Status of point-of-care testing: promise, realities, and possibilities

Microelectrical sensors as emerging platforms for protein biomarker detection in point-of-care diagnostics

Current methods used to measure protein expression on microarrays, such as labeled fluorescent imaging, are not well suited for real-time, diagnostic measurements at the point of care. Studies have shown that microelectrical sensors utilizing silica nanowire, impedimetric, surface acoustic wave, magnetic nanoparticle and microantenna technologies have the potential to impact disease diagnosis by offering sensing characteristics that rival conventional sensing techniques. Their ability to transduce protein binding events into electrical signals may prove essential for the development of next-generation point-of-care devices for molecular diagnostics, where they could be easily integrated with microarray, microfluidic and telemetry technologies. However, common limitations associated with the microelectrical sensors, including problems with sensor fabrication and sensitivity, must first be resolved. This review describes governing technical concepts and provides examples demonstrating the use of various microelectrical sensors in the diagnosis of disease via protein biomarkers.

Point‐of‐care testing has a limited effect on time to clinical decision in primary health care

OBJECTIVE

To investigate the clinical logistics of laboratory routines at primary health care centres (PHCs).

DESIGN AND METHODS

Prospective registration was carried out for each PHC using questionnaires during 2-week intervals between the end of November 2001 and mid-January 2002. The study included 9 PHCs in the county of Ostergötland and 4 in the county of Jönköping, Sweden, with different numbers of blood tests analysed using point-of-care testing (POCT). Data for B-glucose, HbA1c, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), thyroid-stimulating hormone (TSH), T4, cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides were collected. Main outcome measures were median time from sampling to available test result (TATa) and median time from sampling to clinical decision (TATd), and the proportion of patients informed of the outcome of the blood test in question during the sampling occasion.

RESULTS

A total of 3542 samples were collected. The median TATa showed that B-glucose, ESR and CRP were immediately analysed at all 13 PHCs. For the other tests, TATa varied from immediately to about two days. The median TATd varied from immediately to about a week. When POCT was used, 30% of the patients were informed about the outcome of the test during the sampling occasion.

CONCLUSION

POCT has a limited effect on the clinical logistics in PHCs.

Fast laboratory test results alone cannot deliver the benefits of near patient testing: a follow-up study after 3 years of extended laboratory service at a primary health care centre

OBJECTIVES

Technological development has progressed towards point-of-care testing (POCT) at primary health care centres (PHCs). However, to our knowledge, there has been no extensive evaluation of the effects on patient and clinical logistics when an extended laboratory service (ELS) is offered.

METHODS

Questionnaires were used to evaluate patient logistics before the introduction of ELS and after 6 months, as the proportion of consultations completed within one visit. That is, the patient is sampled, the test result is made available, and the patient is informed of the clinical decision. After 3 years of ELS, clinical logistics were followed up using questionnaires and by measuring turnaround time (TAT) from sampling to available test result (TATa) and from sampling to a clinical decision (TATd), and the proportion of laboratory test results reported back to the patient on the day of sampling (TATi).

RESULTS

After 6 months of ELS, the theoretical proportion of consultations which could be completed within 1 day had increased from 20% to 68%, while the proportion of patients desiring this situation had increased from 72% to 85%. After 3 years of ELS, the TATi was 56%. However, the majority of these tests were from the menu available before ELS. While 66% of patients wished to receive the laboratory test results at the consultation, this was achieved in 42% of cases. Patients below 65 years of age were more anxious than older patients to complete the consultation within a single PHC visit.

CONCLUSIONS

The clinical logistics concerning TATi did not correspond to the patients' wishes. When the consultation was completed within 1 day, the majority of the laboratory analyses were from the menu available before ELS. An ELS alone cannot deliver all the desired benefits of POCT.

