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REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

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REMOTE HEALTH ATLAS i-STAT® 1 ANALYSERS

1. General Information

The i-STAT® Analyser is a portable medical device used for point-of-care (POC) pathology testing for a range of chemistry tests including electrolytes, urea, creatinine, blood gases, PT/INR and Troponin I. The i-STAT® Analyser is designed to operate as a networked system allowing the electronic downloading of client and Quality Control (QC) results from the device and the uploading of software to the device. Point-of-care testing (POCT) provides many advantages including prompt pathology results that aid in determining appropriate on-site clinical management of the client and hence potentially better outcomes. Results obtained using the i-STAT compare favourably in accuracy and precision to formal laboratory results when a trained operator performs the POC test and quality testing procedures are rigorously followed. On a cost per use basis, iSTAT is well placed against equivalent tests provided by formal laboratories. Despite obvious advantages, there remains a need to restrict the use of the i-STAT® Analyser due to potential cost pressures and the requirements involved in assuring quality. While relative costs of individual tests are favourable, they are currently not claimable through Medicare (with the exception of haemoglobin testing) and hence every test performed using an i-STAT® Analyser becomes a direct cost to the RHB. For this reason, criteria for the authorised use of i-STAT cartridges have been developed. Outside of these criteria, routine channels for laboratory pathology testing should still be utilised despite the presence of an i-STAT® Analyser. Although the i-STAT® Analyser is relatively easy to operate there are potential risks to this valuable equipment, and the quality of results, if misused. This, coupled with the need to appreciate the quality management and supply issues surrounding the use of the analysers, dictates that staff must be appropriately trained and certified as a Qualified i-STAT Operator, before using the equipment. Use by staff that are not certified by the RHB as Qualified iSTAT Operators, is not authorised. The i-STAT® Analyser is not standard equipment in remote health centres. An original purchase of i-STAT® Analysers in Central Australian sites was made possible following a Commonwealth funding initiative in 2005. Subsequently a number of other i-STAT® Analysers have been procured in other CA and TE health centres. There are approximately 30 analysers in the DoH Remote Health network. POCT conducted on RHB i-STAT® Analysers is managed through a partnership agreement between the Northern Territory Department of Health (DoH) and the Community Point-ofCare Services (CPS) unit within the Flinders University Rural Clinical School. When selecting sites for the placement of equipment, RHB has considered the placement of other POC equipment, access to general laboratory services, transportation difficulties and the health service requirements of the community. Information in this document includes: When to Perform a Test How to Perform a Test Point of Care Testing (POCT) Training and Competency Quality Management Technical and Other Support Information

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 1 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

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Medicare Claiming Ordering Consumables Storage of Cartridges and Quality Controls Documentation Maintenance / Cleaning / Location

2.

Definitions

Central Data Station (CDS): a specific i-STAT database located at the Flinders CPS unit, capable of electronically capturing patient data and results of QC testing, as well as performing other management functions for the Departmental i-STAT fleet. Downloader: a desktop electronic IT device capable of facilitating transmission of data between the i-STAT® Analyser and a CDS, via the Internet. Some downloader's have a recharger function. Electronic Simulator: a device used to perform an external QC check on the analyser's electronic signal-reading function. i-STAT Cartridge: a small, single use, disposable pathology test kit, to which a small sample of blood is added. Qualified i-STAT Operator: Clinical staff who have successfully completed training provided by Finders CPS unit or `self directed' training supervised by POCT Resource Staff and the Flinders CPS unit, who hold a current POCT Certificate. There are two levels of training provided ­ `basic' and `full'. For information about POCT Training see Section 4.3. POCT Resource Staff: Clinical staff who have successfully completed primary training provided by Flinders CPS unit and hold a current POCT Competency Certificate, who have demonstrated advanced competency skills for client and quality testing, who participate in regular `skill update' sessions provided by the Flinders CPS unit, and who are able to provide training support to others. POCT Resource Staff may be in support positions such as Public Health Nurse, Nursing Coordinators or PPNs or `on-site' (current Qualified i-STAT Operator working at a remote health centre). Flinders Community Point-of-Care Services Unit: a specialist POCT provider, with experience in the delivery of POCT services to rural and remote health services around Australia. NT POCT Management Committee: the management committee, comprising representatives of the DoH, Flinders CPS unit and other stakeholder groups, responsible for the overseeing the NT POCT Program for i-STAT and DCA 2000+ Analysers.

