Who Performs Point-of-Care Testing?

SPECIAL
REPORT
Stephanie H. Summers, PhD, MT(ASCP)SBB
Denise Harmening, PhD, MT(ASCP)SBB
Mary E. Lunz, PhD
Who Performs Point-of-Care
Testing?
FEBRUARY 1998
VOLUME 29, NUMBER 2
From the Office of
Interdisciplinary
Studies, College of
Health Sciences,
Georgia State
University, Atlanta
(Dr Summers), the
Department of
Medical and
Research Technology,
University of
Maryland School of
Medicine, Baltimore
(Dr Harmening), and
Examination
Activities, ASCP
Board of Registry,
Chicago (Dr Lunz).
Requests for reprints
to Dr Summers,
College of Health
Sciences, Georgia
State University,
University Plaza,
Atlanta, GA 30303;
or e-mail:
[email protected]
LABORATORY MEDICINE
85
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A"\s a result of technological advances in laboraPOCT is changing the way health care profestory instrumentation, clinical laboratories have sionals think about laboratory medicine. The test
witnessed and helped propel many changes in systems introduced in today's marketplace are
diagnostic testing. One important change has designed for use by clinical and nonclinical perbeen the evolution of point-of-care testing sonnel outside the central laboratory. These
(POCT). 1 POCT, extolled as a revolution in changes have sparked controversy and opportuhealth care, is changing the face of laboratory nity throughout the health care industry, raising
operations and providing an opportunity to questions about the laboratory's role in the
improve customer service. POCT usually involves implementation of POCT, the validity of the
small handheld devices used to measure one or results, cost-effectiveness, and who should pertwo analytes or instruments used in critical care form and supervise the performance of POCT.9
units or emergency departments to measure full
The American Society of Clinical Pathologists
panels of analytes. POCT permits more rapid pro- Board of Registry (ASCP BOR) Research and
vision of laboratory results, in turn permitting Development Committee assessed who performs
more rapid assessment of health status. This sin- and supervises POCT by including items in a
gle characteristic gives POCT its greatest appeal. national survey. We report the data from that
Current literature supports the relation between survey in this article.
5-minute-or-less therapeutic turnaround times
and decreased morbidity and mortality in the Methods
critical care setting owing to increased diagnostic In 1993, the ASCP BOR Research and Developand therapeutic efficiency.2-6
ment Committee launched a longitudinal study
Point-of-care testing, alternative-site testing, of medical technologists to determine career patnear-patient testing, bedside testing, and decentral-terns. A cohort representing a national sample of
ized testing are the terms used to describe labora- ASCP BOR-eligible medical technologists was
tory testing performed outside the main labora- identified for follow-up for a 10-year period.
In 1995, year 3 of the study, questions were
tory. In addition to use in nonlaboratory hospital
included
to determine the number and types of
sites, POCT is used in patients' homes, in dialysis
institutions
performing POCT and who, within
centers, in drug rehabilitation centers, in the
those
institutions,
performs and supervises the
workplace, and in physician offices. Emergency
testing.
The
responses
of 342 medical technolomedical technicians and insurance companies
gists
who
indicated
that
their institution peralso use POCT for health screenings. Decenformed
POCT
form
the
basis for this report.
tralized testing has evolved because of the develThis
sample
represents
about
30% of the total
opment of user-friendly laboratory analyzers and
prospective
study
cohort.
the needs for rapid assessment of the conditions
of patients in critical care units and better management of patient care. 7 ' 8 POCT permits the Survey Questions
reporting of test results on a real-time basis and, The five following questions were asked:
much like fax machines and on-line computer
1. In what aspects of POCT is your laboratory
services, is being integrated into daily protocols
involved?
for direct patient care.
2. Who performs POCT at your institution?
©
3. What tests are done at the point of care at your
institution?
4. Who trains personnel to perform POCT?
5. Who supervises personnel performing POCT?
Demographic information was collected in other
parts of the survey.
