standard operating procedure for point of care …

of 19 PELC Point of Care Testing SOP V3 February 2021

STANDARD OPERATING PROCEDURE FOR POINT OF

CARE TESTING IN THE URGENT TREATMENT

CENTRES

Version 1.3

Issued: February 2021

Revision Date: February 2022

PELC Point of Care Testing SOP V1.3 February 2021 of 19

DOCUMENT INFORMATION

Version Date: February 2021

Version Number: 1.3

Status: Approved in lieu of agreed updates completed 9th March 2021

Next Revision Due:

February 2024

Developed by: Dr Sarfaraz Munshi Kenrick Manhertz, Helen Mason

Key Contact: Dr Sarfaraz Munshi

Approved by: Sue Elliott- Integrated Governance Committee -Chair

Date Approved: March 2021

Version Control

This document is a controlled document. All previous versions should be removed from

use and archived. If you are reading a printed copy of this document, you should check

the PELC Policy e-folder to ensure that you are using the most current version.

Version No.

Description Version Date Author

1.0 First draft

February 2021 Dr Sarfaraz Munshi, Rory McMahon, Kenrick Manhertz

1.2 Review of draft

February 2021 Helen Mason

1.3 Final review of outstanding comments

March 2021 Helen Mason

This document is controlled and maintained on behalf of The Partnership of East London Cooperatives by the PELC governance team.

DISTRIBUTION LIST

All employees, and temporary staff with clinical input

All Urgent Treatment Centres

Reception Staff All Urgent Treatment Centres

Operational Staff All Urgent Treatment Centres

RELATED DOCUMENTS

BHRUT Cyberlabs Request Form

BHRUT and PELC policies: Handling of Hazardous Substances

BHRUT Policy, labelling of substances.


CONTENTS PAGE

1. INTRODUCTION 4

2. POLICY STATEMENT 4

3. PURPOSE OF POLICY 4

4. SCOPE OF POLICY 4

5. GLOSSARY OF KEY TERMS 4

6. ROLES AND RESPONSIBILITIES 4

7. PROCESS FOR POINT OF CARE TESTING USING HOSPITAL LAB 7

8. TRAINING AND SUPPORT 8

9. IMPLEMENTATION 8

10. MONITORING ARRANGEMENTS 8

11. REFERENCES 8

Appendix A: Glossary of terms

Appendix B: Flowchart for process

Appendix C: Diagnostic Pathways on Adastra

Appendix D: Process for Point of Care Testing- EPOC machine

Appendix E: NELFT guidelines on Collecting blood samples.

Appendix F: Point of Care Testing: DVT Pathway

Appendix G -Internal and External stakeholders

Appendix H -Sources of further advice


1. Introduction

1.1 Point of Care Testing (POCT) for patients attending the UTCs is designed to enhance capability within the UTCs at Queens and KGH by offering the capability to process an array of blood samples.

1.2 POCT is a terminology used to refer to blood tests performed by both laboratory and non-laboratory staff at the point of care, with an associated rapid turnaround time. 1.3 All Pathology specimens must be obtained and transported with care in accordance with existing procedures, as accidents could result in the transmission of infection to clinical, laboratory and ancillary staff. 2. Policy Statement

2.1 The Partnership of East London Cooperatives (PELC) aims to ensure that all relevant staff are provided with sufficient clarity on the process involved in Point of Care Testing within the UTCs.

3. Purpose of this SOP 3.1 The purpose of this Standard Operating Procedure (SOP) is to set out a clear guide for staff on their roles and responsibilities in relation to Point of Care Testing as well as general principles. It seeks to establish the correct procedures for the collection, handling and transport of laboratory samples. This document is intended to address the Clinicians and Healthcare Assistants within the UTC. 4. Scope of this SOP

4.1 This SOP relates to all employees including flexible, permanent, new starters, locum, temporary, sessional, students working in the Urgent Treatment Centres, across PELC sites, and relates to all Point of Care testing. 5. Glossary of Key Terms

5.1 A glossary is provided at Appendix A. 6. Roles and Responsibilities

Each individual member of staff within PELC/NELFT is responsible for complying with the standards set out in this SOP if they collect, handle and/or transport pathology specimens. They need to be aware of their personal responsibilities in preventing the spread of infection and should also continually assess whether they personally meet the required standards.

It is the responsibility of Directors and Managers to ensure compliance with

this policy.


6.1 Medical Director and Clinical Leads

The Medical Director is responsible for supporting GPs in following the process correctly including reviewing in an appropriate manner.

6.2 Nurses (Streamers, Urgent Care and Advance Nurse Practitioners)

6.2.1 BHRUT is responsible for ensuring that all POCT machines and facilities are in good working order. PELC operational team should escalate all issue with the machine to the BHRUT Lab. 6.2.2 Blood samples are collected from the patient in accordance with clinical best practice, by HCAs. Where HCAs are unavailable, UCPs are responsible for collection. This will be the responsibility of the NELFT nurse lead 6.2.3 The NELFT Nurse Lead is responsible for ensuring the UCPs are following the process correctly and reviewing blood results in a timely manner. .

