How to keep your lab from failing inspections

ABG machines are a great device to have around, particularly in emergency situations. Yet recently the lab bosses have created new recommendations and policies for us to follow that are very inconvenient. However, as I have learned, a necessary evil.

An article in the May 10, 2010, issue of the AARC Times by John Campbell, "Preventing 'proficiency Referral' from happening to your health care organization," does a great job of detailing the importance of proper ABG and ABG machine handling in order to pass laboratory inspections to prevent mandatory lab closure.

We all have shortcuts, some of which we choose not to share for obvious reasons. One shortcut of many RTs in my department is we do so few ABGs that we rarely placed a sticker with the patient's name on them. We also rarely heeded the yellow warning lights on the ABG machine that warned that the equipment must be checked before further ABGs can be reported by the machine.

However, a recent crackdown has changed our behavior. The new policy is as follows:

• Identify patient
• proper sanitisers
• label syringe
• Check for yellow light on ABG machine
• If yellow, fix problem or run maintenance
• If question mark on ABG report throw it away.
• Run monthly control (every RT must do this once a year)

Some of those rules are common sense, although some are a pain in the arse, particularly the check the yellow light and do maintenance. You see, we used to have the ABG machine in the RT Cave, and the reason we gave it to lab was so we wouldn't have to do this anymore.
So here we are learning how to do it once again. In a way, it seems we might as well take care of it ourselves. Yet the RT Boss has decided it's best off in lab where they can do the appropriate check on it, after all, he noted, "They are the lab equipment experts."
Actually, I know of many RT departments that run their own ABG machine, and they do so just fine. So, technically speaking, there is no reason we can't do it ourselves. But, be it as it may, it's no longer our machine.
Inspections of labs are made at least once a year by MANY companies, including the Centers of Medicare and Medical Services (CMS), or some other CMS contracted agency commonly called CLIA inspection or by some other accredited agency that is deemed qualified to do these things such as the College of American Pathologies or the Joint Commission.
Once an inspection is done the hospital must not lapse, because new inspectors could arrive at anytime.
The reason for inspections are obvious: machines are expected to be accurate. Results are important for obvious reasons, and inspections -- however annoying or redundant -- are needed.
Here are some of the things inspectors look for:

• Only qualified and selected individuals handle and draw samples and run machine, etc.
• One person in charge of device responsible for making sure things are done in accordance to policies.
• ABGs are labeled properly. The inspectors are known to look in waste dispensers to make sure syringes are labeled.
• Proper documentation
• Critical values are noted and highlighted on ABG results
• A note on ABG stating that doctor or nurse was notified of critical values
• All staff rotate doing controls
• Problems immediately reported to lab director or medical director

Refusal or failure of procedure or evaluation will or MAY result in closing of the lab, which would mean we RTs would be unable to use the ABG machine. ABGs would have to be run to other hospitals and run through their ABG machine.
According to Campbell, "CMS gives 5 days notice to offending labs that its CLIA certificate is being revoked. This notice will hold that the proficiency referral was intentional even if, in fact, it was not. This notice can come by mail or even face, and the 5 day period also includes weekends."
Campbell notes there is an appeals process, yet CMS usually wins. Likewise, lab closings are reported to local newspapers, which can provide a bad image to the hospital. He notes monetary costs can be staggering, from $500,000 to a million in legal fees, decreased credibility and image, decrease confidence in your facility, and inability to run labs at your hospital.
So, however annoying, follow the ABG policy set at your hospital.