Point-of-care testing of proteins

Point-of-care testing (POCT) is a fast developing area in clinical diagnostics that is considered to be one of the main driving forces for the future in vitro diagnostic market. POCT means decentralized testing at the site of patient care. The most important POCT devices are handheld blood glucose sensors. In some of these sensors, after the application of less than 1 microl whole blood, the results are displayed in less than 10 s. For protein determination, the most commonly used devices are based on lateral flow technology. Although these devices are convenient to use, the results are often only qualitative or semiquantitative. The review will illuminate some of the current methods employed in POCT for proteins and will discuss the outlook for techniques (e.g., electrochemical immunosensors) that could have a great impact on future POCT of proteins.

Quality and timeliness in medical laboratory testing

In terms of testing, modern laboratory medicine can be divided into centralized testing in central laboratories and point-of-care testing (POCT). Centralized laboratory medicine offers high-quality results, as guaranteed by the use of quality management programs and the excellence of the staff. POCT is performed by clinical staff, and so such testing has moved back closer to the patient. POCT has the advantage of shortening the turnaround time, which potentially benefits the patient. However, the clinical laboratory testing expertise of clinical staff is limited. Consequently, when deciding which components of laboratory testing must be conducted in central laboratories and which components as POCT (in relation to quality and timeliness), it will be medical necessity, medical utility, technological capabilities and costs that will have to be ascertained. Provided adequate quality can be guaranteed, POCT is preferable, considering its timeliness, when testing vital parameters. It is also preferred when the central laboratory cannot guarantee the delivery of results of short turn-around-time (STAT) markers within 60 or (even better) 30 min. POCT should not replace centralized medical laboratory testing in general, but it should be used in cases where positive effects on patient care have been clearly demonstrated.

Microalbuminuria Measured by three Different Methods, Blood Pressure and Cardiovascular Risk Factors in Elderly Swedish Males

Microalbuminuria is associated with hypertension and is a strong risk factor for subsequent chronic disease, both renal and coronary heart disease (CHD), Presently there are several methods available for measurement of microalbuminuria. The aim of this study was to evaluate if the three different methods gave similar information or if one of the assays were superior to the others. Blood pressure, inflammatory markers and cardiovascular mortality and morbidity were correlated with urine albumin analysed with a point-of-care testing (POCT) instrument, nephelometric determination of albumin and albumin/creatinine ratio in elderly males. The study population consisted of 103 diabetic and 603 nondiabetic males (age 77 years) in a cross-sectional study. We analyzed urine albumin with a HemoCue® Urine Albumin POCT instrument and a ProSpec® nephelometer and albumin/creatinine ratio. There were strong correlations between both systolic and diastolic blood pressure and all three urine albumin methods (p < 0.0001). There were also significant correlations between the different urine albumin measurements and serum amyloid A component, high-sensitivity C-reactive protein and interleukin-6. The three different urine albumin methods studied provided similar information in relation to cardiovascular disease. There was a strong correlation between systolic and diastolic blood pressure and microalbuminuria in both the whole study population and in nondiabetic males emphasizing the role of hypertension in glomerular damage. The good correlation between the studied urine albumin measurements show that all three methods can be used for monitoring urine albumin excretion.

Detection of proteins and bacteria using an array of feedback capacitance sensors

An integrated array of micron-dimension capacitors, originally developed for biometric applications (fingerprint identification), was engineered for detection of biological agents such as proteins and bacteria. This device consists of an array of 93,184 (256 x 364) individual capacitor-based sensing elements located underneath a thin (0.8 microm) layer of glass. This glass layer can be functionalized with organosilane-based monolayers to provide groups amenable for the immobilization of bioreceptors such as antibodies, enzymes, peptides, aptamers, and nucleotides. Upon functionalization with antibodies and in conjunction with signal amplification schemes that result in perturbation of the dielectric constant around the captured antigens, this system can be used as a detector of biological agents. Two signal amplification schemes were tested in this work: one consisted of 4 microm diameter latex immunobeads and a second one was based on colloidal gold catalyzed reduction of silver. These signal amplification approaches were demonstrated and show that this system is capable of specific detection of bacteria (Escherichia coli) and proteins (ovalbumin). The present work shows proof-of-principle demonstration that a simple fingerprint detector based on feedback capacitance measurements can be implemented as a biosensor. The approach presented could be easily expanded to simultaneously test for a large number of analytes and multiple samples given that this device has a large number of detectors. The device and required instrumentation is highly portable and does not require expensive and bulky instrumentation because it relies purely on electronic detection.