6.3 Healthcare Assistants (HCA)/ Health Care Support Worker (HCSW)

6.3.1 Healthcare Assistants must carry out the required daily unit checks include cleaning POCT pieces of equipment, checking levels of phlebotomy consumables, and reporting any issues to the shift leader.

6.3.2 HCAs must report any malfunctioning POCT equipment to Service Delivery Manager, or in their absence the Shift Manager, and prepare for repair, using the decontamination certificate.In the absence of a HCSW, this should be done by any person on site who discovers the issue.

6.4 Receptionists

6.4.1 Receptionists are responsible for ensuring that patients identified for POCT testing are booked into the blood request queue, ensuring that the patients are flagged on the system as gone for diagnostics and returned from diagnostics, using the agreed lexicon.

6.5. UCP Shift Leads

6.5.1 UCP Shift Leads are responsible for ensuring that all POCT facilities are quality checked at the beginning of every shift and are to ensure relevant actions are taken to remedy any identified problem. 6.5.2 UCP Shift Leads are responsible for ensuring that nursing staff on duty are aware of the POCT process and the likelihood of them being called upon to assist with the collecting of blood samples during their shift.


6.6 Service Delivery Managers

6.6.1 Service Delivery Managers are responsible for overseeing the smooth running of all operations within the UTC, including the POCT process. Any issues with equipment, testing, and process must be escalated by the SDM to the relevant responsible manager.

7. The Process for POINT OF CARE TESTING

This SOP should be read in conjunction with all Infection Control Standard Operating Procedures and Policies.

The following bloods can be requested in the UTC.

VBG

Full Blood Count

Urea and Creatinine

Liver Function Test

C-Reactive Protein

D-Dimer

7.1 Standard precautions apply to the handling of all specimens.

Hands must always be washed before and after obtaining and handling

specimens.

All cuts and lesions must be covered with a waterproof dressing.

For the protection of all staff, disposable (non-latex) gloves MUST be worn

if there is any likelihood of contact with blood or body fluids. If individuals

experience problems such as skin irritation or dermatitis they must be

referred to the Occupational Health Department by NELFT manager for

appropriate advice and management.

Specimen containers must not be used for any other purpose and the tops

must be closed securely. Care must be taken not to contaminate the outside

of the container with blood or other material.

All needles must be discarded appropriately i.e., into vacutainer holders.

Syringes must be disposed of safely into sharps bins.


7.2 Obtaining Blood Samples

7.2.1 On arrival to the UTC, the patient is seen by the Streamer and if found appropriate for POCT, the Streamer will flag this on the Adastra system.

HCAs and UCPs should always ensure that the container and request forms are always be labelled with positive identification of the patient’s name, date of birth, unit number, date and time of sample, and adequate clinical information must be provided on the Cyberlabs form by the relevant requesting Doctor. (Specimens will only be analysed if they are labelled in accordance with the BHRUT Trust Policy).

Blood samples must be placed in the bags attached to the forms and bags must be correctly sealed at all times. Several blood samples from one patient can be placed in the same bag.

For more detailed information and training regarding venepuncture and blood samples please see NELFT guidelines in Appendix D. 7.2.2 Restock of consumables pursuant to point of care testing. BHRUT Stores will be responsible, as per the SLA, for bearing the full cost of restocking all phlebotomy-based consumables. All requests should go to [email protected] BHRUT will restock on a weekly basis, as part of existing restock rounds. Should a restock be missed, immediate notification should be made by the shift leader to [email protected]

7.3 Diagnostic Pathways on Adastra

(See Appendix B for User guide)

7.4 Process for POCT using the hospital lab.

7.4.1 The below is a sample of the blood request form that is to be used for the requesting of a blood test from the hospital lab.

mailto:[email protected]

mailto:[email protected]


BIOCHEMISTRY / HAEMATOLOGY / POCT REQUESTS

V2 02/2021

7.4.2 Specimen Transport and data Storage

All samples are to be sent to the lab via the Pod system or equivalent. If the Pod system is not working – samples will need to be transported physically. VBG results need to be scanned onto the Adastra records. Lab results will be made available on Cyberlab.

8. Training and Support 8.1 All staff involved in undertaking the POCT procedure must be first be signed off as competent as appropriate within the dimensions of that role, including, but not limited to:

a) Familiarity with SOPs b) Use of cyberlabs c) Phlebotomy/blood taking

NHS no.

