Angela and Bibi

So good morning. My name’s Angela Lynam as John said and I’m team lead and this is Raheela Bibi who is our Point of Care Manager. So Point of Care testing, just to give you a very brief overview of it. It’s near patient testing as I’m sure you’re aware of. Part of my role is to oversee all the different pieces of equipment that we have in the clinical areas over Pennine that is now northern east sector that is shortly going to be Northern Care Alliance because we’re in transit of joining together. So I’m going to pass you over to Raheela who is going to take you through the first part of the presentation and then I’m going to take you through for the connectivity and the training side of it.

OK thank you Angela. So today we’re talking about our point of care service at the north east sector. So we’re going to keep a general overview and basically what we’re going to do is go through how we started in point of care, where we are now and basically where we see point of care testing in the future. So historically as you can see, point of care wasn’t centrally managed so the wards directly purchased their equipment from suppliers. That basically meant that each of the wards and different clinical areas would have different types of equipment in place. So for example, I’ve got a few pictures up there. I don’t know whether you can recognise any of them. But for blood gas analysis for example we had seven different types of gas machines in situ so the practice was very varied. And basically there was no quality management system in place at that time. So what we did was, I think as point of care was increasing it became quite evident that pathology needed to be involved.

So I know we’ve got a lot of people here for EBME and the medical device aspects but point of care testing kind of comes under that umbrella. I think that’s why John’s invited us to speak today. But point of care testing is diagnostic equipment. So are you taking your blood samples and sending them to the laboratory this is you’ve got your smaller machines in clinical areas like your glucose meters, your gas machines, things like that. So basically they’re very small versions of laboratory equipment so it kind of made sense that the management of those devices would come under the pathology department. So the pathology department established a policy which was trust wide and also set up a trust wide point of care governance committee. And the first target and kind of objective of that committee and the policy was to make sure that we standardised all the equipment.

So that was quite a big project that was kind of taken on across the four hospitals. As you can imagine, we’ve got different services, different staff groups, different clinical departments and to kind of get the cooperation I think and the buy in of everybody to standardise was quite a big task. So that was the first aspect that we did. And then the other thing was purchasing of equipment was centrally managed. That was brought under the pathology department as well where we’d liaise with procurement and we would work with specific suppliers and do equipment selection and choose something that was fit for purpose and of benefit to our trust. And then we’d draw that out as an installation across each of the sites. So one of the big things I think that was achieved back then was connectivity. So all the devices were connected by a data management system and fed through the laboratory information system and that then feeds into the electronic patient record.

So that was something that was established back in 2008. We touched on education and we also produced training documents so we had a standard process and protocols that all the clinical teams could use whether they were a hospital in north Manchester or whether they’re in a hospital at Oldham or whether there was neonatal services or ITU services, the practice was standard. So one of the first achievements that we managed at that time, we achieved CPA accreditation. So CPA, I don’t know if everybody knows, it’s Clinical Pathology Accreditation. So it’s very focused on pathology aspects again. But at that time there was very few hospitals that had achieved this, so that was quite a big breakthrough for our department at that time.

So in 2012 we developed further and we actually managed to set up a point of care facility which was at one of our remote hospitals that didn’t have a centralised lab. So what we did was we had an urgent care centre, so not an A&E department but they still needed to triage patients and basically either admit or discharge based on some diagnostic results. But because there was no laboratory on site we turned to point of care and thought well how can the devices that we’ve got in use or the devices that are available on the market to give our clinicians and our nursing teams the tools and the results to be able to make a decision on the patient basically. So we set up a facility that gave the full profile. So we’ve got a room where the clinical teams can go in and perform these tests and we make sure that those devices are fully functioning and they’re accurate to give the actual result they need.

So where we were prior to COVID? So as Angela touched on, we’re actually in a stage where we’re transitioning to join another trust. So we’ve got two aspects going on at the moment in Manchester. So one of our main sites is being taken over by Central Manchester. So we’re losing quite a big site. But on the other hand we’re joining with another site. So as you can imagine we’re kind of back a number of years where we’ve got different systems in place again and different processes. So this is where our challenge is now. So we were at the stage we were going for UKAS accreditation. So we had complied to standards which are international standards, again for pathology and laboratories. But obviously we’ve had to kind of put a hold on that now and we’re focusing on the transition with our partner hospitals.