Reliability of point-of-care hematocrit, blood gas, electrolyte, lactate and glucose measurement during cardiopulmonary bypass

BACKGROUND

Recently, the GEM Premier blood gas analyser was upgraded to the GEM Premier 3000. In addition to pH, pCO2, pO2, Na+, K+, Ca2+, and hematocrit measurement, glucose and lactate can be measured on the GEM Premier 3000. In this prospective clinical study, the analytical performance of the GEM Premier 3000 was compared with the Ciba Corning 865 analyser for blood gas/electrolytes/metabolites, and for hematocrit with the Sysmex XE 2100 instrument.

METHODS

During a 6-month period, 127 blood samples were analysed on both the GEM Premier 3000 analyser and our laboratory analysers (Ciba Corning 865/Sysmex 2100 instrument), and compared using the agreement analysis for quantitative data.

RESULTS

With the exception of K+, the other parameters (pCO2, pO2, Na+, Ca2+, hematocrit, glucose, and lactate) can be described in terms of the mean and standard deviation of the differences. For K+ measurement, a clear linear trend (r=0.79, p<0.001) in the deviation of the GEM Premier 3000 from the Ciba Corning was noticed, ie, in the lower or upper K+ reference range, the GEM Premier 3000 measured systematically too low or too high, respectively. Furthermore, in comparison with the other parameters, a therapeutically unacceptable systematic difference (mean of difference: -2.2%, p=0.05) in hematocrit measurement on the GEM Premier 3000 was observed for hematocrit values below 30%. The variance of the readings for the GEM Premier 3000 measurements was at clinically acceptable levels.

CONCLUSION

The GEM Premier 3000 analyser seems to be suitable for point-of-care testing of electrolytes, metabolites, and blood gases during cardiopulmonary bypass. However, its downward bias in hematocrit values below 30% suggests that using the GEM Premier 3000 as a transfusion trigger leads to overtreatment with packed red cells.

Point-of-Care Testing and Cardiac Biomarkers: The Standard of Care and Vision for Chest Pain Centers

Point-of-care testing (POCT) is defined as testing at or near the site of patient care. POCTdecreases therapeutic turnaround time (TTAT), increases clinical efficiency, and improves medical and economic outcomes. TTAT represents the time from test ordering to patient treatment. POC technologies have become ubiquitous in the United States, and, therefore,so has the potential for speed, convenience, and satisfaction, strong advantages for physicians, nurses, and patients in chest pain centers. POCT is applied most beneficially through the collaborative teamwork of clinicians and laboratorians who use integrative strategies, performance maps, clinical algorithms, and care paths (critical pathways). For example, clinical investigators have shown that on-site integration of testing for cardiac injury markers (myoglobin, creatinine kinase myocardial band [CKMB],and cardiac troponin I [cTnI]) in accelerated diagnostic algorithms produces effective screening, less hospitalization, and substantial savings. Chest pain centers, which now total over 150 accredited in the United States, incorporate similar types of protocol-driven performance enhancements. This optimization allows chest pain centers to improve patient evaluation, treatment, survival, and discharge. This article focuses on cardiac biomarker POCT for chest pain centers and emergency medicine.

Point-of-care immunotesting: Approaching the analytical performance of central laboratory methods

The use of point-of-care (POC) immunoassays has increased significantly and the menu of analytes continues to expand. Most of the rapid immunoassays are currently based on simple manual assay devices such as the immunochromatographic, agglutination, and immunofiltration assays. Although automated readers have recently been introduced at an increasing pace, the major benefit of these genuinely hand-portable assay devices is that they do not usually necessitate instrumentation but can be performed anywhere. Significant advances in assay and detection technologies have, however, recently facilitated the introduction of truly quantitative, sophisticated immunoassay methods to POC settings as well, with the analytical performance characteristics approaching those of conventional laboratory assays. Furthermore, innovative assay technologies such as those based on immunosensors have been introduced to POC testing (POCT) without ever being employed in clinical laboratories. However, further simplification of the assay procedures and analyzers is still feasible, and strong efforts are directed towards the development of miniaturized and simple, yet sensitive and quantitative, novel assay technologies to keep up with the increasing expectations set on future POC immunotesting.

