Reevaluation of Point of Care Testing Implementation

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Reevaluation of Point of Care Testing
Implementation

• Andrew Maclennan
• PGY 1
• Presented 7/16/2008

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Background - Enhanced Care for Diabetic Patients

• Care providers use surrogate markers of patient
  health such as Hgb A1C and cholesterol profiles
  to guide therapy.
• Helpful to have results at patient encounter
• Goal of UNC Internal Medicine Clinics test
  surrogate markers in at least 90 of patients
  with indications
• In 2004, POC protocols instituted

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Background
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Background Impact of Past Cholesterol Ordering
Interventions
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CQI Model for ImprovementFundamental Questions
for Improvement

• Aim
• Measures
• Changes/Evidence-based strategies

What are we trying to accomplish?
How will we know that changes are an improvement?
What changes can we make that will result in
an improvement?
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
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PDSA Plan-Do-Study-Act Cycles for Testing Change

• Plan
• What are your aims and goals for this cycle?
• Develop plan to test the change.
• Develop plan for data collection (measures).
• Do
• Perform your test/change.
• Collect data.
• Study
• Analyze your data (quantitative and qualitative).
  
• Did you encounter problems?
• What did you learn?
• Act
• Did you achieve your aims and goals?
• Are you ready to spread/implement the change?
• If not, what changes are needed for next PDSA
  cycle?

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PDSA CyclesTests of Change to Drive Improvement
Changes that result in improvement
Learning
Learning
Cycle 3 Aims Measures Changes
Cycle 2 Aims Measures Changes
Cycle 1 Aims Measures Changes
Ideas
DeWalt
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POC Database for Diabetic Patients

• POC list automatically generated each day for the
  following days patients
• Follows guidelines to recommend when A1C and
  TC/HDL testing indicated
• Can evaluate efficacy by comparing POC list vs.
  WebCIS data

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Cycle 1 POC ImplementationInitial Data
Collection

• Who Abigail Miller (pharmacy student), Annie
  Whitney, Rob Malone
• What Measurements of TC/HDL and A1C obtained vs
  indicated
• When March 2008
• Where ACC Internal Medicine Clinics
• How long 10 Clinic Days

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Cycle 1 Abigail Miller

• Average Daily A1C Tests Obtained
• 45 of indicated tests actually obtained.
• 4-17 POC A1C tests indicated/day.

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Cycle 1 Abigail Miller

• Average Daily TC/HDL Tests Obtained
• 31 of indicated tests actually obtained.
• 1-8 TC/HDL tests indicated/day.

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Cycle 1

• Conclusions
• Many patients with indications for POC testing
  not receiving it.
• Future Directions
• Why arent patients receiving their indicated
  testing?

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Cycle 2 Plan

• Quantify the effectiveness of the current system
  for POC testing.
• Identify areas where patients are falling
  through the cracks .
• Specific questions
• 1. Has the rate of POC testing improved since
  March 2008?
• 2. Where is the breakdown occurringin ordering
  the POC tests or in carrying out the orders?

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Plan for test

• Who Andrew Maclennan, Annie Whitney, Rob Malone
• What Quantify the number of indicated POC tests
  that were indicated and carried out on diabetic
  patients.
• When 5/28/08 -- 6/23/08
• Where UNC ACC clinics
• How Data collected using the POC testing
  database and WebCIS

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Plan for Data Collection

• Calculate of indicated POC testing that
  actually occurred.
• Compile list of patients missing POC testing
• Determine whether indicated POC tests were
  actually ordered in the system.
• Look for patterns
• Where did breakdown occur?

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Data

• 13 Days of Data Collected
• POC A1C
• 109 Tests Indicated
• 88 Tests Carried Out (81)
• TC/HDL
• 38 Tests Indicated
• 25 Tests Carried Out (66)

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Patterns?

• Errors
• dont occur more frequently on specific days.
• Dont occur on one side of the ACC more often
  than others

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Why Didnt Patients Receive POC A1C?
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Process of POC Lab Ordering
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Intervention

• Simplify ordering process
• Eliminate steps 1-5
• Diabetic patients also have yellow sheets stapled
  to their billing forms
• Sheets state whether POC testing is indicated
• Order POC labs straight from the yellow sheets
• Front desk can initial that POC labs were ordered
  or not
• Can write reason why labs not ordered
• Traceable record left behind

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Data - Yellow sheet intervention

• 3 Days of Data Collected
• POC A1C
• 24 Tests Indicated
• 20 Tests Carried Out (83)
• TC/HDL
• 7 Tests Indicated
• 5 Tests Carried Out (71)

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After yellow sheet POC procedure
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Data Why wasnt indicated testing carried out?

• 3 of the 4 patients who missed A1c testing and 1
  of the 2 patients who missed TC/HDL testing had
  no front desk initials on the yellow paper.
• ? Was everybody informed of change?
• 1 patient was not tested because of test results
  from an outside dialysis center.
• Front desk staff noted this on the yellow sheet,
  improving communication.

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What was learned?

• Indicated POC A1c and TC/HDL testing is being
  carried out at a high rate, but still short of
  the 90 goal.
• Streamlining the ordering process is feasible
• Fewer steps for human error
• Some patients are still being missed
• With better communication on yellow sheets, we
  may be able to understand why.

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Were goals met?

• Current levels of POC A1c and TC/HDL testing were
  measured.
• Area identified where patients falling through
  cracks.
• Intervention tried
• At least as effective as previous system
• Still room for improvement

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Next steps

• Continue ordering POC with the yellow sheets.
• Ensure that all front desk employees are informed
  of this new procedure.
• Re-measure POC testing rates afterwards.
• Institute Redundancy
• Nurses also check yellow sheets and take
  appropriate action?
• Pipe dream?
• Integrate POC database with GE scheduling/WebCIS
  to automatically order POC testing.