CEO SUMMARY: Point-of-care testing (POCT) continues to gain acceptance in hospitals across the nation. One factor in this trend is improved technology for both the POC assays and the POC systems, each of which contributes to a more accurate and reproducible POC test result. But an equally important factor is tight management of a hospital’s POC testing program by its clinical laboratory team. Norman Regional Health System provides insights about what is needed to be successful with POCT.
EXAMPLES OF PROGRESSIVE HOSPITAL LABORATORIES that support extensive use of point-of-care testing (POCT) in diverse clinical settings are becoming more common.
This is true of Norman Regional Health System in Norman, Oklahoma. It has made POCT the centerpiece of its laboratory service since it opened a new Long- Term Acute Care (L-TAC) facility five years ago. Use of POC tests solved several problems that are familiar to most pathologists and hospital laboratory directors.
“Our 50-bed L-TAC facility was a remodeled nursing home and there wasn’t space for even a small laboratory,” explained Danny Myers, Director of Laboratory Services for Norman Regional. “Also, for the purposes of establishing an on-site laboratory, it is a low volume facility. That makes it difficult to justify the capital expenditure and staffing costs of a lab in that facility.”
There was another unique challenge to servicing this L-TAC facility from the hospital core lab, which is located only about two miles away. “Though routine lab tests can be sent by courier to the central lab, the route between the L-TAC facility and the hospital crosses a railroad track,” observed Myers. “The problem is that mile-long trains regularly come to a complete stop on that track and nowhere in town is there a single underpass or bridge that crosses the railroad track.
“Encountering a stopped train on that track can delay our couriers by 30 minutes or more,” he added. “This situation may soon change, as the city recently commenced construction on an underpass.”
Clinical Need For POCT
Independent of the courier transport issue was a basic clinical requirement. “About two-thirds of the patients at the L-TAC facility are on ventilators,” said Myers. “Physicians and nurses constantly do blood gas tests to determine adjustments to the ventilators. Point-of-care testing was the only solution that made sense for the facility.”
To open the facility, Norman Regional purchased four i-Stat POC testing devices, one for each wing. “The L-TAC staff runs blood gasses and chem-8 tests on the device, although this POC device is capable of doing more,” said Myers. “The staff also do glucose testing and dip-stick urine testing at their facility. For everything else, our hospital is their reference lab.”
POCT Used In Several Areas
The L-TAC is not the only service in the Norman Regional system that uses POC testing. “We have POC devices in the ER, surgery and recovery, ICU, and the NICU,” Myers explained. “The NICU uses more POCT than the other clinical areas within the hospital.
“The clinical staff likes the fact that it requires only a heel stick to do blood gasses, chem-8s, and ionized calcium tests on the POC device,” he said. “With critical babies, a fast answer is important. The other significant benefit is that, were these tests to be done in the core lab, a venipuncture would often be required. That’s not preferable when treating these tiny babies.”
Testing for specific situations is the primary use of POCT in other clinical departments. “For example, the ICU only uses their POCT device when a patient crashes and they need fast results on blood gasses and chem-8 tests,” he explained. “The OR and recovery room use the POC device for coagulation tests and blood gasses.”
Successes And A Setback
Norman Regional’s ER provides examples of both a POCT success and a setback. “Our emergency room uses the i-Stat to run the first troponin test on patients that present with chest pain, though subsequent troponins are sent to the central laboratory,” noted Myers. “This has been a successful use of POCT.
“That was not true of our experience with POC testing for CKMB and myoglobin testing,” he recalled. “Our emergency room doctors lobbied for a POCT device that would do CKMB, myoglobin, and troponin. The salesman had done a good job convincing them that it would improve patient care.
“Despite our lab’s concerns about the accuracy of this POCT analyzer, we agreed to purchase these devices, at a price of $64,000 each, plus the cost of reagents,” continued Myers. “This turned out to be an expensive mistake!