Data Analysis
Data were analyzed with descriptive statistics and
cross-tabulations. We describe overall patterns
and patterns among institutions of various sizes
and locations.
Results
Demographic Characteristics
Development of
Procedures 56%
Proficiency Testing 3%
Laboratory personnel most frequently develop
procedures for POCT (Fig 1), while nurses most
frequently perform POCT (Fig 2).
POCT most frequently involved measurement
of the level of glucose in the urine by dipstick.
Measurement of the blood glucose level ran a
close second, and measurement of blood gases
was third (Table). The levels of hemoglobin,
breath alcohol, electrolytes, and cholesterol were
least frequently measured by POCT. Hospitals
offer the largest menu for POCT.
Location, ie, whether the institution is urban,
suburban, or rural, can make a difference. The
information provided in Figure 1 was further
analyzed according to the location of the respondent's institution. Results are charted in Figure 3,
which shows that, although patterns vary, the
laboratory is least frequently involved with proficiency testing for POCT and most frequently
involved with development of procedures. The
laboratory trains personnel for performance of
POCT in 49% of the institutions; the nursing
department trains personnel in 34% of the institutions; and other departments have this responsibility in 17% of the institutions. The laboratory
most frequently has this responsibility in urban
and rural institutions (Fig 4).
The nursing department most frequently
(50%) supervises the personnel who perform
POCT, followed by the laboratory (33%) and
other departments (17%). Assignment of supervisory responsibility to the nursing department is
logical because nurses most frequently perform
POCT. Although, the nursing department most
Laboratory
Staff 10%
Competency
Assessment 9%
Respiratory
Therapy
Staff 16%
Quality Control and
Assurance 15%
Nursing
Staff 52%
Instrument
Maintenance 17%
Fig 2. Response to the question: "Who performs
point-of-care testing (POCT) at your institution?" (n = 309).
POCT-Related Task
86
LABORATORY MEDICINE
VOLUME 29, NUMBER 2
Staff Performing POCT
FEBRUARY 1998
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Fig 1. Response to
the question: "In
what aspects of
point-of-care testing
[excluding the
testing itself] is your
laboratory
involved?"(n = 248).
All 342 respondents in the sample were employed
in the laboratory in 1995. Forty-two percent were
employed in hospitals with 300 or fewer beds,
46% in hospitals with more than 300 beds, and
the remaining 12% in independent laboratories,
physician office laboratories, academic institutions (ie, schools, universities, and colleges), or
industry. The majority of respondents (56%)
worked in urban settings, 25% worked in suburban settings, and 19% worked in rural settings.
Most (89%) were employed full time. Forty-two
percent worked the day shift, 29% worked the
evening shift, 17% worked the night shift, and
12% rotated shifts. The area of employment of
more than half of the respondents was somewhat
evenly distributed throughout the laboratory;
however, 47% of the respondents worked as generalists in all areas of the laboratory. Of the
respondents, 82% indicated that they never performed POCT.
Performance and Supervision of POCT
often supervises the personnel who perform
POCT, the laboratory supervises them almost as
often in urban institutions (Fig 5).
In 52% of the institutions, POCT is performed
by nursing staff members. Only 8% of the survey
respondents indicated that medical technologists
perform POCT. Medical laboratory technicians
perform less than 1% of POCT. Other health care
professionals performing POCT are respiratory
therapy staff (16%), assistants (9%), and physicians (6%). A wider range of health care professionals performs POCT in hospitals than in other
settings where POCT is provided. Outside the
hospital, nursing staff are the primary providers
of POCT.
eral patient units.10 Our data confirm these results.
However, a survey of critical care nursing personnel indicated that critical care nurses prefer that
laboratory personnel operate in vitro diagnostic
equipment because they believed that performing
laboratory testing detracted from other patient
care duties.11 The inference may be a desire for
greater laboratory involvement in POCT.