3.

3.1 3.2

Responsibilities

Clinical Staff (i-STAT sites) Undertake training and achieve competency in the use of the i-STAT® Analyser Qualified i-STAT Operator (Basic and Full)

Basic training qualifies Operators to: Perform POCT within clinical criteria guidelines Maintain the security of your unique Operator ID Number Ensure Medicare Benefit claiming following i-STAT POC haemoglobin testing Full training further qualifies Operators to: Perform routine quality management processes for POCT 3.3 Point of Care Testing (POCT) Resource Staff Undertake Full Training and achieve competency in the use of the i-STAT® Analyser and quality management processes

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 2 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

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3.4 3.5 3.6 3.7

Maintain POCT competency and current Certificate Provide training support for Qualified i-STAT Operators at participating health centres Identify operator, device, technical or supply issues at participating health centres and report these back to the PPN or Flinders CPS unit Primary Health Care Manager (PHCM) Ensure that POCT is performed by Qualified i-STAT Operators only Ensure maintenance, data downloads and software updates are completed by the Qualified i-STAT Operator as recommended Ensure Qualified i-STAT Operators adhere to Medicare claiming processes Manage POCT stock levels and storage Ensure the POC Essential Checks Forms and QC Result Sheets are located in the POC Quality Assurance Folder Ensure all i-STAT operators are aware of the location and purpose of the POC Quality Assurance Folder Perform / delegate POCT quality management tasks to relevant Qualified i-STAT Operators Evaluate and take action to correct issues identified through QA activities In conjunction with the PPN, identify an on-site POCT Resource person Coordinate POCT training for clinical staff with visits by mobile POCT Resource Staff, when required Professional Practice Nurse (PPN) Maintain asset inventory data base of i-STAT POCT equipment Maintain appropriate levels of consumable stock Manage the distribution of stock orders to health centres Conduct training and competency assessment for clinical staff as required Arrange distribution of POC Quality Assurance Package to each health centre Provide telephone support to Qualified i-STAT Operators / POCT Resource Staff as required Provide technical support where appropriate Coordinate repairs, maintenance and software updates (where necessary) Medical Practitioner Knowledge of POCT clinical criteria guidelines Provide clinical direction for the interpreting and actioning of POCT results, where needed Participate in i-STAT Operator training Optimise Medicare Benefit claiming for POCT Flinders University - Community Point-of-Care Services Unit (CPS Unit) Provide i-STAT training for groups as determined by the NT POCT Management Committee Determine training program content and resources Conduct competency assessment of i-STAT Operators Maintain a Competency Register of Qualified i-STAT Operators and POCT Resource Staff (including their unique Operator ID number) Provide advanced or `skill update' training sessions for POCT Resource Staff where possible Co-ordinate and manage a Quality Management program for the i-STAT Provide telephone support hotline for remote health centres from 9am to 5pm weekdays Maintain a Device Asset Register for all i-STATs in use in the NT Manage the Central Data Station network for the i-STAT devices Collect and analyse data for research purposes subject to direction of Management Committee Organise and participate in meetings of the NT POCT Management Committee

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 3 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

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Prepare monthly reports to the NT POCT Management Committee

A Flow Chart (intranet) summarises the responsibilities and relationships of the above stakeholders.

4.

