Labs adjust to POCTs

Oct. 1, 2009

Despite the growing use of point-of-care tests (POCT),
questions are being raised as to whether these tests are actually reducing
the workload for laboratory professionals. Since most labs tend to oversee
these tests and may have to duplicate certain tests if POCT results are
questioned, labs are being taking on even more responsibilities.

Linda Nugteren, POCT coordinator for Lee Memorial Health
System in Fort Myers, FL, says about 500,000 POC tests were performed
throughout the system’s healthcare facilities last year. And while there are
4,000 trained persons administering these tests, Lee Memorial’s labs employ
only about 250. Nugteren says POCTs are done only in STAT situations when
results are needed quickly. But she admits that sometimes these tests are
repeated in the lab.

This calls into question the accuracy of many POCTs, says
Rebecca Taalbi, POCT coordinator at Wheaton Franciscan Healthcare-St.
Francis, in Milwaukee, WI. “A lot of POC applications have great value,” she
says. “They allow nurses to know results quickly while the patient is still
present.” But, she adds, “Labs and nursing staff question the results of
POCTs.” Taalbi explains that while POC testing devices are allowed a 20%
plus or minus variance in values, lab tests are allowed only a 5%
plus-or-minus variance. Time also can be a factor, she says.

In the emergency department (ED), all patients receive
some sort of POCT, which may include a urine dipstick, urine pregnancy test,
glucose, or fecal occult blood test. But the Wheaton Franciscan ED decided
to stop administering POC chemistry tests. “We do an upstream draw so we
have blood already in the lab waiting for orders,” Taalbi says. “Doctors
were finding that lab results were coming back sooner or at the same time as

Sarasota Memorial Hospital in Sarasota, FL, employs about
100 people in its lab and administers about 10 different POCTs in the
hospital and off-site facilities, says Pam Driggs, POCT coordinator. In
surgery alone between September 2008 and September 2009, 6,079 i-STAT tests
were performed. This single device can measure sodium, potassium, chloride,
and glucose levels, as well as providing information on hemoglobin,
hematocrit, and blood gasses. In radiology, where creatinine levels also are
measured, 6,835 i-STAT tests were run during the same period.

For the lab, this technology has been a boon. “Before
POCT, all that would have been done in the lab,” Driggs says. Plus, i-STAT
results are reported in two minutes and automatically entered into the LIS,
she notes.

Additionally, in the 20-plus years since POCTs were first
introduced to Sarasota Memorial, the volume of tests being run in the lab
has been declining, she says.

Venice Regional Medical Center in Venice, FL, added i-STAT
to its battery of POC tests in the early 2000s and has been using it for
cardiac surgery, cardiac catherizations, critical care, and special
radiological procedures, says Eileen McGrail, assistant lab director. In the
ER, POC tests include those for glucose, urine, fecal blood, and pregnancy.
She says the hospital hopes to add POC cardiac testing in the near future.

For Venice Regional, the proliferation of POCTs has been
beneficial. “It has taken the burden of running many of the STAT type tests
out of the lab and put them at the bedside,” McGrail says. “This then allows
the technical staff to be available to run more complex and, sometimes,
esoteric testing in the main lab.”

By not having to send some tests out to a reference lab,
the hospital has been able to save money. For example, the parathyroid
hormone, or PTH, with calcium test was brought in-house, she says, adding,
“We can do it for less cost than a reference lab.” Although the lab has
taken on more testing, it was still able to promote a bench tech to the
newly-created position of POCT coordinator, McGrail says.

With more POC tests being adopted by hospitals, there
comes an additional level of responsibility for hospital labs. “Our POCT
program is monitored by laboratory personnel,” explains McGrail. “All the
training for nursing personnel, for the operation, quality-control and
testing procedures are done by the laboratory POCT coordinator.

“As a CAP-accredited laboratory, CAP proficiency testing
is performed on all POCT equipment,” she continues.” All operators are
randomly selected to perform proficiency testing. All operators are given
annual competency evaluations which are administered and monitored by the
laboratory POCT coordinator.”

At Lee Memorial, where nurses do the bulk of POC testing,
Nugteren says operators of non-waived tests are trained by the POCT
coordinator, while those administering waived tests are trained by members
of the clinical education department and laboratory staff. Sarasota
Memorial’s Driggs says she personally trains some operators, while
designated “point people” also serve as trainers under the hospital’s
nursing education program. Taalbi, at Wheaton Franciscan, says initial
training on POCT equipment is done by the POCT company’s sales executive.
Once this operator is proficient, he then trains other nurses. The lab staff
are not trained on POC tests, she adds. The lab does, however, keep backup
instruments for all 11 POC tests administered in 28 different areas of the
hospital. Should a malfunction occur on the floor, that instrument is
immediately replaced. “And if the backups go down, then the tests are run in
the lab,” she says.

While POCTs have added another level of responsibility to
both the lab and nursing staff, the ability to get results fast continues to
drive their adoption. “Ultimately, the goal of POC testing is to provide
timely, accurate, and error-free results to help physicians and nursing
properly manage patient care,” says McGrail. “Teamwork is the key to a
successful POCT program.”

Richard R. Rogoski is a freelance journalist based in
Durham, NC. Contact him at [email protected] .