Point-of-Care Laboratory Management in the O.R. Setting:

Our Opti CCA Experience

Central Carolina Perfusion

Associates, Inc.Winston-Salem,

NC

Howard Coston, BS, CCP, LPWinston-Salem, NC

Overview – A Historical TimelineCardiac Program History• Forsyth Medical Center – 850 beds, 2nd largest hospital in NC• Cardiac program initiated in 1987• Current annual caseload ~ 700 procedures, all adult• 4 perfusionists staffing 3 operating rooms“Point of Care” History • 1987 – 2001: Succession of large, table-top Ciba-Corning devices typical for a standard lab, very heavy with no portability - placed in the perfusion department work room, centrally located between 3 O.R. rooms - supervised & maintained by the respiratory department - significant time required to maintain multiple electrodes required to perform range of tests necessary for cardiac surgery arena - complicated reagent and blood/waste product management - necessitated dedicated personnel to perform tests

A New Day Dawns!

• 2000: New Point-of-Care coordinator from the main lab arrives!

• Needs assessment review with Perfusion and POC coordinator

a) Low maintenanceb) Reliability of testing outcomes c) Portabilityd) Electronic controlse) Storage of testing suppliesf) Data managementg) Customer and technical support

• Ultimately chose to evaluate I-Stat, Gem & Opti

“But soft, what light through yonder window breaks?” Romeo

Needs Assessment Outcomes – The Envelope Please!

1. Low Maintenance/Supplies Storage/Portability▫ No reagents, single use cassettes that calibrate prior to use ▫ Room temperature cassette storage – never refrigerated▫ Standing inventory orders, with flexibility for caseload variability▫ No waste fluids or blood to be disposed of▫ AC or battery operation▫ Small size (12 lbs) does not require dedicated space▫ Virtually no moving parts to fail

- approximately once a year replace aspiration pump- occasionally requires fuse replacement Note: both interventions managed by POC staff, does

not require biomed department assistance ▫ Still have 4 original instruments with only minor repairs (7 years as of 9/2008)

2. Testing Reliability/CAP Compliance/QC’s ▫ Electronic controls for daily QC’s (3 levels every 8 hours) ▫ Liquid QC’s performed monthly & with each cassette shipment ▫ Validation studies correlate with main laboratory instruments ▫ Automatic aspiration of sample ▫ Co-oximeter technology for Hgb measurement, not calculation ▫ Rare cassette failure (typically “dirty optics”) ▫ CAP Proficiency Testing

- commercially available QC’s for Blood Gas/Electrolytes- Hgb technology unique – no available commercial QC’s

“CAP: if no testing product available commercially , an acceptable alternative must be developed”

- POC department developed in-house alternative

Needs Assessment Outcomes – The Envelope Please!

4. Customer & Technical Support ▫ FMC was early user for the O.R. setting▫ Early challenges:

- CAP proficiency survey deficiencies * Minimum 10 peer group participants for

benchmarking * Non-comparable “other instrument” survey group * Extensive liaison work with CAP done by tech

support- Proprietary Hgb measurement technology (QC dilemma)

▫ POC manager characterized customer and technical support as “incredible”

Needs Assessment Outcomes – The Envelope Please!3. Data Management

▫ Integrated printer – 1 copy each for anesthesia and perfusion- thermal paper cannot be placed in the Medical

Record▫ QC and patient testing information downloaded weekly to main lab (network docking station in perfusion work room)

The Point-of-Care Benefits

1. Significantly decreased maintenance requirements

2. Decreased perfusion personnel requirements

3. Rapid turn-around time for lab results (< 3 minutes)

4. Facilitation of tight glucose management

5. Simple management of 5,163 patient tests in 2007- 4,647 cardiac surgery tests (7.4 tests/procedure)- 516 main O.R. tests

* managed by anesthesia tech staff