4.1

Procedure

When to Perform a Test

Use of the i-STAT analyser is restricted to qualified i-STAT Operators only. Due to the operational cost of POCT to Remote Health, discriminate use of the i-STAT is essential. In this light, criteria for use have been established, and will directly or indirectly involve authority from a Medical Practitioner. i-STAT tests are used for the assessment and management of both chronic and acute clinical conditions. Where i-STAT analysers are available they are to be prioritised for use before other testing equipment; particularly the Roche CoaguChek® XS and Troponin T Sensitive Test Procedures (intranet). Criteria for use of each cartridge type are: CARTRIDGE

Chem8+

measures Na, K+, Cl, ionized Ca, total CO2, Urea, Creat, Hct; calculates Hb and anion gap

CRITERIA

- restricted to use in a clinical scenario where the immediate results will significantly affect the clinical outcome on the day. - the creatinine test on the Chem8+ cartridge (with resultant calculation of eGFR) may be used in the management of a client with established diabetes and / or renal disease. - restricted to use in clients on anti-coagulation therapy at intervals determined by a Medical Practitioner - restricted to use within the Acute Coronary Syndromes protocol per the Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM), in consultation with a Medical Practitioner - authorisation for their use is given by the Medical Practitioner - use will be for monitoring acid-base status / respiratory response - venous whole blood samples must be used for testing

PT/INR Cardiac Troponin I (cTnI)

Blood Gas (CG4)

4.2

How to Perform a Test

Observe Standard Precautions when performing a test. There are different cartridges for different tests. All the cartridge types share similar features and the test procedure for performing any test on the i-STAT is essentially similar. Qualified i-STAT Operators are required to enter their unique Operator ID number when preparing the i-STAT to perform a test. As i-STAT use is restricted to Qualified i-STAT Operators, so too is the Operator ID number ­ this number is only for use by the person it is assigned to. To perform a POC test on the i-STAT, refer to the poster How to Perform a Patient Test on the i-STAT 300 (intranet) for a quick step-by-step guide. See also Point-of-Care Training Manual. 4.3 Point of Care Testing (POCT) Training and Competency The use of i-STAT analysers is restricted to appropriately trained staff. Having only competent staff performing POCT is an important feature of ensuring the reliability of results obtained from these devices. In work units with i-STAT® Analysers, it is recommended that all clinical staff become qualified i-STAT Operators. To be recognised as a qualified i-STAT Operator, an individual must undertake training and complete a competency assessment process (required every two years to maintain competency).

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 4 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

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Training can be undertaken to attain two levels of competency, basic and full: - Basic Training equips an operator to perform tests in a safe manner and allows a clinician to gain the benefit of autonomous use of the i-STAT® Analyser during clinical scenarios. - Full Training provides additional competency with aspects of managing the i-STAT analyser quality program at the health centre level. Training can be undertaken via two avenues. While attending a Primary Training session is generally the preferred option, it is usually not logistically possible to channel all prospective users through this method. Therefore a Self Directed option is more commonly used by Remote Health Branch. Primary Training

Training Mode (Full Training) Face to face training / workshop provided by the Flinders CPS unit. Staff successfully completing this training option will be deemed to have received Full Training.

Note: Notification regarding training workshops will be distributed to relevant health centres.

Self Directed Learning

(Basic or Full Training options) Self directed learning using of a set of training resources enabling a choice of Basic or Full Training provided by the Flinders CPS unit. This is supported by POCT Resource staff. As it is not always possible to readily attend Primary Training, utilisation of the self directed learning package is the preferred option to promptly prepare for competency assessment.

