Point-of-care testing: a critical review

How to Realize the Benefits of Point-of-Care Testing at the General Practice: A Comparison of Four High-Income Countries

BACKGROUND

In some countries, such as the Netherlands and Norway, point-of-care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders (also referred to as value networks). The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations.

METHODS

The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country.

RESULTS

The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for general practitioners (GPs) aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support.

CONCLUSION

Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible.

Point-of-care testing in primary care: A systematic review on implementation aspects addressed in test evaluations

OBJECTIVES

There are numerous point-of-care tests (POCTs) available on the market, but many of these are not used. This study reviewed literature pertaining to the evaluation/usage of POCTs in primary care, to investigate whether outcomes being reported reflect aspects previously demonstrated to be important for general practitioners (GPs) in the decision to implement a POCT in practice.

METHODS

Scopus and Medline were searched to identify studies that evaluated a POCT in primary care. We identified abstracts and full-texts consisting of applied studies (eg trials, simulations, observational studies) and qualitative studies (eg interviews, surveys). Data were extracted from the included studies, such as the type of study, the extent to which manufacturers were involved in the study, and the biomarker/assay measured by the test(s). Studies were evaluated to summarise the extent to which they reported on, amongst others, clinical utility, user-friendliness, turnaround-time and technical performance (aspects previously identified as important).

RESULTS

The initial search resulted in 1398 publications, of which 125 met the inclusion criteria. From these studies, 83 POCTs across several disease areas (including cardiovascular disease, venous thromboembolism and respiratory-tract-infections) were identified. There was an inconsistency between what is reported in the studies and what GPs consider important. GPs perceive clinical utility as the most important aspect, yet this was rarely included explicitly in test evaluations in the literature, with only 8% of evaluations incorporating it in their analysis/discussion.

CONCLUSIONS

This review showed that, despite the growing market and development of new POCTs, studies evaluating such tests fail to report on aspects that GPs find important. To ensure that an evaluation of a POCT is useful to primary care clinicians, future evaluations should not only focus on the technical performance aspects of a test, but also report on the aspects relating to the clinical utility and risks.

Evaluation of the bedside Quikread go® CRP test in the management of febrile infants at the emergency department

Recently C-reactive protein (CRP) point-of-care tests have been developed. We aimed to validate a bedside CRP test (QuikRead go® CRP), to compare it with the laboratory CRP (ARCHITECT c8000 Abbott, Germany) test in children with fever without source (FWS), and to evaluate the optimal CRP cut-off value to identify those patients at a high risk for serious bacterial infection (SBI). The CRP bedside test was prospectively performed in capillary blood samples concurrently with the laboratory CRP testing for 283 well-appearing infants aged 1 to 24 months with FWS attending the emergency department (ED) between May 2013 and August 2015. The mean difference between the laboratory CRP and the QuikRead go CRP values was 0.71 mg/L (p = 0.444). Pearson's correlation coefficient between the CRPs was r = 0.929 (p < 0.001). SBI was diagnosed in 34 patients (12.0%). The area under the receiver operating characteristics (ROC) curve obtained was 0.87 (95%CI: 0.82-0.90) for an optimal CRP cut-off value of > 10 mg/L (sensitivity: 94.1%, specificity: 49.0%, positive predictive value: 20.1%, negative predictive value: 98.4%), as a predictor of SBI. Nearly 45% of the patients were at a low risk for SBI according to CRP value; thus, additional laboratory tests would have been hypothetically avoided. There was a very strong, positive correlation between the QuikRead go CRP test and laboratory CRP determination. The QuikRead go CRP test provides reliable results to rule out SBI. Its implementation at the ED would improve the management of infants with FWS.

Measurement of activated coagulation time in children: evaluation of the blood-saving kaolin i-STAT activated coagulation time technique in pediatric cardiac anesthesia

OBJECTIVE

To compare the activated coagulation times (ACTs) measured with the blood-saving kaolin i-STAT 1 ACT technique (Abbott Point of Care Inc, Princeton, NJ) with ACTs obtained from the widely used ACTR II device (Medtronic, Inc, Minneapolis, MN) in children undergoing cardiac surgery.

DESIGN

A prospective, observational single-center study.

PARTICIPANTS

Forty-four pediatric cardiac surgery patients.

INTERVENTION

Surgery was performed with cardiopulmonary bypass (CPB) necessitating heparinization.

METHODS AND MAIN RESULTS

ACTs measured on the i-STAT 1 device (2 × 95 μL) were compared with those obtained from the Medtronic ACTR II device (2 × 0.5 mL). Blood samples were drawn before, during, and after heparinization for CPB and paired for statistical analysis. The 2 techniques were compared using simple and multiregression analyses and the Bland-Altman method. In total, 179 intrarater and 142 interrater data pairs were analyzed. The intrarater reliability of the 2 devices was good, with a mean bias and limits of agreement of +2.0 and -55.5/+59.5 seconds for the Medtronic ACTR II and +0.5 and -59.9/+60.9 seconds for the i-STAT 1. An interrater reliability analysis of the mean of simultaneously measured ACT of the Medtronic ACTR II and both i-STAT 1 devices yielded a mean bias of -5.3 seconds and limits of agreement of -210.1/+199.5 seconds. A comparison of the higher of the paired ACT values from both devices showed similar results. After the removal of heparin, the i-STAT 1's ACT values became significantly lower than those measured on the Medtronic ACTR II (p < 0.001). Simple and multiregression analyses revealed that base excess independently influenced the mean bias of the ACT values from the Medtronic ACTR II (p = 0.037) and i-STAT 1 devices (p = 0.036).

