CEO SUMMARY: Managing point-of-care testing (POCT) at a multi-hospital health system like Johns Hopkins Medicine (JHM) often means overseeing thousands of nurses and staff members who perform such tests. Lessons learned at JHM in standardizing POCT, training staff, and maintaining quality results were shared at last spring’s Executive War College.
POINT-OF-CARE TESTING (POCT) continues to expand. At the same time, mergers and acquisitions bring formerly separate hospitals and clinical laboratories under a single health system’s banner. These developments often trigger inefficiencies and inconsistencies in the operation and management of a far-flung POCT program.
Baltimore-based Johns Hopkins Medicine (JHM) experienced that exact dilemma and learned certain lessons that other health system laboratories and hospitals—regardless of size—can use to help standardize POCT and ensure accurate, reproducible results.
“Clinical laboratories that want to get a better handle on their point-of-care testing endeavors can learn from what Hopkins has done and adjust it for their own approach,” said Jeanne Mumford, Pathology Manager for POCT at JHM. Mumford presented at April’s Executive War College Conference for Laboratory and Pathology Management in a session titled, “Standardizing Point-of-Care Testing and Harmonizing Workflows Between Hospitals and Ambulatory Locations.”
During her 22 years of laboratory experience—12 years working with POCT—Mumford recognized that the following factors help smooth out aspects of this testing:
- Multidisciplinary collaborations within and beyond the hospital can overcome workflow inefficiencies.
- Standardized POCT processes and equipment are essential to achieve more consistency in how staff use these tests.
- Middleware technology can link disparate analyzers and laboratory information systems (LIS) to streamline the production of POCT results.
Challenges at Johns Hopkins
The lab team at Johns Hopkins Medicine faced most of the same POCT challenges that confront other hospital and health system laboratories. Johns Hopkins is a large hospital system, which from a lab operations perspective can sometimes be a detriment because many different processes are used.
“Geography is one of our biggest challenges at Johns Hopkins because we have five hospitals in the Baltimore and Washington, D.C., region,” Mumford noted. “In addition, we have dozens of ambulatory sites delivering primary care and specialty care throughout Maryland and into Northern Virginia.”
JHM also has a partnership to run the Johns Hopkins All Children’s Hospital in St. Petersburg, Fla. Serving multiple sites is complicated because each has its own staff and systems in place.
“At each site, different members of the clinical team do POCT,” she explained. “These are multidisciplinary teams that include certified nursing assistants, medical assistants, licensed practical nurses, and physician assistants, among other professionals. In addition, we have more than 40 point-of-care testing sites across Maryland, Northern Virginia, and the Washington D.C. areas where we oversee testing.”
Legacy POC Test Systems
At most of its sites JHM has some integrated instruments, but not all are interfaced to the central laboratory information system, Mumford said. “For example, we have a tear osmolarity vendor that provides us with a legacy instrument that’s been in our system for longer than I have. And that system was never meant to connect to the other parts of our system. Therefore, when we use it, we run it as a manual test,” she noted.
“We also have a variety of manual tests that many health systems run in their physicians’ offices or even in their laboratory settings as a reference test,” she told attendees at the conference. (See sidebar below, “Interfaced, Non-Interfaced POCT at Johns Hopkins,” for further details.)
To deal with these challenges, the POCT team at JHM undertook several critical steps, any of which other hospital laboratories could emulate. Among the most effective is using “guests” to help convey to staff the importance of consistency in POCT approaches and discuss what works, Mumford said.
JHM hosts monthly meetings with commercial labs and internal core labs, she explained. During these meetings, support staff from the commercial or core labs explain how other healthcare systems have solved problems they encounter with POCT and how JHM may be able to apply those same lessons.
Point-of-care coordinators, which Mumford referred to as POCCs, also can conduct monthly or quarterly meetings with testing personnel, unit managers, and those who train the testing personnel and managers.
Regular and frequent meetings with nurse administrators to outline problems and solutions also can improve POCT workflows and results, she added. Of course, daily huddles on as many units and floors as possible help ensure that all professional staff involved in POCT are consistently following standardized procedures the lab has implemented for POCT, she noted.
A further way to improve efficiency in POCT: Invite lab vendor representatives to participate in training for staff, Mumford suggested.
“You can bring in vendor reps to your sites to perform on-site training to help your staff complete your competency checklist,” she said. “Keep in mind that vendor reps are likely to have a good rapport with your POCT staff and often reach out to lab managers several times a year to offer their support.”
Standardizing POCT and related processes can bring about more efficiency. Such goals are not always easy to accomplish, particularly in larger healthcare systems, but Mumford said the effort is worth it.
JHM followed a three-step process to standardize POCT:
STEP 1: Standardize all testing throughout the Hopkins system. To do so, staff in the labs explain the most efficient and patient-centric procedures that they use when conducting POCT. In this way, they teach clinical best practices to those doing the testing at the point of care.
“To do that, I oversee all point-of-care tests, requests, and field studies,” Mumford explained. “We work very closely with all the local lab directors, administrative teams, and their point-of-care coordinators at each hospital.”
