Standard Operating Procedure for Point of Care Testing (POCT) using Piccolo Desktop Analyser in Clinical Areas

Transcription

1 Standard Operating Procedure for Point of Care Testing (POCT) using Piccolo Desktop Analyser in Clinical Areas Reference No: Version: 1.2 Ratified by: G_CS_56 LCHS Trust Board Date Ratified: 31 st March 2015 Name of originator/author: Name of approving committee/responsible individual: Matron Louth and Skegness Hospital Quality Scrutiny Group Date Approved: 12 th March 2015 Date issued: November 2017 Review date: May 2018 Target audience: Distributed via: All Nurse and Doctors working within Urgent Care Trust Website Page 1 of 15

2 Standard Operating Procedure (SOP) Point of Care Testing (POCT) using Piccolo Desktop Analyser in Clinical areas Version Section/Para/A ppendix Version Control Sheet Version/Description of Amendments Date Author/Amended by 1 New Document March 2017 Matron Louth and Skegness Hospital 1.1 Policy Extended May 2017 Corporate Assurance Manager 1.2 Policy Extended November 2017 Corporate Assurance Manager Copyright 2017 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. Page 2 of 12

3 Standard Operating Procedure (SOP) for Point of Care Testing (POCT) using Piccolo Desktop Analyser in Clinical areas. i. Version control sheet ii. Policy statement Contents Section Background 4 Page Procedure 5/6/7/8 Signatory sheet 9 Page 3 of 12

4 Standard Operating Procedure (SOP) for Point of Care Testing (POCT) using Desktop Analysers in Clinical areas. Statement Introduction Point of Care Testing (POCT) is defined as any analytical test performed by a member of the healthcare team outside the conventional laboratory setting. Background POCT is capable of producing results in a timely manner that allows clinical decisions to be made quickly, potentially allowing better clinical (and/or economical) outcome. Statement Responsibilities Training Dissemination Resource implication This SOP provides advice and guidance on the use of the Piccolo Desktop analyser. Managers and service leads are responsible for ensuring that Standard Operating Procedures are in place for all clinical situations involving the handling of medicines. Standard Operating Procedures must be reviewed and updated at least once every 12 months and whenever procedures are amended. Managers and service leads are responsible for ensuring that any staff training needs are met to ensure implementation of this policy. Training should be provided to ensure that all staff working to Standard Operating Procedures are competent to do so. Website Intranet / This policy has been developed in line with national and local guidance documents supporting the production of Standard Operating Procedures and for the operation of desktop POCT analysers. Page 4 of 12

5 Standard Operating Procedure (SOP) for Point of Care Testing (POCT) using Piccolo Desktop Analyser in Clinical areas. Piccolo Analyser Use The analyser is to be used when test results are required urgently. To wait for routine transport to take bloods to the Path Links laboratory at Diana Princess of Wales Hospital, Grimsby would lead to a delay in patient care. Or During the out of hours period when there is no routine transport scheduled.to take blood samples to the laboratory at Grimsby. The analyser must be identified as appropriate for the tests required. (Is there a more appropriate POCT device which could be used? see flow chart) The analyser is not to be used as a substitute for routine Path Links venous sample testing. Analysis of Patient Sample Universal Precautions including PPE are to be used when using the Piccolo POCT Analyser. Staff who have not been trained and assessed as competent to use the equipment must not use the analyser. Need identified for blood sample testing using Piccolo POCT. Appropriate disk required for POC tests identified and removed from fridge at least 5 minutes prior to sample analysis. Blood sample to be obtained from the patient as per venepuncture guidelines, in a Green lithium heparin vacutainer (or blood gas syringe). Fill the tube at least half full. Blood bottle to be labelled with the patients identifiable details full name, date of birth, NHS number, date and time of sample. Specimens should be tested at the point of care and should be analysed immediately after collection. Blood sample is to be transferred from the vacutainer into the analysing disc using a pipette. Discard the disposable plastic pipette tip in a sharps bin. Do Not Discard the Grey pipette. (Dispense approximately 100 μl of the blood sample into the disc via the sample chamber) Dispose of the vacutainer sample in the sharps bin. Page 5 of 12

6 Place the disk cassette in to the Piccolo disk drawer, follow the on screen instructions. Analysis of the blood sample will take place automatically. Results will print out following the completion of the analysis. Remove the used cassette from the Piccolo disk drawer, dispose of disc in a sharps bin provided. [Blood samples from ABG syringe are suitable for use in the Piccolo, blood gas analyser and cardiac marker machine. Interpretation of Results It is the responsibility of the clinician requesting the sample analysis to interpret the results. Reference ranges are supplied as a guide only. If the responsible clinician disagrees with the results obtained from the Piccolo Analyser, or if results appear erroneous, venous samples should be obtained for testing by Path Links. Results are printed from the analyser. These should be immediately scanned on to SystmOne on completion of the test. The hard copy should be filed appropriately. Access to the Piccolo Analyser. Users of the Piccolo Analyser will be issued with individual access codes, after completing the appropriate training. Access codes are to remain confidential; it is the responsibility of the individual user to ensure this. A code may be reset by a super user should this be required. All users of the Piccolo POCT analyser will have read the Analyser Operators Manual prior to using the machine. Training to use the Piccolo Analyser. All staff requiring access to the Piccolo Analyser will complete the appropriate training prior to being issued with an access code. Training will be carried out by a super user. Training will take place prior to use and periodically afterwards. Super Users Super users are designated members of staff who are responsible for overseeing the training of further operators of the analysers and overseeing the quality assurance processes locally. They should liaise with the manager of the department and the Point of Care Testing Committee of ULHT and Path Links on issues such as problems with operators, quality assurance issues or other governance issues identified. In addition, the Super Users will attend the Point of Care Testing Committee to represent LCHST and provide a link with Path Links laboratories to Page 6 of 12