So as you can see we are a discipline within our own right. So even though we sit in pathology we are trust wide and we are being recognised as such. OK. Did I skip a slide there. No. Yes. So obviously we found ourselves in the middle of a pandemic last year. I’m just thinking, is that the slide? Yes there we go sorry. It’s the right slide now. So we had to think of different ways of how we now manage our service. So a lot of the things that we did previously was face to face. We visit clinical departments, we go into A&Es, we go into ITUs, we work very closely with nursing staff, we work very closely with doctors. And last year we found that obviously we’re not able to do that anymore and we’re very limited in how we are able to deliver our quality service. How do we train our staff? How do we maintain our equipment? So our business as usual had to be re-thinked basically. So we had to put different processes around that.

What was very beneficial for us at that time was the fact that we were connected. So I know a lot of the trusts are still working towards a full connected system. So we’ve been very fortunate when we were in the middle of this pandemic that we had a lot of our systems already connected so we could do a lot of these functions remotely. So what we did was, our training was delivered remotely. We could monitor our devices remotely, look at the functionality of it. We could look at the performance of that. We could ensure that the results that we got off the devices were going into electronic patient records. And that was one of the biggest things that I think our clinicians were really clear on that they required. So obviously they can’t go back to a device say that’s in A&E in a red area or in an ITU situation in a red area where you’ve got positive COVID patients. They could sit at their nursing stations or doctor stations and they could log on and they’d have the full history, the full results for that patient, so that really helped them with their patient management.

One of the other things we did have as well was our asset management. So as you can imagine, to accommodate for the pandemic a lot of the hospital services were changing. So like elective services obviously were being cancelled. Your theatre lists were being cancelled. So we were opening up areas for management of COVID patients. So our ITUs really extended out. Our A&E departments really extended out. So we had a lot of movement of equipment. We had a lot of new equipment coming in as well. But I think keeping a track on where those devices were kind of became quite challenging but because we had our connected systems we could know exactly where one device was moved from and where it is situated now and when that happened with a full audit behind it. So I think that was another tool that we found that was quite useful for us.

So the challenge continues. I think even though we’re in a situation where we were under a lot of pressure and we had to react quite quickly with bringing in new equipment, we couldn’t compromise on the standards that we had. So we do comply to UKAS standards and they are quite regulated and quite strict. So when we have to provide an audit trail we have to provide our report so we have to be responsible and accountable for the fact that that device that is in place is absolutely above board. So this was very challenging for us since last year. And as you can see, there’s a lot of things there that we do have to make sure that it’s happening. So just a couple of points that I want to talk about. So comparison with pathology. So we couldn’t put any device in a clinical area even though it was a really short deadline and really quick target. We couldn’t put a device in unless we’ve done our verification with the laboratory.

So we still had to make sure that that laboratory compared well with what we had with the device in use and the results could be used interchangeably. Sample integrity again that comes with our training. So we still had to deliver the training to the same standard. So availability of staffing with sickness rates going up with staff and obviously with isolation and family members who were testing positive and things like that became really difficult for us as well. And usually we do hold large numbers of link nurse training days. So obviously we couldn’t hold large numbers of people in those specific areas so we had to break down those groups and kind of put on more sessions and make sure we still had the same support for our clinical teams. And again, technical issues, we were in a good position because we can dial in remotely to our devices so we can do the majority of the troubleshooting from our office and from the laboratory.

Some things will require us obviously to go to the clinical setting and some hands on maintenance is required but a lot of it we can kind of devise and troubleshoot from behind our offices. So what’s next. So we’ve had a very challenging year like I said and it’s been really difficult times. It’s obviously not ending here. Our next focus is on our winter pressures. So we’re already having these conversations with our infection control teams and our planning teams in terms of what is required going forward. As you can see from that first table, I just wanted to put a couple of our main devices on there just to give you an indication of how much we’ve increased in our equipment numbers. So the main ones are like your blood gas obviously for respiratory monitoring. Glucose meters are general equipment anyway. And ketone testing. And we also brought in handheld devices like the iStats which can give us a varied repertoire of tests. So those have been really useful as well.

We’ve also implemented COVID testing in our A&E departments to help with patient flow and patient management. Whether they go into side rooms or cohort bays or things like that. It’s been quite difficult in terms of managing with the limited devices that we have because everything’s been allocated by the Department of Health. So we’re not able to purchase like we would normally the numbers of equipment we want. So we have to work with what we’ve been given. And how do we divide that across our four or five hospital sites? How many devices depending on A&E attendances and, where the busy areas are, things like that. And also it’s not been our usual way of equipment selection. So we were basically just given a device and we had to work with that device. So again like I said before, we didn’t drop on quality. We still did evaluations, we still did our verification workarounds and made sure that that equipment was fit for purpose. Some needed more processes put in place so they weren’t as straight forward as we would like.

