A-339 Timely Audits and Open Communications are key to Improved Device Result Transmission and Reduction of Potential Errors at the Point of Care

Abstract Background The Point of Care (POC) department was notified by an end user in the cardiac catheterization laboratory (Cath Lab) of i-STAT activated clotting time (ACT) results not transmitting to a patient's chart. Subsequent audits determined that this failed transmission was due to a delay in properly docking of the i-STAT into its downloader. Upon a broader and more thorough investigation, it became clear that this was a systemic issue among und-users of all i-STAT ACT testing for heparin dosage monitoring, as many cases went without transmission to patient electronic medical records (EMR). Not only did this present patient safety concerns related to the lack of documentation of test performance, it led to an approximate 67, 000 loss in charge capture over the course of 2 calendar years. Here, we describe the steps taken to implement process improvements in order to ensure patient results are charted in a timely fashion. Methods The first step in rectifying this issue was initiating dialogue between POC and the Cath Lab. Laboratory and nursing leadership and all i-STAT ACT superusers were made aware of this reoccurring issue and the negative effects it could have on patient care. Escalation through these administrative channels of the associated risks to patient care facilitated more effective communication of the expectation that i-STATS need to be docked immediately after completion of each case. It was also reiterated to our end users to be mindful of receiving a successful acknowledgment message to ensure that test results were being sent to the EMR. The next course of action was for POC to increase the frequency of Cath Lab audits. If i-STATs in high volume areas were found to have not transmitted data to our POCT middleware (Abbott RALS) in the prior 4 days, the cause was investigated. Several investigations proved fruitful in identifying issues related to i-STAT docking stations that affected communication with the LIS, which were swiftly corrected as to not impede Cath Lab workflow. Results Marked improvement in documentation of patient results was noted in 2023. Total result transmission failures on i-STATS in Cath Lab were reduced from 12% (2021) and 9% (2022) to 1% (2023). This not only represents hundreds of patient tests that were successfully charted, but a year over year charge capture increase of approximately 30, 000. Conclusions This project shows that open lines of communication to patient care areas combined with timely audits by POC Coordinators can have tremendous benefits on patient care at little to no additional institutional cost. Periodic POC quality assurance should include review of successful connectivity for interfaced test systems to ensure all testing performed is documented to the EMR.