7 facilitate any trouble shooting/advice required in the operation and use of the POCT equipment. Cleaning and Maintenance. A daily cleaning regime is to be followed. The machine is to be visually inspected for evidence of soiling or damage prior to each use. It is to be cleaned and decontaminated at least once a day or as required if it is visibly soiled. The machine is to be cleaned using Tuffie Wipes or other equivalent Biocide wipes. A Daily cleaning log is to be completed. Any identified faults or error messages are to be reported in the first instance to the super users or department manager. Do Not Use sign to be placed on the machine until the fault is rectified. Upon acknowledgement of a fault, a super user will liaise with the manager and the manufacturer. The air filter is to be washed and changed monthly. The Filter is to be washed in warm soapy water following procedure identified in user manual. (Sec 9.3) Analyser software updates may be released periodically. Disks will be sent to the nominated person (Matron Urgent Care) and the machine will be updated by a super user. Waste Management and Disposal Waste generated through the use of the Piccolo Analyser is to be disposed of in accordance with the Trust Waste Management Policies. Reagent Disks, plastic pipettes and soiled specimen containers to be discarded in to a sharps bin. Ordering of Consumables Consumables such as pipette tips, reagent disks and printer paper to be ordered as required. A super user or the Department manager is to be made aware of low stocks. Quality Control and Quality Assurance Internal quality control samples will be sent to the department on Mondays and Thursdays. The member of staff who takes receipt of the quality control samples are responsible for ensuring the QC test is carried out. Page 7 of 12

8 The QC test is to be carried out using the Control Menu on the analyser, following the onscreen prompts. The QC sample must be tested on the day of receipt. If the QC test produces unsatisfactory results, then the machine must not be used until the problem is resolved. It should be reported in the first instance to the super users or the department manager. Do Not Use sign to be placed on the machine until the fault is rectified. Upon acknowledgement of a fault, a super user will liaise with the manager and the manufacturer. External Quality Assurance samples will be delivered on a monthly basis, and should be measured on the day of receipt for all indicated scheme analytes. The results are to be reported to the EQA Scheme organisers. EQA results and performance will be monitored and reviewed by the POCT Committee. MULTIPLE TESTS ARE AVAILABLE, WITH SOME TESTS DUPLICATED ON DIFFERENT MACHINES. (CHOOSE CHEAPEST TEST AVAILABLE THAT FITS YOUR NEED) ARTERIAL ANALYSER PICCOLO GEN CHEM PICCOLO MET LYTE COST for 1 COST COST cartridge Urea (BUN) Urea (BUN) Creatinine Creatinine Albumin ALP ALT Amylase AST Gamma GT Ionised Calcium Calcium Glucose Glucose Glucose Total Bilirubin Total Protein Uric acid GASES (O 2, CO 2 & ph) Bicarbonate (HCO 3 ) Haemoglobin Haematocrit Sodium Sodium Potassium Potassium Lactate C Reactive Protein CK Chloride Page 8 of 12

9 All staff who will be working to this SOP should sign below to say they have read and understood the SOP and agree to act in accordance with its requirements. Name Job Title Signature Date Page 9 of 12

10 Appendix A NHSLA Monitoring Template Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group/ committee Frequency of monitoring/audit Responsible individuals/ group/ committee (multidisciplinary) for review of results Responsible individuals/ group/ committee for development of action plan Responsible individuals/ group/ committee for monitoring of action plan Daily Checks Audit Paul Cooper UCC Manager Monthly Paul Cooper UCC Manager Paul Cooper UCC Manager Paul Cooper UCC Manager Page 10 of 12

11 Appendix B Name of Policy/Procedure/Function* Equality Analysis Carried out by: Paul Cooper Date: 06/03/15 Equality & Human rights Lead: Qurban Hussain Director\General Manager: Sue Cousland *In this template the term policy\service is used as shorthand for what needs to be analysed. Policy\Service needs to be understood broadly to embrace the full range of policies, practices, activities and decisions: essentially everything we do, whether it is formally written down or whether it is informal custom and practice. This includes existing policies and any new policies under development. Page 11 of 12

12 Section 1 to be completed for all policies A. B. C. D. Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are expected to be Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details Will/Does the implementation of the policy\service result in different impacts for protected characteristics? The aim of this service operating procedure is to produce a unified approach to the administration and care of patients requiring oxygen therapy: - All patients who require routine bloods analysed that is appropriate to their clinical condition and in line with national guidance. - Medicines and treatment will be prescribed according to a target range to treat. - Those who administer treatment based on results will monitor the patient. The policy defines how the patient will be treated for those patients that require intervention. No No Disability Sexual Orientation Sex Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers If you have answered Yes to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out by: Paul Cooper Yes No Page 12 of 12