Resources

Instruction is provided using: - PowerPoint presentation - Training Manual - Training Posters - i-STAT Analyser, Simulator, Downloader, Cartridges and QCs

Facilitated by Flinders CPS unit and other qualified trainers during the training session

- Training manual - Training DVD (includes a live practical

demonstration of how to how to conduct POCT for client and quality testing)

- Training Posters - i-STAT Analyser, Simulator, Downloader,

Cartridges and QCs

Facilitated by POCT Resource staff (PPN and other qualified trainers)

Assessment

1. Complete the Training and Competency Checklist (as applicable for Full or Basic Training) 2. Written competency assessment (for Full OR Basic Training) 3. Practical competency assessment comprising: - Simulator test - 2 x QC tests for Full Training (obtaining the correct results), OR - 1 x client test (using a QC sample if required) for Basic Training Competency Certificate If both written and practical assessments are acceptable, Flinders CPS Unit will issue a Competency Certificate on the day / forward to staff for the self directed learning option (and an individual Operator ID will be assigned).

Note: Should the trainee fail either step of the competency process, any shortfalls in knowledge will be addressed by further instruction and reassessment.

4.3.1

POCT Resource Staff

POCT Resource Staff are those who: - have successfully completed the Full Training option - hold a current POCT Competency Certificate - have demonstrated advanced competency skills for client and quality testing - participate in regular client and/or quality testing. In particular, POCT Resource Staff contribute to providing training support for aspiring and qualified i-STAT operators at participating health centres.

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 5 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

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POCT Resource Staff include a number of staff that are well placed to provide this support role during visits to health centres (some Public Health Nurses, Nursing Coordinators and PPNs). Also, where possible, a suitable health centre staff member may take on this role and provide assistance in locally overseeing the use of i-STAT and facilitating competency assessments of new staff. Potentially these locally based staff may assist on a regional basis. POCT Resource Staff are able to access training resources and written competency assessment forms from the PPN. A Flow Chart summarises the POCT Training and Competency processes. 4.4 Quality Management An essential part of conducting routine POCT is the regular monitoring or `checking' of the precision and accuracy of the analyser. Quality procedures are integral components of the quality management system and include: - Weekly Checks - Quality Control Checks (intranet) - Software Updates Performing these quality procedures is critical; without them there can be no assurance that results generated by POCT devices are sufficiently accurate for client care. Quality procedures are also an important component of maintaining a high level of i-STAT Operator competency. Quality procedures may only be performed by a Qualified i-STAT Operator. Once the procedures are completed both the Point-of-Care Essential Checks Form and the appropriate QC Result Sheet is to be signed and returned as instructed on the form. 4.4.1 Weekly Checks i-STAT Weekly Checks involve the following: - stock levels and expiry dates - battery check - i-STAT data download - an Electronic Simulator Test (intranet) A completed weekly check should be signed off on the Point of Care Essential Checks Form. 4.4.2 Quality Control (QC) Checks QC checks on the i-STAT involve the testing of an artificial sample (mainly liquid or dried blood made up with a liquid solution in the case of INR) that is produced by the manufacturer. This sample has an assigned, or `target' value, for each POC test being measured, and limits for acceptable performance around that target are set by the CPS unit (consistent with those used in laboratories). The results of QC testing can be compared to the assigned values and limits for acceptable performance and an immediate assessment made of the quality of the device's performance. If QC results are outside acceptable limits, then patient testing should stop until the reason for poor performance has been rectified through consultation with the Flinders CPS unit. QC Checks are required for each type of cartridge used with the i-STAT analyser. The frequency and timing of the QC check varies according to the cartridge type: i-STAT Quality Control Check Timetable

Fortnightly Monthly Chem8 (Level 1 - first fortnight of month / Level 3 ­ second fortnight of the month) Tn1 Level 2 / PT/INR Level 2 / CG4 Level 1

For information on how to perform a QC Check please refer to either the i-STAT Poster (intranet) for a quick reference step by step guide or the Point-of-Care Training Manual.