Reduction in red blood cell transfusions using a bedside analyzer in extremely low birth weight infants

BACKGROUND

Preterm infants typically experience heavy phlebotomy losses from frequent laboratory testing in the first few weeks of life. This results in anemia, requiring red blood cell (RBC) transfusions. We recently introduced a bedside point-of-care (POC) blood gas analyzer (iSTAT, Princeton, NJ) that requires a smaller volume of blood to replace conventional Radiometer blood gas and electrolyte analysis used by our neonatal intensive care unit (NICU). The smaller volume of blood required for sampling (100 vs 300-500 microl), provided an opportunity to assess if a decrease in phlebotomy loss occurred and, if so, to determine if this resulted in decreased transfusions administered to extremely low birth weight (ELBW) infants.

OBJECTIVE

We hypothesized that the use of the POC iSTAT analyzer that measures pH, PCO(2), PO(2), hemoglobin, hematocrit, serum sodium, serum potassium and ionized calcium would result in a significant decrease in the number and volume of RBC transfusions in the first 2 weeks of life.

DESIGN/METHODS

A retrospective chart review was conducted of all inborn premature infants with birth weights less than 1000 g admitted to the NICU that survived for 2 weeks of age during two separate 1-year periods. Blood gas analysis was performed by conventional laboratory methods during the first period (designated Pre-POC testing) and by the iSTAT POC device during the second period (designated post-POC testing). Data collected for individual infants included the number of RBC transfusions, volume of RBCs transfused, and the number and kind of blood testing done. There was no effort to change either the RBC transfusion criteria applied or blood testing practices.

RESULTS

The mean (+/-SD) number of RBC transfusions administered in the first 2 weeks after birth was 5.7+/-3.74 (n=46) in the pre-POC testing period to 3.1+/-2.07 (n=34) in the post-POC testing period (p<0.001), a 46% reduction. The mean volume of RBC transfusions decreased by 43% with use of the POC analyzer, that is, from 78.4+/-51.6 ml/kg in the pre-POC testing group to 44.4+/-32.9 ml/kg in the Post-POC testing group (p<0.002). There was no difference between the two periods in the total number of laboratory blood tests done.

CONCLUSIONS

Use of a bedside blood gas analyzer is associated with clinically important reductions in RBC transfusions in the ELBW infant during the first two weeks of life.

Challenges of implementing Point-of-Care Testing (POCT) glucose meters in a pediatric acute care setting

OBJECTIVES

To investigate factors contributing to analytical bias in POCT glucose values generated by the NICU versus the core laboratory.

METHODS

The LifeScan Flexx hospital system glucose meters (SureStep) were used in precision and comparison studies between the NICU and laboratory (ABL715 and Vitros 950).

RESULTS

Analysis of 40 neonatal blood samples revealed a positive bias between the NICU glucose meters versus either the laboratory glucose meter or instrument (mean difference of 0.28 and 0.21 mmol/L, respectively). Linear regression analysis (R2 = 0.0584) of the difference in glucose results versus time elapsed between measurements indicated that the bias observed between the NICU and laboratory glucose meters was not due to in vitro glycolysis for samples transported on ice. Further analysis indicated that the bias appeared to be mostly operator driven, with different NICU operators exhibiting different mean biases. Increasing the amount of blood applied to the SureStep Pro test strip (e.g., 60 vs. 20 microL), led to higher values for glucose concentration for the same blood. Nearly 50% of all glucose values reported for the NICU were obtained by the SureStep Flexx glucose meters in a 3-month period following the introduction of POCT, yet the number of laboratory-reported glucose results for the same period increased by 21% as compared to the previous year.

