air a little dirty laundry,” Dr. Perry said midway through the session, launching into a “scenario which shows you that as laboratory medical directors, if we don’t pay attention to point-of-care testing, we can get into trouble.”

At a pediatric hospital, nursing staff were performing thromboelastogram (TEG) testing in the PICU, Dr. Perry said. “We in the lab agreed to let them do it. The nurses in the PICU were trained how to draw the blood and perform the TEG testing, and the PICU physician, who had done TEG testing where he trained, was going to do the analytical interpretation.”

At the time, the laboratory didn’t have a designated point-of-care coordinator. “But somebody in the lab was put in charge of training the nursing staff on performing the testing, which was a bit of a challenge,” she said. Nurses in the PICU performed about 150 TEG tests per year.

No issues with test performance had been reported to the central laboratory, so the laboratory medical director didn’t realize anything was awry until CAP inspection. “Lo and behold,” said Dr. Perry, “21 of our 23 phase two deficiencies were related to TEG. This was a big wake-up call to the laboratory and hospital and everyone else.”

Dr. Perry polled session attendees about what they would do in that situation, given the following options: meet with the PICU director to review the deficiencies and come up with a new plan; cease TEG testing in the PICU; or cry, scream, and yell.

“There’s more than one right answer on this one,” she said. “Cry, scream, yell, and swear happened initially,” before the laboratory medical director, PICU director, and hospital administration made the call to cease TEG testing in the PICU.

“Obviously, our PICU physicians were not happy with this decision,” she said. “But the decision was made partly because we didn’t think we could take care of fixing all of the problems with the instrument in a timely manner to provide accurate testing. Literally, we pulled TEG out of the PICU, put it on a cart, and put it in a box in the laboratory and buried it.” The response to the CAP: testing no longer performed.

Of course, the laboratory still needed to determine a new approach to providing TEG testing. For a year and a half, it sent samples to another laboratory in the city. “That was not a great answer in that TEG is a real-time whole blood test so you like to do it right away,” Dr. Perry said. Second, transporting samples from the pediatric hospital to the other hospital and receiving results back was taking two to three hours, and “of course the PICU wanted it back in about two minutes.”

The laboratory began to discuss moving testing to the pediatric hospital’s central laboratory. “This brought up a whole lot of questions, not just related to TEG,” Dr. Perry said. For example, “What should we do in the lab so this never happens again?”

For one, the laboratory medical director was able to justify a full-time point-of-care coordinator position to hospital administration. “If you don’t have a point-of-care coordinator, life as a laboratory medical director is a real challenge.”

Other valuable lessons? Before beginning a new point-of-care test, “we actually have to go to the PICU or the OR or the ED and make sure testing personnel are trained, stay competent, and do proficiency testing.”

“This is a reminder to all of us who are laboratory medical directors,” she said, that if there is a problem with point of care, “it’s not just the coordinator who’s going to get dinged. It’s us. We need to pay attention too.”

The TEG instrument, Dr. Perry said, is now located in the central laboratory of the pediatric hospital. PICU personnel draw the blood samples, which are then transported to the central lab where laboratory medical technologists perform the testing and enter the results so PICU physicians can see and interpret them. TEG testing is now billed for, “which we found out actually hadn’t been happening.” Three years later, “patient care is back in a good place.”

Scenario No. 4: A 300-bed community hospital with 20 operating rooms has one Hemochron for ACT in two ORs, one EPOC, and six blood glucose meters.

“A new CV surgeon arrives in town, who’s kind of a bit of a cowboy, Dr. Perry said. “He says he wants an additional Hemochron, as well as two EPOCs for the PACU and the cardiac care unit, ‘in the OR when I start tomorrow.’”

Dr. Perry asked session attendees if in this situation they would simply order the new devices and install them, meet with the OR and cardiac team leaders to develop an implementation plan, or pull the POC devices from where they are and move them to where the surgeon directs.

“As laboratorians, we get requests for all sorts of things,” Dr. Perry said. “Many times, we can fix the problem with what we already have. And other times we need to change things, but it involves workflow and people.”

Handling the new surgeon’s request correctly, she said, would require meeting with the OR cardiac team and asking questions: “First we need to know, how many cases are you going to be doing? Will all cardiac cases require point-of-care testing? If so, which ones? Do you just need the coag piece, the Hemochrons? Do you need glucose tests? Do you need EPOCs? Who’s going to do the testing? Many times it’s the perfusionists, but it could also be the nurses. Who’s going to purchase the instruments? Sometimes it’s the OR that purchases them, and sometimes it’s the lab.”

Once new equipment is implemented, it’s the responsibility of the point-of-care coordinator to provide training and draft a procedure, determine the IT interfacing, and verify billing. “As those who run point-of-care programs all know, most people who do the testing have no idea of the reporting side, the billing side, and the ordering side. All they know is they have a device and they want to put a drop of blood and get a number. So it’s our job to make sure all the rest of the elements are done,” she said.

Charna Albert is CAP TODAY associate contributing editor.