Urban
Suburban
Rural
60
XI
•L
o
•5 50
>
w 40
Although instruments such as blood glucometers
and portable chemistry units have been proved
accurate when used by staff with limited technical laboratory expertise, training and monitoring
of these staff members by knowledgeable laboratory personnel and implementation of appropriate quality control procedures are necessary to
prevent error. The role of the laboratory is vital,
and laboratory personnel must take a proactive
approach to POCT.
A 1993 study showed the substantial role of the
nursing department in executing POCT in the
emergency department, the operating room, and
the intensive care unit, at the bedside, and on genUrban
H Suburban
I
CO
in
•I 20
J I ih I
S 10
Proficiency
Testing
Quality
Control and
Assurance
Instrument
Maintenance
Competency Development
Assessment of Procedures
POCT-Related Task
Fig 3. Laboratory involvement in point-of-care testing (POCT), excluding testing,
according to location of the institution (N = 342).
Urban
Rural
60
I Suburban
I Rural
80
50
CO
CO
40
30
* 20
10
Laboratory
Nursing
Laboratory
Other
Department That Trains POCT Staff
Nursing
3i
Other
Department That Supervises POCT Staff
Fig 4. Responsibility for training personnel to perform point-of-care
testing (POCT) according to urban, suburban, or rural location of
the institution (N = 342).
Fig 5. Responsibility for supervision of personnel who perform
point-of-care testing (POCT) according to urban, suburban, or rural
location of the institution (N = 342).
FEBRUARY 1998
VOLUME 29, NUMBER 2
LABORATORY MEDICINE
87
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3 30
Comment
POINT-OF-CARE T ESTS PERFORMED
AT 342 RESPOND ENTS' INSTITUTIONS
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LABORATORY MEDICINE
VOLUME 29, NUMBER 2
FEBRUARY 1998
key players all have a stake in the evolving technology for POCT and its evaluation and implementation. Each brings expertise and perspective
to the development of new systems that are
viable, reliable, and cost-effective and that conform to standards.
Conclusion
Because training personnel to perform POCT
seems increasingly to be a responsibility of the
laboratory, the laboratory personnel involved in
training, as well as in retraining and recognition
of competency to perform POCT, must emphasize that these programs are provided as a service to the direct-care personnel. Medical technologists long have been isolated behind the
laboratory doors, away from the public and
peers. POCT provides them with the opportunity to become more visible partners in the
health care team.®
Acknowledgments
The ASCP BOR Research and Development Committee
includes Betty Bergstrom, PhD; Denise Harmening, PhD,
MT(ASCP); Robert Gay, MD; Larry Ludlow, PhD; Mary
Lunz, PhD; Sally Rudmann, PhD, MT(ASCP)SBB; H. (esse
Guiles, EdD, MT(ASCP); and Stephanie Summers, PhD,
MT(ASCP)SBB.
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Training is an important
part of POCT,
% of Tests
Test
particularly when per34.3
Urine dipstick
sonnel who perform
POCT are not educated
33.6
Blood glucose
in laboratory medicine.
The study by Bickford10
16.4
Blood gases
revealed that nursing
staff more often had
Activated clotting time
6.5
the responsibility for
training, closely folProtime/activated partial
lowed (in most cases)
thromboplastin time
3.7
by the laboratory. Our
data seem to indicate
Hemoglobin
that a shift has occurred in the responsiBreath alcohol
1.5
bility for training for
the performance of
Electrolytes
1.2
POCT. In institutions
where
POCT is per0.3
Cholesterol
formed, the laboratory
has the primary responsibility for developing
procedures and training personnel to perform
POCT, but frequently, the nursing department
then assumes the responsibility for performing
and supervising POCT. In addition, the nursing
department most frequently performs POCT,
even when the laboratory supervises the performance of POCT. Therefore, the best approach to
POCT involves formation of a partnership
among the nursing department, other personnel
who perform POCT, and the laboratory.12 The