CONCLUSIONS

Operator error appears to be a source of bias present between the NICU and laboratory, and despite glucose meter utilization in the NICU, the number of glucose measurements by the central laboratory increased after POCT introduction.

Point-of-care testing: an introduction

OBJECTIVE

To review available literature and provide perspective on point-of-care testing, focusing on the impact it has on treatment outcomes in patient care, the impact it has on the costs of patient care, and the role it has in the delivery of pharmaceutical care.

DATA SOURCES

Information was retrieved from MEDLINE English literature searches using PubMed (1965-August 2003) and included search terms of point-of-care testing, near patient testing, pharmaceutical care, pharmacists, outcomes, and economics. Additionally, references from retrieved articles were reviewed to identify literature not detected by literature searches.

STUDY SELECTION AND DATA EXTRACTION

Comparative studies, demonstration project reports, and systematic reviews were selected. Other related resources, such as government documents, relevant legislation, and government regulations, were included. Emphasis was placed on comparative studies and demonstration project reports. In the absence of these data, other resources were included.

DATA SYNTHESIS

Point-of-care testing devices and technology are increasingly used in the delivery of care and therapeutic decision making. No studies have evaluated the impact of point-of-care testing, by itself, on patient care and outcomes. All studies have incorporated point-of-care testing with changes in the way patient care is delivered and have shown significant improvements when this approach is taken. The cost of point-of-care testing is greater than traditional laboratory testing, but the increased cost may be offset by improvements in the management of patient care, improvements in patient outcomes, and decreased utilization of the healthcare system. Point-of-care testing has been used successfully by pharmacists in disease management programs. Various government regulations and legislation impact the use of point-of-care testing.

CONCLUSIONS

Limited data indicate that point-of-care testing, when combined with changes in healthcare delivery systems, may improve patient outcomes and decrease the overall cost of health care. Pharmacists have used point-of-care testing in programs designed to improve patient care but must carefully consider regulations and laws that govern the use of these devices. There is a great need for additional investigation into the use of point-of-care testing in patient care.

Comparison of point-of-care-testing glucose meters with standard laboratory measurement of the 50g-glucose-challenge test (GCT) during pregnancy

OBJECTIVES

Although glucose meters are well-established instruments for self-monitoring blood glucose levels, diagnostic and screening procedures should be performed using standard laboratory methods. In addition to standard laboratory methods, HemoCue is authorized for screening and diagnostic purposes in Germany. The rapid development of other glucose meters makes it necessary to re-evaluate this recommendation. Our objective was to test the usefulness of glucose meters in screening pregnant patients for gestational diabetes.

METHODS

The 50-g glucose challenge test was administered to one hundred and ninety-three pregnant patients whose blood glucose levels were then simultaneously measured with five portable meters and the HemoCue. The results were compared to our standard method (Hexokinase). A cut-off of 7.8 mmol/L was used and sensitivity, specificity, accuracy, the Youden index, and the Kappa index were calculated. The tests were performed by well-trained personnel (C.D. and U.S.).

RESULTS

1212 measurements were performed on 193 patients. All glucose meters showed a very good correlation (r > 0.90). None of the measurements showed an extreme deviation necessitating the error grid analysis. The GlucoTouch (5.93% +/- 7.4) and the HemoCue (-9.04% +/- 5.9) showed a mean deviation greater than 5%. None of the meters had a mean deviation greater than 10%. The accuracy fluctuated between 0.85 and 0.94. The Kappa index was between 66 to 85. In our clinical trial, the Accu-Chek, Glucotouch, OneTouch, and Precision demonstrated greater accuracy and a higher Kappa index than the HemoCue.

CONCLUSIONS

Our data showed good concordance in statistical and clinical parameters for most of the six glucose meters. The HemoCue, recommended as a standard method in several countries, did not show better concordance than most of the tested glucose meters. When used by well-trained personnel, the accuracy of the Accu-Chek, Glucotouch, One-Touch, and Precision was acceptable for use in gestational diabetes screening.