STEP 2: Establish a single structure for improving the quality of patient care. “We have a huge healthcare system, but you can scale this down to any size medical laboratory or system, as long as you have a tiered approach to decision-making,” she said.
For example, JHM has committees for patient safety and quality, an ambulatory quality council, and the Armstrong Institute for Patient Safety and Quality, which coordinates patient safety efforts in the Hopkins system.
“On our committees, we have deputy directors for nursing and for every scope of care across medicine,” she added. “One thing we do is ask which point-of-care devices work best and which ones can we integrate into our system.”
STEP 3: Standardize equipment and processes as much as possible. If a health system is vast, doing so may not be feasible, but aim to tackle as much as you can, Mumford said.
“I have six hospitals, which means I have six procedures for glucose testing,” she commented. Those various processes piggybacked from legacy systems each hospital had in place when JHM acquired that facility.
“For example, when we acquired a hospital in the suburbs outside of Washington D.C., that hospital had a blood gas solution that they used for many years before Hopkins came along,” she added. “They don’t do any blood gases in their core lab. All their blood gases for the entire campus are performed at the point of care.
“One size does not fit all, and that’s okay,” she concluded. To offset these conflicts, JHM contracts with two lab vendors that offer good pricing. “Those two vendors can supply us with everything we need. We tell them the metrics we’re trying to improve, such as time to treatment, time to discharge, or length of stay.”
In 2010, JHM began a years-long journey to implement a new electronic health record (EHR) system. Medical laboratory representatives from JHM visited many hospital systems across the country that had various EHR systems.
“Once we selected our EHR, we took inventory of all the LIS systems and medical records we had in place and formulated a plan to implement our new IT infrastructure across the system,” Mumford reported.
“We started this process 12 years ago, and in 2022 we might be finishing the final leg. To do that, we will be bringing in an LIS to the All Children’s Hospital in Florida,” she added.
The inventory showed that JHM had POCT instruments that were not interfaced throughout the system. This is a normal finding at any healthcare system that is growing and partnering with other hospitals, and for JHM, it has been bearable thanks to a piece of technology called middleware.
Use of Middleware
Middleware provides a method of communication between applications that would otherwise not have any way to exchange data, such as with software tools and databases, according to TechTarget. IT departments in healthcare should be familiar with middleware.
“At Hopkins, we all connect to a single middleware product, which means the middleware is the hub that gives us the connectivity we need to make the system work throughout all six hospitals and all ambulatory sites,” Mumford explained.
“Our middleware product allows us to have a daily, weekly, monthly, and ad hoc workflow,” she continued. “That allows us to standardize practices, such as accounting for instrument connectivity.”
Medical laboratories that are evaluating their POCT processes should consider the best practices from across the health system and adopt what works best in their facilities.
What is feasible at JHM may not work for every other lab or hospital, Mumford acknowledged. But the approaches are solid and can be used regardless of a facility’s size or complexity.
“Just because my strategies are based on a healthcare system that is highly complex and diverse does not mean that these strategies will not help you if you’re working in a smaller institution or even a larger institution,” Mumford observed.
Contact Jeanne Mumford at 443-287-8543 or firstname.lastname@example.org.
Interfaced, Non-Interfaced POCT at Johns Hopkins
HERE IS A LIST of point-of-care tests and devices that are interfaced and non-interfaced at Johns Hopkins Medicine:
- ACT-LR, ACT Plus
- Blood gases
- Glucose, whole blood
- O2 Saturation
- SARS-CoV-2 only and 4PLEX molecular
- Urine HCG
- Fecal occult blood
- PPM (multiple)
- Rapid HCV
- Rapid HIV 1/2 antibody
- Urine HCG
- SARS AG
- SARS-CoV-2 PCR
- Specific gravity
- Strep A
- Tear osmolarity
- Urine drug screen
Efforts to Standardize Glucose Monitoring
ONE OF THE WAYS TO UNDERSTAND THE COMPLEXITY of the Johns Hopkins Medicine (JHM) health system is to consider the numbers: at JHM there are 2,677 inpatient hospital beds, more than 50 ambulatory sites with glucose testing, more than 11,700 glucose operators, and 14 point-of-care coordinators (POCCs).
“Across the world, glucose is the bread and butter of point-of-care testing,” explained Jeanne Mumford, Pathology Manager for point-of-care testing (POCT) at JHM. “There are always questions asked on the POCT listservs: ‘What is the magic formula for determining how many POCCs you need based on how much work you have?’ for example. While I don’t know the answer to this question, I would argue that 14 POCCs across our system still aren’t enough to support our ever-growing and expanding needs. Several point-of-care experts in my network are working on establishing a formula. Maybe we’ll have a decent guideline soon.”
Standardizing glucose monitoring is a significant challenge and has a big payoff. “It’s worth every penny in the millions that we’ve spent standardizing systems in general,” she declared. “I say that because in the process of taking care of patients in all of our institutions, regardless of the size of the POCT program, we know that laboratory testing plays a critical role in establishing safe and effective patient care.”