But again it was something that we weren’t prepared to just put out there just because we were kind of told here you go, you’ve got 10 pieces of kit. Just put them in you’re A&E department. So we made sure we covered all our standards. The next hurdle like I said is winter pressures. So we have to now incorporate your COVID testing. We’ve got the flu test and the RSV. So we’re looking for multiplex devices. And again, a lot of the suppliers actually have systems that give us a one device that can do all of that platform of testing. So it becomes difficult in terms of one swab per test. How many swabs can you take from a patient in A&E who’s come and who’s already quite ill. But we do need something in place that will help us with our patient flow because obviously we are expecting a lot of attendances in A&E as we go towards winter.

So going forward, what was highlighted to us through the pandemic, so there’s three points I think were key for us. One was training and quality. So those two things that we couldn’t compromise on. One was the connectivity. And again, we were in the fortunate position that a lot of our systems are connected. And then the third one was tracking of the devices so we knew exactly where our equipment was, how many we had, how many we need, which ones were functioning. All that kind of stuff. So we were quite lucky in a lot of those aspects. So I now want to hand over to Angela because Angela’s going to touch on our connective systems and tell you exactly what we’ve got in place, the different kind of data management systems and how they help us basically in doing the job that we do.

ANGELA LYNAM

OK thanks. Well I am if I can see, thank you Nina for your glasses. I left my glasses at home so I’m going to try my best. So if you have a look at this slide, we originally had this in place before the pandemic, but it proved to be crucial during the pandemic for updating documentation. We put virtual learning on there which we wouldn’t normally do. In particular for the new doctors for the blood gas training because we couldn’t accommodate them because normally we would do face to face. So it proved to be crucial for that. If you can see just at the side in the blue sections, that’s all the different pieces of equipment that we have out in the clinical area. Obviously we’ve added to that with COVID and it, on each one, if you click on each one it will bring you to the section, it’ll give you all the documentation, all the SOP, quick reference guides, any updates, anything that you need to know about that piece of kit, the clinicians on the ward can get and read and they can also contact us as well if required.

So everything that they would need to know about that particular piece of kit. So if we look on the next one. This is our contact details. Again because they were changing and we were in transition with the hospitals, it was important with MFT, they was changing. They at one point were contacting people over there which was causing some confusion. So again this was a vital part of documentation that was required for the clinical areas. And looking just at this time an example of the blood gas documentation that we have on there to support all the areas. In particular A&Es and ITUs that was required, more so again in the COVID time earlier on in the year. So all the documentation’s on there at the bottom as you can see. So I’m sure it’s quite clear, yeah. So you can just see everything that they can just click on and they can get any form of information that they need. Next.

The training and access to documents. Again we had to adapt. So normally we would do face to face training. It proves to be better for the clinicians and when they’re released from the wards as well. What we had to do was get all this information on there so the education practitioners could take it forward for the staff to make sure that they were still covered and still competent during the time when the areas were closed down in the hospital over the year. So this is just some of our training documentation that we put in place. We’ve got the competency there. Again in particular I’m looking at the glucose and the blood gas as well. Onto our connectivity. So I’m using the blood gas for the connectivity. I’m not sure if any of you are familiar with this. So this is [GEM med plus 0:23:28]. Now this goes into a middle data management corp accelerator. Once that goes into there it then goes into our lab centre.

So the consultants on ITU again in the closed down areas can monitor the patient without having to don and doff and go into that red area, so this crucial again. All the time for monitoring and managing the equipment and the users but more so in the pandemic. We’ve got two servers that accommodate now, because we’re separating from north Manchester we’ve had to set up a new server to accommodate their blood gas analysers that are over there. In total we have 38 blood gas analysers. I’ve lost count because we’ve put so many in at the time. So this is what we work with and it’s really easy, it’s very functional and it’s easy for us to monitor and more so to check for the users as well as sampling errors, aborted samples and just the complete management of the system. We have a full audit trail off it for patients which we quite often get asked in any kind of, if there’s been any issues around patients or any coroners reports, we can pull full audit trails off for that patient’s journey right the way through from the time they’ve come in to the time they’ve gone home.

