They also replaced the large blood-gas analyzers and relied solely on a hand-held version. There was some resistance. “The initial resistance came from nursing. But it was short lived,” Melnick says. “Now, 100% would not give up the hand-held blood analyzer. “Once the test is done, it is done,” he adds. “There is no need for a follow up.” Another result of additional POCTs was the hospital’s ability to eliminate its STAT lab. “Running a STAT lab is not cheap because it has to run 24 hours a day,” Melnick says.
By administering tests at the point of care with the hand-held
blood analyzer and getting results almost instantaneously,
there is less chance that errors can occur.
Not surprising, the expansion of bedside testing and the elimination of the STAT lab became a concern of lab employees who feared their jobs would be in jeopardy. But Melnick states, “No positions were lost in the transition.” In fact, many STAT lab techs were simply reassigned within the core lab. Additionally, this shifting of lab personnel ultimately reduced turnaround times for STAT tests the lab still needed to run, he says.
You need to have buy-in from a number of people.
Out of the more than 80,000 lab tests Miami Children’s Hospital performs each year, approximately 70,000 are done at the point of care, Melnick says. Among those are blood cases, glucose, lactate, hematocrit, hemoglobin, clotting times, and electrolytes. Early on, the hospital’s cardiac intensive-care unit (ICU) team conducted a study of POC lactate level tests on the outcomes of children with congenital cardiac disorders. The study found marked improvements in reduced morbidity and a reduction in the cost of care when test results were available in a few minutes and in real time. “Before, the lab would get these results in 45 minutes,” Melnick says.
By administering tests at the point of care with the hand-held blood analyzer and getting results almost instantaneously, there is less chance that errors can occur. “If blood is not collected properly, the analyzer will not give a reading,” Melnick says. “And because there is nothing to transcribe, there are no transcription errors.”
But capturing data at the bedside is only part of the efficiency equation. “There are docking devices at all ICUs, so all information gets transmitted to the laboratory information system (LIS), then to the hospital information system (HIS),” Melnick explains. While transferring data from the LIS to the HIS is now done via an interface, Melnick says the hospital will soon be rolling out a new LIS that will be fully integrated with the HIS.
Because the lab is responsible for all POC testing, it has complete oversight of data collected from all ICUs, the emergency department, and operating rooms. And because Miami Children’s Hospital also operates four off-site centers that provide basic healthcare to the community, all test results collected at those centers also are integrated into the hospital’s LIS, Melnick says.
Aside from integrating and managing all POCT results, the lab staff also oversees the training of clinicians who administer these tests. “We train super-users, and they will then train other users,” Melnick says. Evaluating POCT proficiency also is handled by the lab, he adds. Quality-control and quality-assurance issues were resolved after the lab took over the responsibility for adherence to federal and state regulations, says Melnick. “In the past, there were some compliance issues. Record keeping was not that good, so the laboratory took complete control of regulatory issues.”
the point of care.
Advice for others
Beginning and expanding the POCT program at Miami Children’s Hospital did not happen overnight. And it would not have happened without the concerted efforts of key players. For those considering initiating a point-of-care testing program, Melnick offers some key advice. “This is an effort that has to be done collectively. You need to have buy-in from a number of people.”
Melnick says that he cannot stress enough how important it is to get a general consensus, and that all those concerned should be aware that the ultimate goal of a POCT program is to improve patient care. A discussion of the pros and cons is necessary, he says, but once champions of the idea are identified, they can convey the positive aspects of the program to others in the hospital.
“Obviously, nurses who work in different areas can cross pollinate,” he says. “It cannot be done top down,” he says. “It all has to start with an honest discussion with stakeholders. Once people see the benefits, they embrace it.”
Richard R. Rogoski is a freelance journalist based in Durham, NC. Contact him at [email protected]. The hand-held blood analyzer used by Steven Melnick, PhD, MD, chief of the Department of Pathology and Clinical Laboratories at Miami Children’s Hospital in Miami, FL, is the i-STAT from Abbott.