CONCLUSION

The kaolin i-STAT 1 ACT technique agreed well with the Medtronic ACTR II technique during the nonheparinized phase that preceded CPB. The overall agreement between the ACT obtained from the 2 devices was poor. The routine use of i-STAT 1 measured ACT values cannot be recommended as a reliable alternative to the Medtronic ACTR II.

Validity of the quick-read C-reactive protein test in the prediction of bacterial pneumonia in the pediatric emergency department

BACKGROUND

C-reactive protein (CRP) values are clinically useful in differentiating viral from bacterial illnesses in children, but the regular test is impractical in the emergency department (ED) setting.

OBJECTIVE

To investigate the validity and feasibility of the 2-min bedside Quick Read (QR)-CRP test in the prediction of bacterial pneumonia in children in the ED.

METHODS

Fifty randomly selected children aged 4 days to 17 years, who presented to a pediatric ED with symptoms and signs of pneumonia over a 6-month period, were prospectively studied. The diagnosis of bacterial/viral pneumonia was based on clinical and radiological findings. CRP was measured in leftover blood (0.2 ml) using the QR-CRP kit. Clinical and laboratory data were statistically analyzed against CRP values for ability to predict bacterial pneumonia.

RESULTS

Thirty-six patients (72%) were diagnosed with bacterial pneumonia and 14 (28%) with viral pneumonia; mean CRP levels were 121.3+/-122 and 27.2+/-26 mg/l, respectively (P=0.007). Significantly higher CRP levels were associated with bacterial than with viral pneumonia in the patients who presented before 96 h of symptom onset (P=0.013-0.028), but not in those who presented later. On receiver operating characteristics analysis, CRP was a better indicator of a chest radiograph picture of bacterial pneumonia (area under the curve=0.79) than absolute neutrophil count (0.78) or white blood cell count (0.73). Combining all three parameters yielded an area of 0.865.

CONCLUSION

The QR-CRP test seems to be an useful predictor of bacterial pneumonia in children, especially those with a shorter illness duration, and is feasible for use in the ED.

The quick-read C-reactive protein test for the prediction of bacterial gastroenteritis in the pediatric emergency department

OBJECTIVE

To determine the clinical usefulness of the bedside Quick-Read (QR) C-reactive protein (CRP) test for predicting bacterial gastroenteritis in the pediatric emergency department.

STUDY DESIGN

We tested for CRP in 44 children who presented to the emergency department with gastroenteritis and underwent blood tests and stool culture. C-reactive protein was measured in leftover blood or serum (0.2 mL) using the immunoturbidimetric QR-CRP test kit. Background and outcome data were collected from the files. Pearson correlation, analysis of variance, and logistic regression were used to determine the diagnostic ability of CRP.

RESULTS

Stool culture was positive for bacteria in 8 patients. High CRP levels correlated with a greater likelihood of a positive culture; the area under the receiver operating characteristics curve was 0.9427. The CRP values of 95 mg/L or higher had a sensitivity of 87% and a specificity of 91.7% for predicting culture-confirmed bacterial gastroenteritis.

CONCLUSIONS

The QR-CRP test seems to be a useful predictor of bacterial gastroenteritis in children. It is amenable for use in the emergency department, making it a promising tool for infection control and for aiding physicians in decisions regarding antibiotic treatment. The CRP levels of 95 mg/L or higher during the first 48 hours are suggestive of bacterial disease.

Point-of-care antithrombotic monitoring in children

INTRODUCTION

The use of oral anticoagulant therapy is increasing in children. Managing anticoagulant therapy in children presents unique challenges, including poor venous access. The advent of point-of-care (POC) monitoring of anticoagulant therapy offers a potential solution to this challenge. This paper reviews the published literature relating to POC monitoring of oral anticoagulant therapy in children.

MATERIALS AND METHODS

A Medline search was conducted and identified key publications. Papers were reviewed with respect to their objectives, populations and POC device investigated. Study limitations were identified.

RESULTS

Five publications and one abstract were identified, reporting studies using five different POC monitors. Three studies had a strong clinical management focus. Outcome measures assessed included target therapeutic range achievement and frequency of adverse events. Correlation between POC and laboratory-based results ranged from 0.83 to 0.96. Home monitoring and self-management using POC monitors were both reported to be preferred compared to standard laboratory testing.

CONCLUSIONS

POC monitoring of oral anticoagulant therapy in children offers considerable advantages. The reviewed literature would suggest such monitoring can be performed accurately and reliably. The impact of quality control issues, such as calibration of thromboplastin ISI in POC devices, has not been explored in a paediatric population. Further studies are needed to clarify such issues and confirm the safety, reliability and efficacy of POC monitoring of oral anticoagulant therapy in children, including its home monitoring and self-management programs.

Point of care pregnancy testing provides staff satisfaction but does not change ED length of stay

Point of care testing (POCT) is widely viewed as possibly improving ED care and reducing length of stay (LOS). However reports are mixed, and regulatory barriers complicate considerations. We studied a simple urine pregnancy assay (human chorionic gonadotropin-HCG). LOS was evaluated when HCG was moved from central lab (HCGLab) to POCT (HCGED) in 2 pre-post 3-month periods (958 HCGLab and 1075 HCGED). HCG patients were compared with a similar control group, and staff perceptions were evaluated. There was no change in LOS for HCG patients (36.8 v 50.85 min, P = .33), although there was one marginal finding of improved LOS for patients presenting with abdominal pain diagnosed as pregnant (P = .17). Staff (28/53 physicians, 18/81 nurses) reported HCGED as positive. POCT does not improve LOS for broad groups of patients, although POCT does change the ED environment. Further study is needed to evaluate how the information flow of POCT changes patient care.

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.