Requesting Dr ……………………………………………………………………………… Adastra no

Surname

Please circle site below Please circle site below:

Forename(s)

QUEENS UTC EXT: 3147/3171

KGH EXT:8424

Sex M / F D.O.B

Relevant clinical details, including drug therapy

Date Time

Specimen: Blood / MSU (Private / NHS)

Please tick:

C-Reactive Protein Venous BGAS (epoc POCT) Full Blood Count Urea and Creatinine

Liver Function Test

D-Dimer

OTHER TESTS REQUIRED: Please write CLEARLY


8.2 Each staff member is accountable for his or her practice and must always act in such a way as to promote and safeguard the wellbeing and interest of patients.

• NELFT UTC Clinical Leads will be responsible for HCA/UCP training

and development for phlebotomy.

• NELFT staff will receive instructions and direction regarding infection

prevention and control practice.

• PELC will be responsible for Cyberlab/Adastra training of Doctors.

9. Implementation 12.1 Upon approval and ratification of this SOP, PELC staff will be notified of it via the BLUESTREAM portal managed by Human Resources. Self-employed staff will be notified via the governance team. Managers are responsible for ensuring that their teams are familiar with this document and are required to update the Governance Team on staff compliance with reading this SOP. The Governance Team/member must communicate with the communications team/equivalent on the need to disseminate to new or revised document and instruct that old versions are removed from circulation. 10. Monitoring Arrangements This SOP will be monitored on a monthly basis through the use of Incident forms (Datix) and feedback given to staff on lessons learnt from incidents.

Element to be monitored

Tool/Method Frequency Lead Reporting Arrangements

Adherence to equipment checking process

Site checks by SDMs

Bi-weekly SDMs SDM weekly report to Head of Operations. Report to line managers responsible for staff in areas of concern. Report to Audit Lead Datix for immediate risks

Correct use of equipment

Site checks by SDMs

Bi-weekly SDMs SDM weekly report to Head of Operations. Report to line managers responsible for staff in areas of concern. Report to Audit Lead Datix for immediate risks

Correct disposal of equipment

Site checks by SDMs

Bi-weekly SDMs SDM weekly report to Head of Operations. Report to line managers


responsible for staff in areas of concern. Report to Audit Lead Datix for immediate risks

Correct recording of information

Adastra case audits

Within current audit process 1% of cases

Clinical Leads

Reported to Audit Lead

11. References


Appendix A: Glossary of Key Terms

POCT Point Of Care Testing

UTC Urgent Treatment Centre

SOP Standard Operating Procedure

PELC Parntership of East London Cooperatives

NELFT North East London Foundation Trust

BHRUT Barking Havering and Redbridge University Hospital Trust

HCA Health Care Assistant

HCSW Health Care Support Worker

UCP Urgent Care Practitioner

VBG Venous Blood Gases


Appendix B: Flowchart for process

Process for Completion of Pathology Form and Adastra Documentation


Appendix C: Diagnostic Pathways on Adastra

Adastra user guide for Point of Care Testing (POCT)

Step 1: (If patients was identified by the streamer for POCT)

Streamer will create a patient record as normal but will enter a key word such as

POCT in the symptoms section, if they suspect that the patient will require the

appropriate blood test. This will allow the Receptionist and the Rapid Assessment GP

to identify this patient quickly.

Step 2: Receptionist when registering the patient will book them under Blood Tests so that

clinicians can identify these patients in the Specialism Queue.


Step 2:

Rapid Assessment GP will record the patient as Send to Diagnostics by right clicking

on the patient’s name.

This option can also be used if patients’ blood sample was sent to the hospital lab for

testing.

Step 3:

Rapid Assessment GP will now need to select the appropriate test from the presented

options, then select next:

Step 4:

When the patient’s results are generated from lab, the Rapid Assessment GP,

Receptionist or HCA should select Return from Diagnostics.


Step 5:

The Rapid Assessment GP will now have the opportunity to record the results on the

patient record and continue with their consultation.

You will have the option to Save the test results on the record and return to the case

later.

Step 1: (If patients was identified for POCT by the GP)

If the GP identifies that the patient requires POCT test during examination, they should

select the Diagnostics at the top of the list or Send to Diagnostic at the bottom of the

list. Patient will then be sent for the blood test.


Step 2:

Clinician will be presented with the option to select the blood test that they require,

then select next.

This box will then appear, select Neither as Print nor Email are not appropriate at this

time.

Step 3:

Follow steps 2 through to Step 5 as above.


Appendix E: NELFT guidelines on Collecting blood samples. Not required as no NELFT SOPs on this


Appendix F: Point of Care Testing: DVT Pathway

Please See below PDF

DVT Pathway Point of Care Testing.pdf

Appendix G: Internal & External Stakeholders

Managers

Clinical staff

Non-Clinical staff

BHRUT

NELFT

Patients


Appendix H: Sources of further Advice

Specialist Area

Name Job Title Contact Details (Telephone Number & E-mail)

Operations Kenrick Manhertz

Head f Operations [email protected]

Clinical Dr Sarfaraz Munshi

Interim joint Medical Director

[email protected]

Governance Sue Elliot

Director of Governance Quality and Nursing

[email protected]

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