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 6 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

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Results of QC testing must be recorded onto the colour-coded QC Result Sheets provided. If the QC result falls within the `green zone' on the result sheet, the device is deemed to be performing to an acceptable analytical standard. If the result falls in the `orange zone', then the device is generally performing well. The QC result is acceptable but the Flinders CPS unit will monitor results carefully and contact the health centre as required. If the QC result falls within the `red zone', use of the analyser for client testing must stop. The health centre is required to contact the Flinders CPS Unit for direction. Refer to the QC Action Sheet (intranet), which summarises the interpretation of QC Results. 4.4.3

®

Software Update

The i-STAT Analyser requires regular software updates every 6 months. If an update is not performed, then the unit will cease to function until the update occurs. Software updates can be performed in several ways. In most instances, the software update will be conducted in the health centre by following some simple instructions issued by the Flinders Remote IT Support Unit, and involves placing the i-STAT® Analyser in the downloader at the appropriate time. Health centres with satellite IT connections may experience slower connection speeds, thus requiring an alternative process. For example emailing software packages & instructions to the health centre or transferring software analyser-to-analyser. Alternatively, sending the i-STAT® Analyser to the CA / TE PPN. For instructions on performing software updates please see the Point-of-Care Training Manual. Technical support to perform software updates is also available, see below. 4.5 Technical and Other Support Information If the test fails, the i-STAT® Analyser will show an error code. Information on the i-STAT Common Error Codes provides a description of the error and suggests actions which may resolve the issue. If the issue cannot be resolved, a telephone support service is available for assistance. Contact details are provided on the Information Sheet ­ Key Contacts for Support Services. 4.6 Medicare Claiming A Medicare rebate is claimable for a haemoglobin measurement using the i-STAT Chem8+ cartridge (Medical Benefit Schedule item number 73802). In addition, if the patient is the holder of a Commonwealth concession card the incentive item number 74991 may also be claimed. See: Point of Care Pathology ­ Overview, Medicare Benefit Claiming and Medicare Items Provided by RANs & AHWs. 4.7 Ordering Consumables Testing Cartridges, QCs and batteries can be ordered using the Point of Care Consumable Order Form and faxed to the PPN (number on form).

Note: Stock levels should be kept to a minimum to avoid wastage. When receiving new stock it should be placed behind existing / older stock so that stock at the front of the refrigerator shelf is the oldest stock and therefore used first. If it is identified that stock may not be used prior to the expiry date, notify the PPN as it may be appropriate to move stock to another location. Expired stock should be clearly marked as expired and returned to the PPN for training purposes.

4.8

Storage of Cartridges and Quality Controls

Cartridges and QCs are to be kept refrigerated at 2 ­ 8º C until product expiry date. Troponin I Cardiac Marker QC Level 2 is the exception, which must be stored frozen. Remote Health has approved that i-STAT cartridges and QCs are stored in the vaccine fridge. During transportation they should be packed in the same way as vaccines (with an ice brick and cold chain monitor in an esky). If adequate refrigeration is unable to be maintained, cartridges should then be stored at room temperature (18 - 30º C). However, when stored at room temperature, cartridges are only

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 7 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

®

stable for 14 days and should be discarded thereafter. If cartridges have been at room temperature and remain unused, they should be labelled with a handwritten new expiry date, and not returned to the fridge. These cartridges must be used prior to accessing a new cartridge. Reminder: Cartridges are only stable for 14 days. 4.9 Documentation 4.9.1 Results

All test results must be transcribed into the client's medical record. In PCIS, results must be entered into the record using dedicated service items. See PCIS User Reference Guide Recording of i-STAT results for details. It is hoped that the ability to download i-STAT results directly from the CDS to PCIS will become available in the future. For paper-based medical records see Medical Record Standards.

Note: Although thermal printers are available for use with i-STAT® Analysers, RHB does not support their use due to the printed image fading over time. While results must be transcribed in the first instance, each analyser has the capacity to store 5000+ records so future checking or retrieval of results may be accessed from the analyser. Additionally the CDS could be interrogated to ascertain results.

