Point of Care Testing Flashcards
What is Point of Care Testing?
•Working definition: “any in-vitro analytical test performed for a patient by a non-laboratory healthcare professional outside the conventional laboratory setting”
What are advanatages of POCT?
- Rapid turnaround for results (No transport delays, faster methodologies): Earlier treatment initiation, Reduced patient waiting, Improved patient empowerment, Financial efficiencies
- Less invasive: Smaller sample volumes
- Portability/accessibility: Reaching remote places – including sample stability, Improved healthcare access (mobility, socioeconomic)
Where is POCT used?
Acute services:
- Complex tertiary referral centre
- District General Hospital
- Out-patient departments
Community services:
- Intermediate Care
- GPs
- Patient’s Homes
- Outreach services
What is disadvantages of POCT?
- Increased risk of adverse incidents and litigation: Ease of processing test and obtaining a result can mislead healthcare professionals into thinking that nothing can go wrong, Less sophisticated equipment
- Pre-analytical, analytical and post-analytical errors e.g. Capillary shut-down, sample processing errors, documentation
- Comparability of methodology/results: Lab-POCT and POCT-POCT
- POCT is expensive compared with conventional laboratory testing: Cost of consumables, Economies of scale (EQA, IT, supporting equipment, duplication of equipment). Staff resources (patient-facing staff)
What are examples of settings where POCT methods used?
- High Street Pharmacies
- Prisons
- Employment screening
- Sports Teams
- War zones
- Natural disasters
What are advantages of glucose meters?
- Improved patient monitoring
- Sample volume
- Empowerment
What are types of glucose meters for patient self testing?
Patients on insulin: Assess insulin requirements and Better glycaemic control
- Capillary blood glucose
- Sensors under skin: This is a small sensor automatically measures & continuously stores glucose readings day and night. You then scan patch to get results.
What are complex blood gas analysers?
- Most common bench-top/complex POCT device
- Arterial, venous or capillary samples
- < 2 mins , 15 - 20 simultaneous analytes
- Gases, electrolytes, metabolites, haemoglobin and derivatives
- Locations: ED, Theatres, ITU, AMU, SCBU
- Adv: Immediate clinical care
What are advantages of portable blood gas instruments?
- Aging population, increasing chronic obstructive pulmonary disease (COPD)
- COPD patients often housebound on O2, socio-economic factors
- Local applications: GP surgeries, patient’s homes
- Adv: Improved patient experience, accessibility, ?O2 bill
What are characterisitis of warfarin monitoring?
- Increasing percentage of population on warfarin therapy
- Large individual variation in metabolism -> monitoring
- Applications: INR outpatient clinics, screening prior to Endoscopic procedure, patient self-testing
- Adv: Improved patient experience and cost saving
What are characterisitics of Urine Screening?
- Screening for new conditions e.g. urinary tract infections
- 5 - 11 analytes on one strip, semi quantitative
- Patients who are ill, procedures, underlying conditions at increased risk
- Manual read vs. machine read
What are characterisitics of HIV Screening?
- 9% of gay men in Manchester are HIV+
- People whose lifestyle puts them at increased risk may be reluctant to attend hospital based services
- Local application: Outreach service
- Adv: Improved patient accessibility and follow-up (public health)
What are characterisitics of Fetal Fibronectin?
- Diagnostic test to assess risk of delivery in preterm labour
- Detectable in vaginal secretions prior to delivery
- Assess risk of delivery in following weeks
- Guide treatment: Steroid administration, Admission, Transfer to tertiary unit
- Adv: Avoid admissions where very low risk and Specialist care for very prem babies
How is Flu testing done?
- Nasopharangeal swab
- Rapid processing time
- Guide treatment, isolation, admission, reduce length of stay
What is the characterisitics of multi-purpose analysers?
- Analyser is a reader; clever technology is in the test cartridge
- Flexible to local needs
- Applications include auxiliary to core laboratory services e.g. ambulatory care unit
- Adv: Varied including economic, patient throughput, bed management
What are examples of rapid growth of POCT?
- HbA1c – outpatient clinics, diabetes monitoring
- CRP – GP surgeries, guide antibiotic prescribing
- D-dimer – GP surgeries,? DVT, PE – treat, refer for scan
- Creatinine – prior to emergency contrast radiology
What are rationales for introducing POCT?
- Bed management decisions
- Reconfiguration of lab services
- Peri/post procedure monitoring
- Initial assessment
- Screening for new conditions
- Monitoring pre-existing conditions
- Accessing remote places
- Accessing remote people
What is Governance?
A system through which an organisation is accountable for quality
What is the criteria assessed for governance of POCT?
