The good, the bad, the ugly A month in the life of a Point Of Care Coordinator
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1 The good, the bad, the ugly A month in the life of a Point Of Care Coordinator Stefanie Van Heule Ghent University Hospital 23/10/2014
2 Ghent University Hospital ± 3000 patients / day ± total admissions (2013) ± consultations (2013) 6000 employees 45 wards + 16 day clinics + surgery rooms + recovery rooms Introduction
3 Department of Laboratory Medicine = Sample analysis + Phlebotomy + Distribution of the samples + Point of Care Testing Average per workday ± lab orders ± bed side samples Introduction
4 POCT = Medical testing at or near the site of patient care 4 Lab technicians Special Chemistry 2 Fulltime POC-Coordinators 1 POC Manager + 1 Clinical biologist Tim Prof. J. Delanghe Elke Dorine Heleen Karen Stefanie Barbara
5
6 Accuchek Inform II (Roche) What: Measurement of glucose in whole blood, near the patient with only one drop of blood Important * Scanning operator ID, patient ID * Quality controls : Low range (30 60 mg/dl) High range ( mg/dl) Users: 1x / 24h REQUIRED 1 STAT Importance QC E-learning + Visiting ward Introduction
7 Rapidlab 1265 / 1245 (Siemens) Rapidpoint 400, 405, 500 (Siemens) What? Measurement in whole blood of * ph * Blood gases: po 2, pco 2 * Electrolytes: Na +, K +, Ca 2+, Cl - (only RL1265, RP ) * Total haemoglobin & CO-oximetrie * Metabolites : glucose, lactate (only RL1265, RP500 ) Use: Nurses, some physicians in the ward Super users: can replace cartridge, perform QC & calibration Selected super users
8 1 month in the life of a POC Coordinator Management of internal & external QC 25 % 35 % Maintenance Management of reagents Lot validation 10 % 10 % (Re)Training operators Introduction 15 % Troubleshooting
9 1) POCT: Maintenance Daily: Glucose (10 ) * Checking status * Checking QC * Checking abnormal results (message) * Management of data users POCT - Maintenance
10 POCT: Maintenance Daily: Blood gases: (10 / instrument ) * Checking status * Checking QC & calibrations * Checking reagent level * Checking events log * Cleaning Rapidcomm device link POCT - Maintenance
11 Rapidcomm POCT - Maintenance
12 Rapidcomm
13 POCT: Maintenance Weekly: * Glucose: (10 ) * Checking data transfer to LIS * Blood gases: (20 /instrument) * Deproteinising (types RL ) * Sample port Problem with glucose data transfer Checking Severe CO-oximetrie problems (types RL ) POCT - Maintenance Deproteinising more frequently (2-3x/week)
14 POCT: Maintenance Monthly: Blood gases: (45 /instrument) * Filling electrode fluid (types RL ) * Changing cartridges * Checking filters QC, calibration errors Monthly (re)filling electrode fluid + Fixed schedule for changing electrodes POCT - Maintenance
15 1 month in the life of a POC Coordinator Management of internal & external QC 25 % 35 % Maintenance Management of reagents 10 % Lot validation 10 % (Re)Training operators 15 % Troubleshooting Introduction
16 2) POCT: Maintenance & troubleshooting 08:00 17:00: 1p/day:2 Fulltime POC-Coordinator 4 Lab technicians Special Chemistry 17:00-08:00 + weekend: Glucose: 2 spare instruments Blood gas: Back-up system Emergency troubleshooting: Clinical chemists in training 1 spare 2 spare / Training troubleshooting: General training on tour + 5 hands-on-training POCT - Troubleshooting
17 POCT: troubleshooting Accuchek Inform II : * E.g. badges, disfunctional, software block, data transmission error, battery error, strip error * Log book * 2014: * Spare instruments were 18 times used * 17 were phased out Problems Emphasize in e-learning POCT - Troubleshooting
18 POCT: troubleshooting Blood gases: Clot, Failed QC & calibration, electrode problems, cartridge problems, CO-oximetrie, Log book Interventions: 2-5/week Problems Maintenance Emphasize pre-analytical phase in e-learning + visiting ward POCT - Troubleshooting
19 1 month in the life of a POC Coordinator Management of internal & external QC 25 % 35 % Maintenance Management of reagents Lot validation 10 % 10 % (Re)Training operators 15 % Troubleshooting
20 3) POCT: Operator training: Glucose Glucose: 1. E-Learning 2. Theoretical test 3. Practical test: ~ Number of QC, patient With POCT coordinator 4. Visiting ward 1x / year Unclear how to get a certification Misunderstandings, frustrations Flowchart Visiting ward 1x / year