“The devices were accurate most of the time, but a few exceptions came back to bite the ER physicians,” he added. “The challenge lies in the fact that these tests have very narrow ranges of normal.
“When there is too much variation, the operator gets false positives,” Myers explained. “Acting on those POCT results, the physician ends up taking patients to the cath lab who aren’t having a heart attack.”
Devices Now Sit On A Shelf
“After a couple of those incidents, the ER physicians stopped using these particular POCT devices,” stated Myers. “Now these $64,000 devices sit on a shelf in my office.
“Meanwhile, the ER docs went back to relying on troponin tests using the i-Stat,” he added. “They combine this with the EKG results to determine if chest pain is the result of a heart attack.”
On balance, both Myers and the health system’s clinical staff are happy with the current use of point-of-care testing. Myers summarized the key reasons behind the success of POCT in his health system.
“First, from day one, we diligently monitored the program every step of the way,” Myers stated. “Two laboratory staff members are dedicated to the functions of POC monitoring and performance improvement.
“Together, they spend about 20 hours of each week on routine POC maintenance and monitoring,” he commented. “They are immediately involved if: 1) there are problems with a POCT device; or, 2) we purchase a new POCT device; or, 3) if additional staff must be trained.
“Second, our laboratory staff members regularly perform correlation testing on the POCT devices,” noted Myers. “This ensures that the test results from the POCT devices match the test results from the central lab. To date, we’ve found the POCT systems we use to be very accurate.
“Third, we monitor the cost of POCT testing,” he stated. “POC testing is an expensive proposition,” he observed, “since a POC assay can be four times or more the cost of doing that same test in the central laboratory.
Maintain Cassette Inventory
“One way to monitor the cost of POC testing is for our laboratory staff to maintain the reagent cassette inventory,” said Myers. “They also handle the necessary calibration any time a POC device is repaired or a new device is purchased.”
Excessive utilization of POCT has not been a problem at Norman Regional. “If the situation demands quick turnaround times, the right POC test can be worth the cost. Across Norman Regional, our clinical staff has generally been conservative with their use of point-of-care testing.”, he said.
“Fourth, and likely the two most important factors in a successful POC testing program are training and security,” said Myers. “Our POC devices are linked to our computer system in the laboratory, and they require a user code to operate.
“Before our laboratory issues a user code to a staff member, he or she has to undergo comprehensive training and show proficiency with the POCT device they will use,” he explained. “Every three months, our laboratory conducts a review of the POCT devices.
“If it is determined that a particular user is abusing the privilege or having continuing problems using the POCT device correctly, he or she will be locked out of the system,” explained Myers. “Even physicians must go through POCT training, show proficiency, and obtain a user code.”
Myers added that the proper selection of the POC assay and testing system is an important factor. “For our purposes, the i-Stat is a good little device,” he noted. “It is very accurate and very reliable. But that will not be true of all the POCT systems currently sold in the market.”
Overall, Myers gave satisfactory marks to the POC test program at Norman Regional. “It’s turned out to be worth the investment in terms of better patient care,” he said. “But POCT success requires more than just a capital investment. There must be a commitment by administration and the hospital laboratory to devote staff time necessary to monitor the program and manage use of POCT. Without leadership from laboratory management and staff, it just wouldn’t work.”
Norman Regional’s success demonstrates that hospital laboratory managers can safely use POC testing in their facilities, under the right conditions. With careful selection of devices, proper testing, and a security and monitoring system, POC testing can be a valuable clinical tool.
How New POC Tests Are Vetted at Norman
EACH REQUEST FOR A NEW POINT-OF-CARE TEST (POCT) at Norman Health System triggers a rigorous review and approval process.
“When a hospital unit wants approval to use a new POC test, they must submit a formal request through the POC Test Committee,” stated Danny Myers, Director of Laboratory Services. “This group of 12 hospital staff is chaired by a pathologist. It includes other physicians, nurses, and technologists. The committee carefully reviews the medical necessity of POC testing. They also weigh the cost of using a POC test against the patient benefit.”