- Clinical and cost effectiveness
- Use valuable resources most effectively
- Fit for purpose
- Accuracy of results
- Define responsibilities of users / accountability
What is the quality mangement system of POCT?
POCT Policy
- Ensure patient safety with respect to POCT
POCT Committee
- Responsible for defining the scope of POCT
- MDT Membership: Clinicians/Nurses, Laboratory professionals, Support services e.g. Procurement, IT, Pharmacy ++
- Role: Link to Trust organisations / board, Strategic direction; applications for new services, Define the scope of POCT; clinical need, financial implications, technical feasibility, procurement, Review audits/incidents
POCT Coordinator/Team
- Delivery of POCT
How is the Cost-Benefit analysis of POCT done?
Is POCT necessary?
- Can the lab transport/service be modified to meet clinical requirements?
Impact on patient care – patient pathway
- Context
- ?Specific patient group
- Benefit of POCT vs lab?
Suitable location for devices?
Who will perform the test?
Finance
- Capital: Device, connectivity, alterations
- Fixed recurrent: IT, maintenance, EQA
- Variable: Consumables, staff
- Economies of scale
How is device selection for POCT conducted?
Test repertoire required?
Analytical quality of devices
- Comparability with lab results: Accuracy and precision, Limitations, interferences, measuring range
- Screening or monitoring?
Infection control
- Waste disposal, cleaning
Minimal operator dependent steps
- Easier to do the test in the correct way
- Volumes, timing, reading
Governance features
- Password access
- QC lockout
- Barcode readers – patient ID
- Connectivity
Size, analysis time, maintenance
Verification prior to implementation
What is the standard operating procedures of POCT?
- Comply with lab standards
- Non-lab audience
- Accessibility
- Controlled
How is the control of substances hazardous to health important?
- Safety of POCT end-users
- Safety of patients / visitors
Why is maintenance of POCT important?
- End user / POCT Team / lab support
- Complexity
- Compliance / recording
How quality assurance undertaken in POCT?
Internal Quality Control
- Routine accuracy/precision check
- Frequency dependant on test
- Blood gas iQM
External Quality Assessment
- National peer review
- End-user or lab staff?: Sample handling/reconstitution
- Scheme availability
Training and Competency Assessment
- Re-assessment interval?
What is the causes of most POCT errors?
- Most POCT errors are operator dependent: Pre-analytical, analytical, post-analytical
What are examples of POCT operators and it usefulness?
- Varied range of HCPs with varied educational background
- Clinical staff are busy people
- Company training or in-house
- POCT Team or cascade trainers / link nurses
What is content of training session?
- Basic principles of testing, clinical application
- Sample collection and handling
- Reagent storage, preparation
- Quality control / External quality assessment
- Procedure for patient testing
- Documentation / reporting results
- Infection control
- Limitations of the systems
- Responsibilities
- Further information sources and supporting materials
How is competency is training asessed?
- Theoretical knowledge
- Practical observation
- E-learning: On-going learning and Knowledge/practice gaps
How is Data for POCT managed?
Records of trained staff
Asset management - device inventory
- Record all device events e.g. maintenance, faults, service
Mechanism for storing results
- Standards, medical, medico-legal, patient recall
- Patient result, person performing test, reagent lots, QC etc
- Identifiable as POCT results
What is stored in a results book?
- Visually read tests / simple non connected devices e.g. HIV, pregnancy testing
- Results handwritten in patient notes
Advantages: tailor made
Disadvantages: time, transcription errors, legibility, lost books, storage
What are the characterisitics of Intermediate devices?
- Results, QC, lot numbers etc stored on the device
- Print out of results - Stuck into patient notes
- Manually enter results into the patient record e.g. via the lab IT system
Advantages: results may be recorded in electronic patient record
Disadvantages: Transcription errors, time consuming, limited to low volume tests
What are advanatges and disadvanatages of Interfaced Devices?
Advantages
- Remote login to devices: Add trained users
- Review QC data
- Results automatically added to the electronic patient record
- Full audit trail of processes
Disadvantages
- Expensive,
- IT support required
How is an Audit of POCT conducted?
Full scope of service
- Vertical, horizontal and examination
- Temperature
- Cascade trainer
Practice
- Cleanliness
- Reagent storage
- IQC and EQA
- Documentation
- Trained staff and numbers
Clinical effectiveness
- Workload
- Impact of test
Follow-up
- Feedback to clinical area
- Action plans
- Clinical audit department
How is Incident reporting conducted in POCT?
Reporting system
Root cause analysis
- Multiple causes?
- ID system failures not place blame
- Corrective action / Preventative Action: System improvements, Education
- Follow up
Examples:
- User sharing unique barcode with others
- Temperature breach in clinic room
