Implementation of a Self-Audit Tool Improves Regulatory Compliance for Point-of-Care Respiratory Virus Testing in the Emergency Department

Abstract

Background: Point-of-care testing in the emergency department decreases wait times and supports evidence-based patient care. However, hurdles to successful implementation include management of interdisciplinary work flows and establishment of an effective quality control program. As COVID-19 testing is now integrated into screening protocols in emergency and urgent care settings, hospital systems must maintain flexible and adaptable respiratory virus testing to adapt to regional trends in transmission. In response to this challenge, our hospital system established a point-of-care respiratory virus laboratory within the emergency department to test for COVID, influenza A/B, and respiratory syncytial virus (RSV). However, maintaining regulatory compliance and standardized protocols within such a dynamic environment became challenging.

Methods: We launched a quality improvement initiative to support improved performance and efficiency in the point-of-care laboratory with a focus on regulatory benchmarks. Following a period of observation and discussion with key stakeholders in the emergency department and pathology, an audit tool was developed and to be deployed in collaboration with ED nursing. Utilizing the new tool, ED nursing would perform audits in parallel to audits performed by point-of-care staff.

Results: Prior to the intervention, the average audit score was approximately 55%; 6 months following the intervention, audit scores have remained stable at approximately 80%, representing a significant improvement in regulatory compliance.

Conclusions: Creation of a regulatory tool enabled real-time cross-departmental monitoring of regulatory compliance. These findings underscore the importance of developing transparent interdisciplinary work flows and effective communication to improve patient care.