Separation high voltage field driven on-chip amperometric detection in capillary electrophoresis

A new potentiostatless detection scheme for amperometric detection in capillary electrophoresis is presented based on the use of microband array electrodes positioned in the capillary electrophoresis electric field. In the present study, the spatial potential difference in the CE separation high-voltage field was measured using two gold microband electrodes positioned in the proximity of the capillary outlet. The induced potential difference between the two electrodes was recorded as a function of the applied separation high voltage and the dependence of the electrochemically generated current on the high-voltage field, and the concentration of a redox couple (Fe(CN)6(4-)/Fe(CN)6(3-)) was investigated. The results show that plots of the generated current versus the CE separation voltage have the same shape as cyclic voltammograms obtained with the same electrodes in a traditional potentiostatic setup and that the current is proportional to the concentration of the redox couple. As a decoupling device is not needed, the described potentiostatless approach significantly simplifies the instrumental setup for amperometric detection. This approach consequently holds great promise for application in inexpensive portable chip-based CE devices.

Deviceless decoupled electrochemical detection of catecholamines in capillary electrophoresis using gold microband array electrodes

Samples containing microM concentrations of dopamine, (+/-)-isoproterenol, para-aminophenol and chlorogenic acid have been separated by capillary electrophoresis (CE) and detected using end-column amperometric detection based on a novel decoupling method. The present decoupling approach involves the use of an electrochemical detector chip containing an array of microband electrodes where the working and reference electrodes are positioned only 10 microm from each other. The short distance between the working and reference electrodes ensures that both electrodes are very similarly affected by the presence of the CE electric field. With this method, no shift in the detection potential was seen when the CE high voltage was applied. This eliminated the need for a reoptimization of the detection potential to compensate for the influence of the separation voltage on the detection. It is also demonstrated that catecholamines can be detected using gold microband electrodes by careful adjustment of the detection potential to avoid the formation of gold oxide. Such careful adjustments of the detection potential are straightforward using the present decoupling method.

An evaluation of three glucose meter systems and their performance in relation to criteria of acceptability for neonatal specimens

BACKGROUND

Prior to making a selection for our hospital, a pediatric institution, we deemed it necessary to evaluate, concurrently, three recently available glucose meter systems, claimed to be suitable for use with neonatal samples.

METHODS

Comparisons were with laboratory plasma analyses. Linearity and precision were also determined.

RESULTS

All meters gave linear responses. Precision determined using quality control material was acceptable. For an in-laboratory side-by-side evaluation, meter 1 showed a small bias but significant result scatter while meter 3 showed a negative bias; mean differences from reference (S.D.) were: -0.30 mmol/l (0.56), 0.06 mmol/l (0.39) and -0.49 mmol/l (0.35) for meters 1, 2 and 3, respectively. Clinical unit testing results gave mean differences from reference (S.D.) of: -0.19 mmol/l (0.56), 0.06 mmol/l (0.48) and -0.12 mmol/l (0.48) for meters 1, 2 and 3, respectively. Using +/- 15% of reference as acceptability thresholds, 61%, 79% and 72% of results for meters 1, 2 and 3 respectively, were within limits. At +/- 20%, the corresponding figures were 81%, 90% and 91%, respectively. All meters showed a sample-hematocrit effect with either negative (meters 1 and 3) or positive (meter 2) bias.

CONCLUSIONS

Regardless of the performance criteria chosen, meter 1 had the worst performance while meter 2 was slightly better in overall than meter 3. Based on performance, general characteristics and user feedback, meter 2 was selected by us. In light of our results, we nonetheless suggest that performance of the meters tested is less than ideal, especially in the context of clinical utility in neonates.

Point-of-care versus laboratory monitoring of patients receiving different anticoagulant therapies

STUDY OBJECTIVE

To compare point-of-care and standard hospital laboratory assays for monitoring patients receiving single or combination anticoagulant regimens.

DESIGN

Prospective analysis.

SETTING

Nursing units and clinics at a large, community hospital.