4.9.2

Quality Management

All POC QC Forms are available in the POC Quality Assurance Folder. The Quality & Safety Team distributes the POC Essential Checks Forms and the QC Result Sheets incrementally at intervals aligned with the distribution of new lot numbers of control solution. These should be placed in the POC Quality Assurance Folder arranged by month when received at the health centre and the PHCM must ensure that: POC QA Records Responsibilities

POC Essential Checks - complete the form by the end of the month in which it is due - send to the PPN (either by scan and e-mail, fax or internal mail) during the first week of the next month - mark the health centre copy as `sent' (either with a `faxed' stamp or hand written) - re-file the health centre copy in the POC Quality Assurance folder by month for ease of reference - on receipt of new forms for the next year, the completed forms are removed from the folder and discarded QC Result Sheet - record results for each QC Check on the appropriate QC Result Sheet (and POC Essential Checks form) - when recording a QC Check ensure that the `Lot Number' on the control solution and QC Result Sheet match - each time a QC test is performed the QC Result Sheet should be completed and faxed to the Flinders CPS Unit. The fax number is provided on the QC Result Sheet form.

4.10

Maintenance / Cleaning / Location

On-site maintenance is minimal. Essentially the weekly check of the i-STAT constitutes adequate maintenance. The downloader should be connected to an active network port and preferably the analyser routinely placed in the downloader when not in use. If the analyser becomes soiled, it should be wiped with a slightly damp soft cloth, using mild general-purpose detergent / warm water. Avoid using excessive fluid. The analyser must be stored in a dust-free location in an air-conditioned room in the health centre within a 16 - 30°C temperature range. Outside of this temperature range the analyser will disable client and quality testing capabilities. Transport of the analyser for off-site use

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006 Page 8 Reviewed: Dec 09, Sept 11,

Next Review: September 2014

REMOTE HEALTH ATLAS ­ Section 11: QUALITY ASSURANCE

i-STAT 1 ANALYSERS

®

should utilise a dedicated bag, taking care to prevent the device being subject to temperature extremes. (Transport of cartridges requires maintenance of the cold chain).

5.

Forms

Point of Care Consumable Order Form POC Essential Checks Form i-STAT Quality Control Result Sheet - Chem8+, distributed by the PPN i-STAT Quality Control Sheet - PT / Cardiac Marker / Blood Gas, distributed by the PPN

6.

References and Supporting Documents

Medicare Items Provided by RANs & AHWs Point of Care Pathology - Overview Quality Assurance Folder - Overview Standard Precautions

Related Atlas Items: CoaguChek® XS Cold Chain Essential Checks Medicare Benefit Claiming

Information Sheet - Key Contacts for Support Services Information Sheet - Troponin T Sensitive Test Procedures (intranet) PCIS User Reference Guide - Recording of i-STAT results i-STAT Posters (intranet) ­ Prepared by Community Point-of-Care Services Unit, Flinders University Rural

Clinical School. © 2010.

Electronic Simulator Test on the i-STAT How to Perform a Patient Test on the i-STAT How to Perform Quality Checks on the i-STAT

Other Patient Tests on the i-STAT Other QC Tests on the i_STAT

Related i-STAT Information (intranet): Flow Chart Summarising Governance Structure for the NT POCT i-Stat Network Flow Chart Summarising Process for POCT Training and Competency Assessment of POCT Operators i-STAT Common Error Codes Point of Care Tests on the i-STAT - A Quick Reference Guide - Adult Point of Care Tests on the i-STAT - Normal Paediatric Reference Guide Quality Control Action Sheet Training and Competency Checklist for i-STAT - BASIC Training and Competency Checklist for i-STAT - FULL Point-of-Care Training Manual (Each DoH Remote health centre with an i-STAT Analyser carries a

copy of this Manual. Also available from Flinders CPS)

i-STAT 1 System Manual, available from PPN Central Australian Rural Practitioners Association Standard Treatment Manual

Developed by: Quality & Safety Team & Flinders University CPS Endorsed by: Remote Executive Leadership Group Release Date: October 2006

Page 9

Reviewed: Dec 09, Sept 11,

Next Review: September 2014

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