POINT OF CARE URINE PREGNANCY TESTING BY NURSING POLICY

Effective Date: 
Mon, 12/02/2013
Revised: 
Wed, 03/18/2015
Policy: 

To provide point of care clinical laboratory testing in various clinic areas to improve patient flow.

Under the direction of the Medical and Clinic Directors, trained  nursing staff can perform point of care urine pregnancy tests in designated clinic areas.
Oversight of the quality control system will be a shared, collaborative responsibility of the Medical and Clinic Directors.

DEFINITIONS
Collector – Staff member who obtains the specimen
Processor – Staff member who performs the test
POC – Point of Care

 

Procedure: 

A.  Training

1.   The Medical and Clinic Directors develop and supervise the processor-training program.
2.   Training records, including annual competency review, are documented and include date trained and certification by Medical Director (Attachment A, UCSC SHC Urine Pregnancy Test POC Training and Competency Record).
3.   Training is updated when a new test or test procedure is implemented.

B.  Specimen Collection and Processing (see link to POC Urine Pregnancy Testing Policy)

C.  Documentation

1.  Processor records test results on appropriate POC quality control log maintained at each testing station. (Attachment B, sample Point of Care Urine Pregnancy QC Log)
2.   Processor enters results for urine pregnancy tests in patient’s electronic health record (EHR).

3.  Point of Care Quality Control Logs are collected from clinics monthly and maintained by the medical Records Department for three years per UCSC SHC retention schedule.

D.  Quality Control and Calibration
1.   Processor checks expiration dates and assures that test kits and appropriate collection materials and forms are available for testing.
2.   Manufacturers’ recommended quality control and calibration steps are followed.
3.   Quality control testing is recorded in corresponding quality control log for each test being performed.
4.   Any abnormalities in quality control testing, such as an "Invalid result" will be noted on the "Problem Log" log with an explanation of the occurrence and resolution. The Processor's supervisor will be notified immediately.   If the control line fails to appear, this is considered an "Invalid result".   Insufficient specimen volume or incorrect procedural techniques are the most likely reasons for control line failure. Review the procedure and repeat the test with a new test cassette. If the problem persists, immediately discontinue using the test kit and notify supervisor.

5.   The Medical or Clinic Director or designee performs a quarterly review of this log.

E.  Quality Assurance
1.   Competency training of staff processors of POC clinical laboratory tests is conducted annually by the designated Clinic Manager, for all POC tests performed at SHC.
2.   Log monitoring
a.   POC logs in two clinical areas (Same Day Clinic and Floor 2 Primary Care Clinic).  Logs are monitored annually by the Medical or Clinic Director or designee, for the determined parameters and compared to the corresponding client record.
b.   Results are reported at SHC Quality Management Committee meetings
3.   Additional monitoring of POC logs in each area may include a random quality review by the designated Clinic Manager, comparing results documented in log to results documented in EHR.

F.  Quality Assurance Activity Reporting Process
1.   POC testing program monitoring, education and training, individual processor performance measures, and corrective action plans are reported quarterly to the Medical Director and the SHC Quality Management Committee.