PATIENTS

One hundred fifty patients receiving anticoagulants for cardiac, vascular, orthopedic, or cancer indications. Thirty patients were enrolled into each treatment group: warfarin, enoxaparin, heparin, warfarin plus enoxaparin, and warfarin plus heparin.

INTERVENTION

Capillary and venous blood samples were collected once in each patient for simultaneous measurement of international normalized ratio (INR) and activated partial thromboplastin time (aPTT) by both assays.

MEASUREMENTS AND MAIN RESULTS

Mean differences in paired INR and paired aPTT by point-of-care and standard assays were small, but 95% confidence intervals were wide. The INR differences were greater for the warfarin plus heparin group than for the warfarin group or warfarin plus enoxaparin group; clinical decision agreement was 47% for warfarin plus heparin, 73% for warfarin, and 93% for warfarin plus enoxaparin. The aPTT difference was greater for the warfarin plus heparin than for the heparin group; however, clinical decision agreement, 67% and 70%, respectively, was similar.

CONCLUSIONS

Point-of-care methods showed limited agreement with standard hospital laboratory assays of coagulation for all treatment groups. For INR values, significantly greater disagreement was noted between the assay methods for the warfarin plus heparin group compared with the warfarin group, but the agreement was similar for the warfarin and warfarin plus enoxaparin groups. Our data indicate that the point-of-care assays should not be considered interchangeable with standard laboratory assays.

Blood analysis at the point of care: issues in application for use in critically ill patients

Major changes in the healthcare environment have increasingly forced hospitals to reconsider their operative structures to maintain cost competitiveness. These changes have included restructuring and numerous hospital mergers, and they have forced hospitals to examine ways to improve operational efficiency. Nowhere in the hospital is this truer than in the critical care areas, where costs are highest, and one of the places where process improvements can be made is in the laboratory analysis. Data indicate that laboratory analysis comprises about 43% of the data used by critical care clinicians to make clinical decisions. The more quickly these data can be provided to the clinicians, the more likely they are to have an impact on the patient's care.Point-of-care testing (POCT) in critical care is one way of simplifying the laboratory analysis process so that laboratory data are more readily available to clinicians. A close collaborative relationship with the clinical laboratory can allow a robust POCT to be implemented in critical care that meets the needs of both the clinical laboratory and the critical care areas. When implemented appropriately, a POCT program in critical care can provide rapid and accurate test results, can be fairly simple to maintain, and can be cost effective. However, successful implementation requires a new set of skills for critical care nurses including knowledge of the laboratory regulatory issues, a commitment to training, recertification, and a quality improvement program related specifically to POCT. Several studies have shown that laboratory turnaround time can be reduced through the implementation of a POCT program. However, at this writing, no studies have linked this decrease in turnaround time to improved patient outcomes, although there are some data to support a decrease in iatrogenic blood loss with the use of POCT. Although the use of POCT in critical care has some distinct benefits, clearly, outcome studies need to be conducted to assess the true impact of POCT on the care of patients who are critically ill.

Cost analysis of a neonatal point-of-care monitor

A hypothetical model using a base case and sensitivity analyses compared averted and incurred costs of in-line monitoring with neonatal intensive care unit satellite laboratory testing. Data were obtained retrospectively for 1 year from 50 consecutive critically ill premature neonates weighing less than 1,000 g at birth whose blood tests were performed in-line and processed at the satellite laboratory. Averted costs included phlebotomies, satellite blood testing, and transfusions; incurred costs included in-line monitor rental, nursing time, and daily monitor validation. In-line monitoring led to cost savings of $324 per neonate and a benefit/cost ratio (BCR) of 1.23 in our base case. Sensitivity and scenario analyses addressed uncertainty and led to a BCR variation of 0.41 to 2.48. Compared with satellite laboratory testing, in-line monitoring of critically ill neonates may generate cost savings through reduced laboratory analysis expense, less phlebotomy loss, and fewer blood transfusions for hospitals with high laboratory cost structures. Because most cost savings result from offsetting indirect costs (eg, building space and hospital overhead) that are of a longer term nature, short-run cost savings are less likely to be realized.