Room Temp monitoring

Do inspectors look at room temp monitoring of POCT tests (example: glucose meter strips and controls). I want to know what others at large and small institutions are doing to achieve this. Thanks!

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If there is a temperature range listed on the product you must monitor it.  We installed temperature monitors everywhere, mostly through our HVAC system.

Hi Milan,

I am in charge of 37 units throughout the hospital and yes I work this alone. I do weekly checks mostly every week there might be a week I don't get a chance to other issues that pop up, besides checking the labeling I am also in charge of monitoring temps that the reagents are stored in along with any POTT QC logs that are on that floor. I break my units up by two days. There are few units I might not visit every week because I know week in and week out they are consistent.

I will attach two different forms: the first form is what I use for my weekly inspection. I have three marking grades A= I checked both temp and reagent labeling B= Temp only ( I was having issues with some units being monitored every day so if I am by the floor or on the unit for other reasons I will pop in to check takes 15 seconds and the final marking is C= Non Glucose checking ( all other POTT that is not Glucometers). Then I have my comments line which I used to take notes which floor is not compliant what the issue is.

The second form is my monthly audit. I created an aligorethm that helps compute my scores: I grade three sections each section is a 1 that is the highest score: section 1 Low level qc does it have a date and intials, section 2 High level QC does it have dates and intials and section 3 are my strips does it have date and intials. Each week that I check I note if compliant if not then I mark the check box in my weekly with a comment: I would say no date on level 1 or no date on strips. Then at the end of the month I take how many times in the month they were not compliant for example: CICU = perfect score then they are 100%, MRICU say they had two weeks out of 4 with no dates then I give them 0.5 points out of 1. I take what is wrong and divided it by number of weeks. When I plug in the numbers excel program does my calculations.

I do this monthly along with my temperatures and the qc logs.

if  you need anything or want to discuss more feel free to contact me.

 

Joseph Rudic BSMT
Point of Care Coordinator
Temple University Hospital
Lab: 215-707-7175 or 2-7175
Cell: 267-990-1796
Joseph.rudic@tuhs.temple.edu

Past experience is that they are only concerned about the temps of the stored reagents….not the vial of strips and controls with each meter case.  In-use reagents in my institution are not temp monitored and has been OK with CAP. 

 

Tracy




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We have an automated system and monitor the supply storage areas.



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TJC asked about temp monitoring and I have either high/low temp monitors that I check each month or you can request HVAC or facilities if they have temp monitoring and as long as it stays within the reagent range you are ok.

you may need to ask HVAC/facilities if they temp monitor where your reagents are stored at room temp.

We recently got cited for this in our TJC inspection. At the suggestion of our surveyor we edited our policy to say that a 30 day supply of strips and controls were exempt from temperature monitoring, per our medical director. As POCC I audit the supplies in clean utility rooms each month to ensure supply levels stay below a 30 day supply. This was scored as corrected on site.

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