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A pain-free inauguration of point-of-care testing.

By identifying stakeholders and including them in the planning process, this hospital beat the "us vs. them" syndrome.

Regardless of what we within the hospital laboratory community think, point-of-care testing (POCT) is here to stay. Its dry, microtesting technology can expedite delivery of accurate results in ever-increasing volumes.

A POCT program can serve as a prototype for the collaboration of other interdisciplinary patient care programs - provided all work together. At our hospital, the newly formed office of bedside testing (OBT) serves as:

* Coordinator for all POCT within the 750-bed facility

* A resource for the planned introduction of new POCT technology

* Liaison for bringing together all involved disciplines

While many facilities use the term POCT to describe testing performed anywhere outside the walls of the central clinical lab, we define POCT as lab testing performed at the patient's bedside.

* Stakeholders. Several UAB departments were stakeholders in POCT and involved with the development of the OBT. Hospital laboratories, our central clinical lab, believed that establishing the OBT was a vital part of the plans to improve turnaround time (TAT) for the facility's critical care testing. In addition, they believed that the use of strategic rather than crisis management was the best approach to the development of POCT.

Hospital labs knew that several other departments would be peripherally involved in POCT including finance, information systems, materials services, medical records, and quality improvement. They knew they did not have sufficient personnel to accomplish POCT on their own, and that if they didn't make a move, someone else would.

Nursing service was dubious of the claims about ease and accuracy of POCT. Their skepticism derived from their experience, several years ago, with correlation studies that compared split-specimen glucose results from bedside glucose meters with those from hospital laboratories' chemistry analyzers. Further, the nurses recognized their lack of knowledge and expertise when it came to handling POCT education and training, quality control and quality improvement, procedure manual development, and certification requirements.

The medical staff had several concerns. The ICU medical directors were worried their patients would not get the 5- to 10-minute TAT they required on many analytes. The non-ICU medical directors were mainly interested in minimizing glucose or coagulation TAT for patients requiring regulation of medications. The medical directors viewed hospital laboratories as the experts on POCT and nursing service as the logical labor force. The pathologists wanted to insure a consistent standard of care related tolaboratory testing. They also demanded all CLIA, CAP, and JCAHO standards be met.

UAB hospital administration was quite interested in making certain that POCT was cost-effective and that it was the most efficient use of human resources, particularly in light of the recent growth of managed care in the Birmingham market. Administration also required that patient care as well as accreditation needs be met.

* Planning. Representatives from each of the stakeholder groups were appointed to the action team. While the team approach helped to save time, it didn't always enhance communication. Having little successful prior collaboration, representatives from the nursing service and hospital laboratories were confrontational. To hospital laboratories' surprise, however, once administrative oversight was resolved ([ILLUSTRATION FOR FIGURE 1 OMITTED]), nursing service became not only a willing partner but a huge proponent.

The jointly managed, hybrid unit envisioned was an experiment for the facility. Everyone on the action team agreed that recruiting personnel with excellent interpersonal skills and the ability to work with all of the constituencies was vital to the success of the unit.

Judging by their past involvement with the ICU medical directors, hospital laboratories felt there would be little willingness on the part of the directors to address the problem of diverse testing requirements. Once they were provided flow charts of the actual test procedures, however, the directors worked with the team to develop an abbreviated critical care menu. And after sharing financial and personnel information with them, the directors decreased their original location requests for POCT implementation from 11 units to 4.

* Implementation. The OBT is composed of two program directors, a registered nurse, and a medical technologist, and is overseen by a hospital laboratories manager and a nursing service director. A medical director from the department of pathology also provides medical oversight and guidance. In addition, a policy advisory group composed of representatives from the ICU medical directors, nursing service, and hospital laboratories reviews requests for expansion of current POCT. The advisory group also considers implementation of new POCT technologies and makes policy recommendations to hospital administration.

OBT's program directors are responsible for the day-to-day oversight of POCT within the facility. They also supervise the education and training of new nurse operators, competency testing ([ILLUSTRATION FOR FIGURE 2 OMITTED]), compliance with accreditation standards, and the evaluation of new POCT equipment.

* Results. Thanks to the careful planning of the action team and the skills of the program directors, the OBT is functioning as designed. We started our program with bedside glucose and soon added electrolytes and hematocrit. Two months into OBT's operation, the unit passed a JCAHO inspection with no deficiencies. Quality improvement activities with the nurse managers are facilitated by monthly activity reports from the program directors. These address QC, inventory control, and test utilization.

Nursing service believes that patient care has improved. They view the OBT as their resource for POCT problem solving, an advocate for nursing issues related to POCT, and as an objective, unbiased listener. The medical staff also believes patient care to be improved because therapeutic interventions can be initiated more rapidly. Hospital laboratories is confident that accurate test results are being reported and echoes nursing service's view of the OBT. Hospital administration view the OBT as the coordinator of all facility POCT. It also believes that OBT is the control for unplanned proliferation of POCT, thereby positioning the facility well for managed care.

* Better communication. A number of unforeseen benefits have occurred. The relationship and communication between nursing service and hospital laboratories has improved dramatically. The medical staff who are involved no longer view hospital laboratories as obstructing the effort to establish POCT, but as a willing partner in the process toward improved patient care.

Implementing POCT went much smoother than anticipated; the buy-in by stakeholders was deeper than expected. The project has stimulated a higher level of professional respect among the stakeholders and between our health care professionals and vendors. The facility is in a much better negotiating position with vendors for services and equipment, now that UAB's unified approach to POCT is in place.

* Future plans. The OBT is currently busy with several projects. We just went on-line with a hand-held blood gas analyzer. We also are evaluating point-of-care coagulation testing. In addition, requests have been made by outpatient services - such as critical care transport and ambulatory dialysis - for inclusion in the program. POCT is indeed an exciting and growing part of the patient care team at the University of Alabama at Birmingham Hospital.

Suggested reading

Baird JE Jr, Weinberg SB. Group Communication: The Essence of Synergy. 2nd ed. Debuque, Ia: Wm. C. Brown Company; 1981.

Hickman CR, Silva MA. Creating Excellence: Managing Corporate Culture, Strategy, and Change in the New Age. New York, NY: New American Library; 1984.

Maddux RB. Team Building: An Exercise in Leadership. Rev. ed. Los Altos, Calif: Crisp Publications; 1988.

Miller WC. The Creative Edge: Fostering Innovation Where You Work. New York, NY: Addison-Wesley; 1987.

Shonk JH. Working in Teams: A Practical Manual for Improving Work Groups. New York, NY: Amacom; 1982.

Harris is the former administrative director of hospital laboratories at the University of Alabama at Birmingham Hospital, Birmingham, Ala. Utz is program director and Gibson is former program director for the office of bedside testing at the hospital.
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Author:Harris, Charlene H.; Utz, Carol; Gibson, Cherie
Publication:Medical Laboratory Observer
Date:Jun 1, 1995
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