Now this is what we manage our glucometers with and we have over 300 glucometers, coagulation for the community, D-Dimers for independent Rochdale that doesn’t have a lab. So again, it’s crucial for us to be able to maintain. We can do precision on this to make sure all the strips and the quality control have been checked before they go out. If not it’s all controlled centrally and we wouldn’t review it in which case it wouldn’t go onto the monitors. Again a crucial part of our kit. This is just another example and it’s just showing you what we’ve got on there. I’m not sure if anyone’s familiar with COVUS or any of the middle data management. So this again, it would go in to POCcelerator and then into lab centre and right into patient notes OK. So this is POCcelerator, this is the middle data management that I’ve mentioned. We have lots of different pieces of equipment on there.

So we have the blood gases going through there, DCAs, the COVID testing, the ID nows that we’re using at the minute and again, we have a full audit trail of these. And this is our quality management which is separate now. When I first came into post many years ago EBME used to control point of care assets and it was deemed that the service was getting much larger and needed a dedicated team to do that. So they took that out of the asset register from EBME and we went into [unclear 0:27:12]. So this is everything that we need to know about that piece of kit. Whether it’s been serviced, if it’s gone back, when it’s gone back, what it’s had done, when it’s come back to us, if it’s not come back to us. So we’ve got everything we need to know and the audits that are actually performed manually on them. All the data around that piece of kit is on here for every piece of kit that we have throughout those four hospitals. Oh are we at the end. That was quick. So that’s it. Is there any questions you’d like to ask?

DR JOHN SANDHAM

So one of the interesting things with connectivity that I’m interested in asking is how does that impact on clinical time and clinical decision making? So for the staff that get the data from the devices how does connectivity help that to become more efficient or does it help them to become more efficient?

ANGELA LYNAM

It doesn’t because they already treat their patient. So the connectivity helps the point of care team to manage and monitor for the quality side of things.

DR JOHN SANDHAM

So the connectivity is more for the management of the devices.

ANGELA LYNAM

Yes.

DR JOHN SANDHAM

So you know where they are and what sort of service state they’re in.

ANGELA LYNAM

Yes.

RAHEELA BIBI

Also for the results as well, you have the history on EPR. So you can look on the device and you get the result immediately on the device but once you’ve put that device down and you’ve walked away from it, if somebody’s looking at patient records you have your full audit trail. And I think in the pandemic it was easier for clinicians not to keep going back to the equipment that was in clinical areas and they could remotely look at the results. I think that’s where the advantage came and that’s where we realised connection was so important for results as well as our management.

ANGELA LYNAM

I noticed, it was Debbie wasn’t it? She was touching on that and the time for patient flow for not having that in medical devices.

DR JOHN SANDHAM

Yes I think that connectivity is something that we talked about at our last conference in 2019 and we see it as something that’s going to happen with all medical equipment at some point in the future and it’s how do you manage it. You’ve got a really good system in place. And also I like your training, the way that you train your users. Everything is connected. And I think you’ve done in incredible job.

ANGELA LYNAM

Thank you.

DR JOHN SANDHAM

Are there any other questions from the audience? Can you ask at the microphone please?

DELEGATE

Hi. Thank you very much, really interesting presentation. Can I ask a question because I come from a health board where we have three nurses who are serving a prison sentence for falsifying documentation around blood gas monitoring etc. And they looked at our electronic information and they said that it wasn’t, the phrase they used was it wasn’t forensic. Meaning if it is was tested in court there were too many holes in it. People could share barcodes and people could give each other passwords. So, your system, is it forensically robust?

ANGELA LYNAM

So we have an example from the coroners. So we have procedures in place that when we train that particular clinician they will then be deemed competent and they will sign that which is a legal document. If then their number is used by somebody else they are still accountable for that sample. If they was to use, for example in an emergency situation, the one that I was going to mention was an A&E department and a very senior member of staff who didn’t have the hospital number. So they used the unique number that we provide, the emergency one, where we can do a full audit trail on that but she didn’t fill in the required fields. Therefore when something happened to the patient and the coroner contacted us, what he wanted was what we provide for them which is a legal document and with no loopholes in. But she didn’t do that so she was then accountable.

 

Angela Lynam and Raheela Bibi's presentation at the EBME Expo : Point of Care Testing, 2021 and Beyond

 

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