21 EXAMPLE E-LEARNING GLUCOSE
22 POCT: Operator training: Glucose certification Questions are devided into 3 categories: Essential, Important, Useful to know Example category 3 (essential) You see the message Quality control is necessary 1. You ignore this message 2. You can do more than 1 patient measurement 3. You first perform a correct QC before you do a patient measurement 4. You can do 1 CITO (urgent) -measurement POCT Training operators
23 POCT: Operator training: Glucose certification Example category 3 (essential) You see the message Quality control is necessary 1. You ignore this message 2. You can do more than 1 patient measurement 3. You first perform a correct QC before you do a patient measurement 4. You can do 1 CITO (urgent) -measurement POCT Training operators
24 POCT: Operator training: Glucose certification Example category 2 (important) What is the influence of squeezing the finger of the patient to get blood? 1. The concentration of glucose is higher because you add interstitial fluid 2. The concentration of glucose is lower because you add interstitial fluid POCT Training operators
25 POCT: Operator training: Glucose certification Example category 2 (important) What is the influence of squeezing the finger of the patient to get blood? 1. The concentration of glucose is higher because you add interstitial fluid 2. The concentration of glucose is lower because you add interstitial fluid POCT Training operators
26 POCT: Glucose e-learning & certification Home developed E-learning: * Tailored according to experience * Developed for nurses Commercial E-learning: * General, rigid * Technical, not targeted for nurses Certification expiry: Warning by EPR Passport authentification (no / individual) Scanning badge as operator ID Automatic synchronisation for badgenumber (high turn-over) Integrated tools for handling recertification data Certification expiry: Warning by No integration for authentification No automatic link with hospital ID No account with QC & Patient results Seperate tools
27 POCT: Training operators: Blood gases E-learning: Specific / ward For users & super users Daily visit: Possibility to ask questions 1x / year: At ward: training POCT Training operators
28 EXAMPLE E-LEARNING BLOOD GASES
29 EXAMPLE E-LEARNING BLOOD GASES
30 1 month in the life of a POC Coordinator Management of internal & external QC 25 % 35 % Maintenance Management of reagents Lot validation 10 % 10 % (Re)Training operators Introduction 15 % Troubleshooting
31 4) POCT: Validation Glucose: * New instrument * New teststrips lot * New QC lot Bloodgas: * New instrument POCT Training operators
32 1 month in the life of a POC Coordinator Management of internal & external QC 25 % 35 % Maintenance Management of reagents Lot validation 10 % 10 % (Re)Training operators Introduction 15 % Troubleshooting
33 5) POCT: Management of reagents Glucose: * Stock * Managing QC, teststrips (lot reservation) Blood gas: * Reagent level * Stock reagent Period changing teststrips => Miscalculation in reports * 2 spare * Schedule changing teststrips * In house developed tool LIS / First in, first out POCT Training operators
34 1 month in the life of a POC Coordinator Management of internal & external QC 25 % 35 % Maintenance Management of reagents Lot validation 10 % 10 % (Re)Training operators Introduction 15 % Troubleshooting
35 6a) POCT: Management of internal QC Glucose: Daily QC follow-up Blood gases: Daily QC follow-up Rapidcomm + LIS POCT Management internal QC
36 6b) POCT: External quality assessment Glucose: EQA (Institute for Public Health) Blood gases: QC Reports : QC Online / RTQC Web POCT External quality assessment
37 POCT External quality assessment
38 POC Experiences PRE ANALYTICAL PHASE: Start of a good measurement When nurses are observed: they follow the rules Still, we detect of user errors ( > 1/week) Bad Good BAD - UGLY Improve processes GOOD E.g. * Frustration, misunderstanding Visiting ward * CO-oximetrie problems More deproteinising The good, The bad, The Ugly
39 POC Future Still learning and growing Video e-learning Online logging Integration of documents in an electronic education portal The good, The bad, The Ugly
40 Conclusion Variable, interesting, challenging Certification, QC very important Communication The good, The bad, The Ugly
41
42
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