Download Patient Data Evaluation and Recommendations

Equipment
Application and
Cleanliness
Perform Quality Control Procedures
The quality of care you provide depends in part on
the proper performance of the equipment you use to
diagnose or treat your patients
• Quality control (QC) is a process designed to ensure
that the devices you use on patients regularly
perform as expected
o Ensures consistently accurate measurements with diagnostic equipment
o Ensures proper device function and patient safety with therapeutic
equipment
NBRC Expectations
You are familiar with the basics of QC, as
applied to common medical devices
used in respiratory care
Laboratory Blood Gas and
Hemoximery Analyzers
• Quality control processes focus on eliminating errors
in:
o Sample collection (pre-analytical phase)
o Sample measurement (post-analytical phase)
o Reporting (post analytical phase)
Pre-Analytical Phase
• Blood collection and handling procedures prior to sample
analysis
• Most common pre-analytical errors that affect measurements
are:
o
o
o
o
Air contamination
Venous admixture
Excess anticoagulant
Continued blood metabolism
o
o
o
Be proficient in sampling techniques/equipment used to draw from various sites
Strictly comply with applicable infection control procedures
Avoid interpretation errors by documenting
• FiO2
• Oxygen delivery device
• Mode of ventilation
• Results of related assessments made at time of sampling
• Need to
• Always ensure that the blood sample is free of these common
errors.
Analytical Phase
• Involves four key elements
o Analyzer calibration and calibration verification
• Calibration is the process whereby the response of an instrument is
compared and adjusted to a known standard
• Standards used to calibrate ABG machines include precision gases
and buffer solutions with know values for pH, PCO2, and PO2
• Standards used to calibrate hemoximeters are solutions with known
values for total Hb, HbO2, carboxyhemoglobin (COHb), and
methemoglobin (MetHb)
• Calibration involves adjusting the analyzer to ensure that its response
is accurate and linear
o Two-point calibration adjusts both the offset (zero point) and gain
(slope) of the instrument.
• Devices with automated calibration require calibration verification by
analyzing a pre-prepared control media with known measurement
values.
Analytical Phase (cont.)
o Actual sample testing
• Always performed by individuals who meet specific competency
requirements for the procedures
• Sample testing must follow protocol aligned with manufacturer
operation specifications
• When performing the analysis you must
o Confirm that the specimen was properly labeled and stored prior
to analysis
o Assess the sample for any obvious pre-analytical errors (air
bubbles or clots
o Confirm that the applicable analyzer calibration procedures
were completed prior to analysis
o Analyze the sample within an acceptable period of time
o Ensure that the sample is properly aspirated / injected into
analyzer
Analytical Phase (cont.)
o Interpretation of the results
• Test should always be interpreted by the ordering physician and must
consider rationale for the measurement and the related patient
information / situation
• Alert or panic values should be pre-established for notification and
follow-up
o Ongoing review of quality control and proficiency testing results
• Must record and continuously monitor data using accepted statistical
methods
o Commonly plotted on a Levy-Jennings chart where control
media analyses over multiple measurements are compared to
the mean and standard deviation for the control media
o Frequent measurements (errors) outside the standard deviation
indicate an instrument that is “out of control”
• Problem identification, appropriate corrective action, and
confirmation of analyzer accuracy is required.
Point of Care Analyzers
• All POCT must be auditable (traceable to patient
tested, instrument operator, date and time of test,
and instrument and process used)
• Most POCT analyzers use self-contained cartridges
for calibration.
o Failure to calibrate stops machine from functioning
• First, rerun with new cartridge
• Second, remove from service if still unable to calibrate
• Most facilities require POCT results to be compared
to results from a calibrated bench-top analyzer as
part of QC program
Pulmonary Function
Equipment
• Quality assurance program makes certain PFT data
is accurate and reproducible
• Must include:
o Proper technician training and review
o Accurate spirometry equipment
• Confirm absolute volume and flow values
• Check volume and flow linearity
• Assess system leakage
• Validate time measurements
o Daily spirometer checks
Pulmonary Function
Equipment, cont.
o Individual maneuver validity checks
• Accurate data depends on
o Proper instruction and coaching of the patient
o Recognition and correction of errors due to poor or incorrect
patient performance
• Obtain at least 3 error–free maneuvers that meet basic acceptability
standards, free of:
o A slow or false start to the maneuver
o Coughing during the maneuver
o Breathing during the maneuver
o Variable effort
o Exhalation time less than 6 seconds
• Ensure reproducibility of results by confirming that the two largest
values for both the FVC and FEV1 are within 0.150L of each other
o Monthly spirometer quality reports
o Documentation of equipment maintenance
Mechanical Ventilators
• Operation verification via power-on self test (POST)
and extended self-test (EST)
• POST
o Tests microprocessor function
o Zeros the sensors
o Performs some basic checks related to patient functions, such as leak
tests.
o Always confirm successful POST before applying ventilator to patient and
whenever circuit is changed
• EST
o POST + series of more comprehensive function checks
o Perform between each application of a ventilator on different patients
o Should be fully documented in writing
• A fail in any portion of a self-test requires removal
from service for repair
Oxygen Analyzers
• Four steps for calibration
o Expose the sensor to a contained source of 100% O2 (in a plastic bag or
glove)
o After the reading stabilizes, adjust the analyzer to 100%
o Remove the sensor from the 100% O2 source
o After restabilization confirm a reading of 21%
• Calibration should occur under same conditions
under which measurement will occur (temperature,
atmospheric pressure, humidity)
Pulse Oximeters
• Operational verification procedure
o
o
o
o
Connect the device to a normal person
Compare the pulse reading with the actual pulse measured manually
Check and confirm an SpO2 reading of 97-100%
Confirm loss of signal detection by removing the device
Common Errors to Avoid
on the Exam
• Never aspirate an arterial blood gas sample or mix it if it
contains air bubbles
• Do not use any gas analyzer that is not or cannot be
calibrated at two points in the range of expected results
• Do not use any pH / blood gas analyzer for reporting
results if the most recent quality control results violate
any of the rules for acceptable performance
• Never proceed with pulmonary function testing if the
spirometer has an uncorrected leak
• Never apply a ventilator to a patient if it has failed its
operational verification testing
• Never circumvent medical gas connection safety
systems (PISS, DISS)
Exam Sure Bets
• Always perform a two-point calibration prior to
using a gas analyzer or monitor
• Always use tonometry whenever the accuracy of a
blood gas analyzer’s PO2 and PCO2 measurements
is in doubt
• Always document the patient’s FiO2, oxygen
delivery device, mode of ventilation, and the results
of any related assessments made when obtaining a
blood sample for analysis
• Always perform leak testing on spirometers before
volume calibration
More Exam Sure Bets
• Always perform an operational verification test
prior to using a mechanical ventilator on any
patient
• Always include a statement about test quality
in the final report of every pulmonary function
test
• When establishing quality assurance programs,
an assessment of the competency of the
technician(s) must be performed initially and
periodically thereafter.
Reference:
Certified Respiratory Therapist Exam Review Guide, Craig
Scanlon, Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers