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Kost GJ, Füzéry AK, Caratao LKR, Tinsay S, Zadran A, Ybañez AP. Using geographic rescue time contours, point-of-care strategies, and spatial care paths to prepare island communities for global warming, rising oceans, and weather disasters. Int J Health Geogr 2023; 22:38. [PMID: 38124128 PMCID: PMC10731708 DOI: 10.1186/s12942-023-00359-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVES To perform geographic contour analysis of sea and land ambulance rescue times in an archipelago subject to super typhoons; to design point-of-care testing strategies for medical emergencies and weather disasters made more intense by global warming and rising oceans; and to assess needs for prehospital testing on spatial care paths that accelerate decision making, increase efficiency, improve outcomes, and enhance standards of care in island nations. METHODS We performed needs assessments, inspected healthcare facilities, and collected ambulance rescue times from professionals in the Bantayan Archipelago, Philippines. We mapped sea/land ambulance rescue routes and time contours. To reveal gaps, we statistically compared the fastest and slowest patient rescue times from islands/islets and barangays to the District Hospital on Bantayan Island. We developed spatial care paths (the fastest routes to care) for acute myocardial infarction, community care, and infectious diseases. We generated a compendium of prehospital diagnostic testing and integrated outcomes evidence, diagnostic needs, and public health goals to recommend point-of-care strategies that build geographic health resilience. RESULTS We observed limited access to COVID-19 assays, absence of blood gas/pH testing for critical care support, and spatial gaps in land and airborne rescues that worsened during inclement weather and sea swells. Mean paired differences (slowest-fastest) in ambulance rescue times to the District Hospital for both islands and barangays were significant (P < 0.0001). Spatial care path analysis showed where point-of-care cardiac troponin testing should be implemented for expedited care of acute myocardial infarction. Geospatial strengths comprised distributed primary care that can be facilitated by point-of-care testing, logical interisland transfers for which decision making and triage could be accelerated with onboard diagnostics, and healthcare networks amenable to medical advances in prehospital testing that accelerate treatment. CONCLUSIONS Point-of-care testing should be positioned upstream close to homes and island populations that have prolonged rescue time contours. Geospatially optimized point-of-need diagnostics and distributed prehospital testing have high potential to improve outcomes. These improvements will potentially decrease disparities in mortality among archipelago versus urban dwellers, help improve island public health, and enhance resilience for increasingly adverse and frequent climate change weather disasters that impact vulnerable coastal areas. [350 words].
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Affiliation(s)
- Gerald J Kost
- Fulbright Scholar 2020-2022, ASEAN Program, Point-of-Care Testing Center for Teaching and Research (POCT•CTR), Pathology and Laboratory Medicine, School of Medicine, University of California, Davis, CA, 95616, USA.
| | - Anna K Füzéry
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Samantha Tinsay
- Municipality of Bantayan, Bantayan-Santa Fe-Madridejos Primary Care Provider Network, Cebu, Philippines
| | - Amanullah Zadran
- POCT·CTR, Public Health Sciences, School of Medicine, University of California, Davis, USA
| | - Adrian P Ybañez
- Institute for Molecular Genetics, Parasitology, and Vector-Borne Diseases, and College of Veterinary Medicine, Cebu Technological University, Cebu, Philippines
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Füzéry AK, Elian FA, Kost GJ. A review of temperature-related challenges and solutions for the Abbott i-STAT and Siemens Healthineers epoc devices. Clin Biochem 2022; 115:49-66. [PMID: 36067872 DOI: 10.1016/j.clinbiochem.2022.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/09/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022]
Abstract
The Abbott i-STAT and Siemens Healthineers epoc are commonly used in the provision of care during emergency medical services calls and other settings. Maintaining these systems within manufacturer's temperature claims in these settings poses challenges across the world. This review summarizes solutions that have been reported in the peer-reviewed literature and proposes additional strategies to further address these challenges. A literature search was performed with Clarivate's Web of Science from inception to August 3, 2022. Search terms included i-STAT, epoc, temperature, cold, hot, heat, freeze, frozen, prehospital, disaster, POCT, point of care, blood gas, helicopter, airplane, and ambulance. One author also reviewed manually every issue of the Journal of Paramedic Practice. The search identified 17 solutions for addressing temperature-related challenges with the i-STAT device, nine solutions for i-STAT cartridges, one solution for the epoc device, and one solution for the epoc test card. The majority of solutions were highly portable and consisted of widely available, inexpensive components. The solutions demonstrated only partial or entirely questionable effectiveness in achieving temperature control. The search also identified five reports on the impact of storage temperatures on cartridges and test cards. The reports suggested that these reagents may be able to withstand storage at temperatures outside of manufacturer's claims with only minimal deterioration in performance. The heterogeneity of solutions and the paucity of evidence on their effectiveness suggest that additional strategies are needed to better understand and further address temperature-related challenges with these systems. A collaborative approach and shared decision making are recommended.
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Affiliation(s)
- Anna K Füzéry
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Alberta Precision Laboratories Point of Care Testing, Edmonton, Alberta, Canada.
| | - Fahed A Elian
- Department of Medical Genetics, University of Alberta, Edmonton, Alberta, Canada
| | - Gerald J Kost
- Fulbright Scholar 2020-2022, ASEAN Program, USA; Point-of-Care Testing Center for Teaching and Research (POCT∙CTR), Department of Pathology and Laboratory Medicine, School of Medicine, University of California, Davis, CA, USA; Knowledge Optimization, Davis, CA, USA
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Pleus S, Heinemann L, Freckmann G, Nauck M, Tytko A, Kaiser P, Petersmann A. Glukosemessung in der Diabetesdiagnostik und -therapie: Laboratoriumsmedizinische Untersuchung inkl. patientennaher Sofortdiagnostik, Blutglukoseselbstmessung und kontinuierliches Glukosemonitoring. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1528-8248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungDie Glukose-„Messlandschaft“ in Deutschland deckt viele verschiedene Einsatzzwecke und -gebiete ab. Sie reicht von hochstandardisiert messenden Laboranalysesystemen mit einem großen Gesamtportfolio von Messgrößen bis hin zu einfachen Systemen für den Patientengebrauch. Aus klinischer Sicht muss die Qualität von Glukosemessungen ausreichend hoch sein, um die vorgesehenen Zwecke, also Diagnosestellung und Verlaufskontrolle, zu erfüllen.In der Heilkunde – also bei Messungen im Rahmen der Gesundheitsversorgung durch medizinisches Personal – definiert die Richtlinie der Bundesärztekammer zur Qualitätssicherung laboratoriumsmedizinischer Untersuchungen Vorgaben an die Qualitätssicherung. Es werden sowohl interne als auch externe (herstellerunabhängige) Qualitätskontrollen gefordert und mit spezifischen Vorgaben versehen. Diese Regelungen gelten demnach auch für alle Glukosemessungen in der Heilkunde, d. h. im Zentrallabor ebenso wie in der patientennahen Sofortdiagnostik.Bei dem Haupteinsatzgebiet von Glukosemessungen, der Verlaufskontrolle durch Patienten mit Diabetes im Rahmen der Blutglukoseselbstmessung, fehlen i. d. R. Kontrollen der Messqualität. Für das kontinuierliche Glukosemonitoring im interstitiellen Gewebe sind Qualitätskontrollen nach dem aktuellen technischen Stand sogar überhaupt nicht möglich. Hinzu kommt, dass eine regelmäßige herstellerunabhängige Kontrolle der Messqualität nicht vorgeschrieben ist. Ziel der Arbeit ist es, einen Überblick über die unterschiedlichen Glukosemesssysteme sowie praktische Aspekte und Probleme bei der Glukosemessung zu geben.
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Affiliation(s)
- Stefan Pleus
- n/a, Institut für Diabetes-Technologie Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Germany
| | - Lutz Heinemann
- Management, Science Consulting in Diabetes GmbH, Neuss, Germany
| | - Guido Freckmann
- n/a, Institut für Diabetes-Technologie Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Germany
| | - Matthias Nauck
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsmedizin Greifswald, Germany
- Partner Site Greifswald, DZHK, Greifswald, Germany
| | | | - Patricia Kaiser
- n/a, INSTAND Gesellschaft zur Förderung der Qualitätssicherung in medizinischen Laboratorien e.V., Düsseldorf, Germany
| | - Astrid Petersmann
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsmedizin Greifswald, Germany
- Universitätsinstitut für Klinische Chemie und Laboratoriumsmedizin, Klinikum Oldenburg AöR, Oldenburg, Germany
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Kost GJ. Geospatial Spread of Antimicrobial Resistance, Bacterial and Fungal Threats to Coronavirus Infectious Disease 2019 (COVID-19) Survival, and Point-of-Care Solutions. Arch Pathol Lab Med 2021; 145:145-167. [PMID: 32886738 DOI: 10.5858/arpa.2020-0284-ra] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT.— Point-of-care testing (POCT) is inherently spatial, that is, performed where needed, and intrinsically temporal, because it accelerates decision-making. POCT efficiency and effectiveness have the potential to facilitate antimicrobial resistance (AMR) detection, decrease risks of coinfections for critically ill patients with coronavirus infectious disease 2019 (COVID-19), and improve the cost-effectiveness of health care. OBJECTIVES.— To assess AMR identification by using POCT, describe the United States AMR Diagnostic Challenge, and improve global standards of care for infectious diseases. DATA SOURCES.— PubMed, World Wide Web, and other sources were searched for papers focusing on AMR and POCT. EndNote X9.1 (Clarivate Analytics) consolidated abstracts, URLs, and PDFs representing approximately 500 articles were assessed for relevance. Panelist insights at Tri•Con 2020 in San Francisco and finalist POC technologies competing for a US $20,000,000 AMR prize are summarized. CONCLUSIONS.— Coinfections represent high risks for COVID-19 patients. POCT potentially will help target specific pathogens, refine choices for antimicrobial drugs, and prevent excess morbidity and mortality. POC assays that identify patterns of pathogen resistance can help tell us how infected individuals spread AMR, where geospatial hotspots are located, when delays cause death, and how to deploy preventative resources. Shared AMR data "clouds" could help reduce critical care burden during pandemics and optimize therapeutic options, similar to use of antibiograms in individual hospitals. Multidisciplinary health care personnel should learn the principles and practice of POCT, so they can meet needs with rapid diagnostic testing. The stakes are high. Antimicrobial resistance is projected to cause millions of deaths annually and cumulative financial loses in the trillions by 2050.
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Affiliation(s)
- Gerald J Kost
- From Knowledge Optimization, Davis, California; and Point-of-Care Testing Center for Teaching and Research (POCT•CTR), University of California, Davis
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Füzéry AK, Kost GJ. Point-of-Care Testing Practices, Failure Modes, and Risk-Mitigation Strategies in Emergency Medical Services Programs in the Canadian Province of Alberta. Arch Pathol Lab Med 2020; 144:1352-1371. [PMID: 33106860 DOI: 10.5858/arpa.2020-0268-oa] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Emergency medical services (EMS) programs have been using point-of-care testing (POCT) for more than 20 years. However, only a handful of reports have been published in all of that time on POCT practices in field settings. OBJECTIVE.— To provide an overview of POCT practices and failure modes in 3 of Alberta's EMS programs, and to propose risk-mitigation strategies for reducing or eliminating these failure modes. DESIGN.— Details about POCT practices, failure modes, and risk-mitigation strategies were gathered through (1) conversations with personnel, (2) in-person tours of EMS bases, (3) accompaniment of EMS personnel on missions, (4) internet searches for publicly available information, and (5) a review of laboratory documents. RESULTS.— Practices were most standardized and robust in the community paramedicine program (single service provider, full laboratory oversight), and least standardized and robust in the air ambulance program (4 service providers, limited laboratory oversight). Common failure modes across all 3 programs included device inoperability due to cold weather, analytical validation procedures that failed to consider the unique challenges of EMS settings, and a lack of real-time electronic transmission of results into the health care record. CONCLUSIONS.— A provincial framework for POCT in EMS programs is desirable. Such a framework should include appropriate funding models, laboratory oversight of POCT, and relevant expertise on POCT in EMS settings. The framework should also incorporate specific guidance on quality standards that are needed to address the unique challenges of performing POCT in field settings.
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Affiliation(s)
- Anna K Füzéry
- From the Point of Care Testing Department, Alberta Precision Laboratories, Edmonton, Alberta, Canada (Füzéry).,the Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada (Füzéry)
| | - Gerald J Kost
- and the Point-of-Care Testing Center for Teaching and Research (POCT·CTR), Department of Pathology and Laboratory Medicine, School of Medicine, University of California, Davis (Kost)
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Kost GJ. Geospatial Hotspots Need Point-of-Care Strategies to Stop Highly Infectious Outbreaks. Arch Pathol Lab Med 2020; 144:1166-1190. [PMID: 32298139 DOI: 10.5858/arpa.2020-0172-ra] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Point-of-care testing (POCT), diagnostic testing at or near the site of patient care, is inherently spatial, that is, performed at points of need, and also intrinsically temporal, because it produces fast actionable results. Outbreaks generate geospatial "hotspots." POC strategies help control hotspots, detect spread, and speed treatment of highly infectious diseases. OBJECTIVES.— To stop outbreaks, accelerate detection, facilitate emergency response for epidemics, mobilize public health practitioners, enhance community resilience, and improve crisis standards of care. DATA SOURCES.— PubMed, World-Wide Web, newsprint, and others were searched until Coronavirus infectious disease-19 was declared a pandemic, the United States, a national emergency, and Europe, the epicenter. Coverage comprised interviews in Asia, email to/from Wuhan, papers, articles, chapters, documents, maps, flowcharts, schematics, and geospatial-associated concepts. EndNote X9.1 (Clarivate Analytics) consolidated literature as abstracts, ULRs, and PDFs, recovering 136 hotspot articles. More than 500 geospatial science articles were assessed for relevance to POCT. CONCLUSIONS.— POCT can interrupt spirals of dysfunction and delay by enhancing disease detection, decision-making, contagion containment, and safe spacing, thereby softening outbreak surges and diminishing risk before human, economic, and cultural losses mount. POCT results identify where infected individuals spread Coronavirus infectious disease-19, when delays cause death, and how to deploy resources. Results in national cloud databases help optimize outbreak control, mitigation, emergency response, and community resilience. The Coronavirus infectious disease-19 pandemic demonstrates unequivocally that governments must support POCT and multidisciplinary healthcare personnel must learn its principles, then adopt POC geospatial strategies, so that onsite diagnostic testing can ramp up to meet needs in times of crisis.
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Affiliation(s)
- Gerald J Kost
- From the POCT•CTR (Point-of-care Testing Center for Teaching and Research), University of California, Davis
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Soenksen LR, Martínez-Corona DA, Iñiguez de Gante S, Phabmixay PS, Marongiu Maggi MJ. Low-Cost Thermal Shield for Rapid Diagnostic Tests Using Phase Change Materials. J Med Device 2018. [DOI: 10.1115/1.4038898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The shelf life of point-of-care and rapid diagnostic tests (POC-RDTs) is commonly compromised by abrupt temperature changes during storage, transportation, and use. This situation is especially relevant in tropical regions and resource-constrained settings where cold chain may be unreliable. Here, we report the use of novel and low-cost passive thermal shield (TS) made from laminated phase change material (PCM) to reduce thermal overload in POC-RDTs. Validation of the proposed design was done through numerical simulation and testing of an octadecane shield prototype in contact with a lateral flow immunoassay. The use of our TS design provided 30–45 min delay in thermal equilibration under constant and oscillating heat load challenges resembling those of field use. The addition of a thin PCM protection layer to POC-RDTs can be a cost-effective, scalable, and reliable solution to provide additional thermal stability to these devices.
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Affiliation(s)
- Luis R. Soenksen
- Department of Mechanical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Ave, Cambridge, MA 02139 e-mail:
| | - David A. Martínez-Corona
- Department of Animal Sciences, Universitat Politecnica de Valencia Camí de Vera, s/n, València 46022, Spain e-mail:
| | - Sofía Iñiguez de Gante
- School of Design, National College of Art and Design, Ireland100 Thomas St, Merchants Quay D08, Dublin 8, Ireland e-mail:
| | - Pierre S. Phabmixay
- Department of Mechanical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Ave, Cambridge, MA 02139 e-mail:
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Gautam S, Batule BS, Kim HY, Park KS, Park HG. Smartphone-based portable wireless optical system for the detection of target analytes. Biotechnol J 2017; 12. [DOI: 10.1002/biot.201600581] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/22/2016] [Accepted: 11/30/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Shreedhar Gautam
- Department of Chemical and Biomolecular Engineering (BK 21+ program); Korea Advanced Institute of Science and Technology (KAIST); Daejeon Republic of Korea
| | - Bhagwan S Batule
- Department of Chemical and Biomolecular Engineering (BK 21+ program); Korea Advanced Institute of Science and Technology (KAIST); Daejeon Republic of Korea
| | - Hyo Yong Kim
- Department of Chemical and Biomolecular Engineering (BK 21+ program); Korea Advanced Institute of Science and Technology (KAIST); Daejeon Republic of Korea
| | - Ki Soo Park
- Department of Chemical and Biomolecular Engineering (BK 21+ program); Korea Advanced Institute of Science and Technology (KAIST); Daejeon Republic of Korea
| | - Hyun Gyu Park
- Department of Chemical and Biomolecular Engineering (BK 21+ program); Korea Advanced Institute of Science and Technology (KAIST); Daejeon Republic of Korea
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Erbach M, Freckmann G, Hinzmann R, Kulzer B, Ziegler R, Heinemann L, Schnell O. Interferences and Limitations in Blood Glucose Self-Testing: An Overview of the Current Knowledge. J Diabetes Sci Technol 2016; 10:1161-8. [PMID: 27044519 PMCID: PMC5032951 DOI: 10.1177/1932296816641433] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In general, patients with diabetes performing self-monitoring of blood glucose (SMBG) can strongly rely on the accuracy of measurement results. However, various factors such as application errors, extreme environmental conditions, extreme hematocrit values, or medication interferences may potentially falsify blood glucose readings. Incorrect blood glucose readings may lead to treatment errors, for example, incorrect insulin dosing. Therefore, the diabetes team as well as the patients should be well informed about limitations in blood glucose testing. The aim of this publication is to review the current knowledge on limitations and interferences in blood glucose testing with the perspective of their clinical relevance.
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Affiliation(s)
| | - Guido Freckmann
- Institut für Diabetes-Technologie Forschungs- und Entwicklungsgesellschaft mbH, Ulm, Germany
| | | | - Bernhard Kulzer
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
| | - Ralph Ziegler
- Diabetes Clinic for Children and Adolescents, Muenster, Germany
| | | | - Oliver Schnell
- Forschergruppe Diabetes e.V., Munich-Neuherberg, Germany
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Pratumvinit B, Charoenkoop N, Niwattisaiwong S, Kost GJ, Tientadakul P. The Effects of Temperature and Relative Humidity on Point-of-Care Glucose Measurements in Hospital Practice in a Tropical Clinical Setting. J Diabetes Sci Technol 2016; 10:1094-100. [PMID: 26908568 PMCID: PMC5032940 DOI: 10.1177/1932296816633485] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hospitals in tropical countries experience conditions that exceed manufacturer temperature and humidity limits for point-of-care (POC) glucose reagents. Our goal was to assess the effects of out-of-limits storage temperature, operating temperature, and operating humidity on POC glucose measurement reliability. METHODS Quality control measurements were performed monthly using glucose test strips stored under controlled conditions and in inpatient wards under ambient conditions. Glucose test strips were evaluated in groups organized by operating temperatures of 24-25 (group 1), 28-29 (group 2), and 33-34°C (group 3), and relative humidity (RH) of ≤70 (group A), ~80 (group B), and ~90% (group C). RESULTS Glucose results for different storage conditions were inconsistent. Measurements at higher operating temperatures had lower values with mean differences of -2.4 (P < .001) and -36.5 (P < .001) mg/dL (28-29 vs 24-25°C), and -3.6 (P < .001) and -37.4 (P < .001) mg/dL (33-34 vs 24-25°C) for low and high control levels, respectively. Measurements at higher RH had lower values with mean differences of -4.0 (P < .001) and -13.2 (P < .001) mg/dL (~80 vs ≤70% RH), and -5.8 (P < .001) and -16.6 (P < .001) mg/dL (~90 vs ≤70% RH) for low and high levels, respectively. CONCLUSIONS High temperature and high RH decreased glucose concentrations for the POC oxidase-based system we evaluated. We recommend that individual hospitals perform stress testing, then determine if maximum absolute differences, which represent highest risk for patients, are clinically significant for decision making by using error grid analysis.
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Affiliation(s)
- Busadee Pratumvinit
- Department of Clinical Pathology, Faculty of Medicine Siriraj hospital, Mahidol University, Bangkok, Thailand
| | - Nattakom Charoenkoop
- Department of Clinical Pathology, Faculty of Medicine Siriraj hospital, Mahidol University, Bangkok, Thailand
| | - Soamsiri Niwattisaiwong
- Department of Clinical Pathology, Faculty of Medicine Siriraj hospital, Mahidol University, Bangkok, Thailand
| | - Gerald J Kost
- Point-of-Care Testing Center for Teaching and Research, School of Medicine, University of California and Knowledge Optimization®, Davis, CA, USA
| | - Panutsaya Tientadakul
- Department of Clinical Pathology, Faculty of Medicine Siriraj hospital, Mahidol University, Bangkok, Thailand
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Wiencek J, Nichols J. Issues in the practical implementation of POCT: overcoming challenges. Expert Rev Mol Diagn 2016; 16:415-22. [PMID: 26783053 DOI: 10.1586/14737159.2016.1141678] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There are many challenges in implementing a successful point-of-care testing (POCT) program. When compared to traditional testing, POCT results are faster and allow for rapid patient treatment. Unfortunately, the excitement of this technology is often lost due to an assortment of practical obstacles. Implementation of POCT requires consideration of the regulatory complexity and amount of documentation to be compliant. As more tests move to the site of patient care, the number of operators that need to be trained and assessed will grow. An effective POCT program rests solely on the foundation of education and training of each operator, but assuring regular competency updates for a large number of staff can be a management issue. Discussed in this article are several of the key obstacles to implementing a POCT program including laboratory quality regulations, compliance documentation and operational management challenges.
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Affiliation(s)
- Joesph Wiencek
- a Department of Pathology, Microbiology and Immunology , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - James Nichols
- a Department of Pathology, Microbiology and Immunology , Vanderbilt University School of Medicine , Nashville , TN , USA
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Performance Evaluation of a Glucose Monitoring System for Point-of-Care Testing With the Critically Ill Patient Population—A Multicenter Study. POINT OF CARE 2015. [DOI: 10.1097/poc.0000000000000045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Louie RF, Ferguson WJ, Curtis CM, Vy JH, Kost GJ. Vulnerability of point-of-care test reagents and instruments to environmental stresses: implications for health professionals and developers. Clin Chem Lab Med 2014; 52:325-35. [PMID: 24114917 DOI: 10.1515/cclm-2013-0440] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/15/2013] [Indexed: 11/15/2022]
Abstract
Strategic integration of point-of-care (POC) diagnostic tools during crisis response can accelerate triage and improve management of victims. Timely differential diagnosis is essential wherever care is provided to rule out or rule in disease, expedite life-saving treatment, and improve utilization of limited resources. POC testing needs to be accurate in any environment in which it is used. Devices are exposed to potentially adverse storage and operating conditions, such as high/low temperature and humidity during emergencies and field rescues. Therefore, characterizing environmental conditions allows technology developers, operators, and responders to understand the broad operational requirements of test reagents, instruments, and equipment in order to improve the quality and delivery of care in complex emergencies, disasters, and austere environmental settings. This review aims to describe the effects of environmental stress on POC testing performance and its impact on decision-making, to describe how to study the effects, and to summarize ways to mitigate the effects of environmental stresses through good laboratory practice, development of robust reagents, and novel thermal packaging solutions.
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Improving Clinical Decision Making and Safety of Point-of-Care Glucose Testing in the Hospital Setting. POINT OF CARE 2014. [DOI: 10.1097/poc.0000000000000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Effects of humidity on foil and vial packaging to preserve glucose and lactate test strips for disaster readiness. Disaster Med Public Health Prep 2014; 8:51-7. [PMID: 24588956 DOI: 10.1017/dmp.2014.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Efficient emergency and disaster response is challenged by environmental conditions exceeding test reagent storage and operating specifications. We assessed the effectiveness of vial and foil packaging in preserving point-of-care (POC) glucose and lactate test strip performance in humid conditions. METHODS Glucose and lactate test strips in both packaging were exposed to mean relative humidity of 97.0 ± 1.1% in an environmental chamber for up to 168 hours. At defined time points, stressed strips were removed and tested in pairs with unstressed strips using whole blood samples spiked to glucose concentrations of 60, 100, and 250 mg/dL (n = 20 paired measurements per level). A Wilcoxon signed rank test was used to compare stressed and unstressed test strip measurements. RESULTS Stressed glucose and lactate test strip measurements differed significantly from unstressed strips, and were inconsistent between experimental trials. Median glucose paired difference was as high as 12.5 mg/dL at the high glucose test concentration. Median lactate bias was -0.2 mmol/L. Stressed strips from vial (3) and foil (7) packaging failed to produce results. CONCLUSIONS Both packaging designs appeared to protect glucose and lactate test strips for at least 1 week of high humidity stress. Documented strip failures revealed the need for improved manufacturing process.
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Dynamic Temperature and Humidity Environmental Profiles: Impact for Future Emergency and Disaster Preparedness and Response. Prehosp Disaster Med 2014; 29:4-12. [DOI: 10.1017/s1049023x13009199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractIntroductionDuring disasters and complex emergencies, environmental conditions can adversely affect the performance of point-of-care (POC) testing. Knowledge of these conditions can help device developers and operators understand the significance of temperature and humidity limits necessary for use of POC devices. First responders will benefit from improved performance for on-site decision making.ObjectiveTo create dynamic temperature and humidity profiles that can be used to assess the environmental robustness of POC devices, reagents, and other resources (eg, drugs), and thereby, to improve preparedness.MethodsSurface temperature and humidity data from the National Climatic Data Center (Asheville, North Carolina USA) was obtained, median hourly temperature and humidity were calculated, and then mathematically stretched profiles were created to include extreme highs and lows. Profiles were created for: (1) Banda Aceh, Indonesia at the time of the 2004 Tsunami; (2) New Orleans, Louisiana USA just before and after Hurricane Katrina made landfall in 2005; (3) Springfield, Massachusetts USA for an ambulance call during the month of January 2009; (4) Port-au-Prince, Haiti following the 2010 earthquake; (5) Sendai, Japan for the March 2011 earthquake and tsunami with comparison to the colder month of January 2011; (6) New York, New York USA after Hurricane Sandy made landfall in 2012; and (7) a 24-hour rescue from Hawaii USA to the Marshall Islands. Profiles were validated by randomly selecting 10 days and determining if (1) temperature and humidity points fell inside and (2) daily variations were encompassed. Mean kinetic temperatures (MKT) were also assessed for each profile.ResultsProfiles accurately modeled conditions during emergency and disaster events and enclosed 100% of maximum and minimum temperature and humidity points. Daily variations also were represented well with 88.6% (62/70) of temperature readings and 71.1% (54/70) of relative humidity readings falling within diurnal patterns. Days not represented well primarily had continuously high humidity. Mean kinetic temperature was useful for severity ranking.ConclusionsSimulating temperature and humidity conditions clearly reveals operational challenges encountered during disasters and emergencies. Understanding of environmental stresses and MKT leads to insights regarding operational robustness necessary for safe and accurate use of POC devices and reagents. Rescue personnel should understand these principles before performing POC testing in adverse environments.FergusonWJ, LouieRF, TangCS, Paw UKT, KostGJ. Dynamic temperature and humidity environmental profiles: impact for future emergency and disaster preparedness and response. Prehosp Disaster Med. 2014;29(1):1-8.
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Lam M, Louie RF, Curtis CM, Ferguson WJ, Vy JH, Truong AT, Sumner SL, Kost GJ. Short-Term Thermal-Humidity Shock Affects Point-of-Care Glucose Testing: Implications for Health Professionals and Patients. J Diabetes Sci Technol 2014; 8:83-88. [PMID: 24876542 PMCID: PMC4454105 DOI: 10.1177/1932296813514325] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective was to assess the effects of short-term (≤1 hour) static high temperature and humidity stresses on the performance of point-of-care (POC) glucose test strips and meters. Glucose meters are used by medical responders and patients in a variety of settings including hospitals, clinics, homes, and the field. Reagent test strips and instruments are potentially exposed to austere environmental conditions. Glucose test strips and meters were exposed to a mean relative humidity of 83.0% (SD = 8.0%) and temperature of 42°C (107.6°F, SD = 3.2) in a Tenney BTRC environmental chamber. Stressed and unstressed glucose reagent strips and meters were tested with spiked blood samples (n = 40 measurements per time point for each of 4 trials) after 15, 30, 45, and 60 minutes of exposure. Wilcoxon's signed rank test was applied to compare measurements test strip and meter measurements to isolate and characterize the magnitude of meter versus test strip effects individually. Stressed POC meters and test strips produced elevated glucose results, with stressed meter bias as high as 20 mg/dL (17.7% error), and stressed test strip bias as high as 13 mg/dL (12.2% error). The aggregate stress effect on meter and test strips yielded a positive bias as high as 33 mg/dL (30.1% error) after 15 minutes of exposure. Short-term exposure (15 minutes) to high temperature and humidity can significantly affect the performance of POC glucose test strips and meters, with measurement biases that potentially affect clinical decision making and patient safety.
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Affiliation(s)
- Mandy Lam
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
| | - Richard F Louie
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
| | - Corbin M Curtis
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
| | - William J Ferguson
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
| | - John H Vy
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
| | - Anh-Thu Truong
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
| | - Stephanie L Sumner
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
| | - Gerald J Kost
- UC Davis POC Technologies Center, Point-of-Care Testing Center for Teaching and Research, Pathology and Laboratory Medicine, University of California, Davis, CA, USA
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Abstract
ABSTRACTNew and reemerging infectious diseases, such as pandemic viruses and resistant bacteria, pose a serious threat in the 21st century. Some of these agents represent global security threats. This review provides an overview of diagnostic challenges presented by pandemic influenza and biothreat agents. The article summarizes recent pandemics and disease outbreaks, point-of-care influenza diagnostic tests, biothreat agents, biothreat instrument systems, and technologies in development. It highlights how medical innovation and health care initiatives can help prepare health care professionals and public health personnel to handle future crises. Based on gap analysis for current point-of-care testing deficiencies, it concludes with policy recommendations that will enhance preparedness. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S193–S202)
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Louie RF, Ferguson WJ, Sumner SL, Yu JN, Curtis CM, Kost GJ. Effects of dynamic temperature and humidity stresses on point-of-care glucose testing for disaster care. Disaster Med Public Health Prep 2013; 6:232-40. [PMID: 23077265 DOI: 10.1001/dmp.2012.42] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To characterize the performance of glucose meter test strips using simulated dynamic temperature and humidity disaster conditions. METHODS Glucose oxidase- and glucose dehydrogenase-based test strips were dynamically stressed for up to 680 hours using an environmental chamber to simulate conditions during Hurricane Katrina. Paired measurements vs control were obtained using 3 aqueous reagent levels for GMS1 and 2 for GMS2. RESULTS Stress affected the performance of GMS1 at level 1 (P < .01); and GMS2 at both levels (P < .001), lowering GMS1 results but elevating GMS2 results. Glucose median-paired differences were elevated at both levels on GMS2 after 72 hours. Median-paired differences (stress minus control) were as much as -10 mg/dL (range, -65 to 33) at level 3 with GMS1, with errors as large as 21.9%. Glucose median-paired differences were as high as 5 mg/dL (range, -1 to 10) for level 1 on GMS2, with absolute errors up to 24.4%. CONCLUSIONS The duration of dynamic stress affected the performance of both GMS1 and GMS2 glucose test strips. Therefore, proper monitoring, handling, and storage of point-of-care (POC) reagents are needed to ensure their integrity and quality of actionable results, thereby minimizing treatment errors in emergency and disaster settings.
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Affiliation(s)
- Richard F Louie
- UC Davis-LLNL POC Technologies Center, Point-of-Care Testing Center for Teaching and Research (POCT-CTR), Pathology and Laboratory Medicine, School of Medicine, University of California-Davis, CA 95616, USA.
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Ramljak S, Lock JP, Schipper C, Musholt PB, Forst T, Lyon M, Pfützner A. Hematocrit interference of blood glucose meters for patient self-measurement. J Diabetes Sci Technol 2013; 7:179-89. [PMID: 23439176 PMCID: PMC3692232 DOI: 10.1177/193229681300700123] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Abnormal hematocrit levels may interfere with glucose readings of patient self-assessment blood glucose (BG) meters. The aim of this laboratory investigation was to assess the potential influence of hematocrit variations on a variety of BG meters applying different measurement technologies. METHODS Venous heparinized blood was manipulated to contain three different BG concentrations (50-90, 120-180, and 280-350 mg/dl) and five different hematocrit levels (25%, 35%, 45%, 55%, and 65%). After careful oxygenation to normal blood oxygen pressure (65-100 mmHg), each sample was measured (eight times) with the following devices: Accu-Chek® Aviva Nano and Active, Breeze®2 and Contour®, FreeStyle Freedom Lite®, GlucoDr. auto™, Glucofix® mio Plus, GlucoLab™, GlucoMen® LX Plus, Nova Max® Link, Nova Max® Plus, OneTouch® Ultra®2 and Verio®, On Call® Plus and Platinum, Optium Xceed®, Precision Xceed®, and TaiDoc Fora TD-4227. A YSI 2300 STAT Plus™ glucose analyzer served as reference method. Stability to hematocrit influence was assumed, with <10% mean glucose result bias between the highest and lowest hematocrit levels. RESULTS Six of the investigated meters showed a stable performance in this investigation: Accu-Chek Active (7%), Glucofix mio Plus (5%), GlucoMen LX Plus (4%), Nova Max Plus (4%), Nova Max Link (7%), and OneTouch Verio (3%). All other meters failed this hematocrit interference test, with FreeStyle Freedom Lite (11%), and On Call Platinum (12%) being the better devices and On Call Plus (68%), GlucoLab (51%), TaiDoc Fora TD-4227 (39%), and Breeze 2 (38%) showing the worst performance. CONCLUSIONS Hematocrit may affect BG meter performance in daily routine. In case of interference, low hematocrit values (<35%) result in too high readings. Our results encourage use of meters that are not affected by hematocrit interference.
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Affiliation(s)
- Sanja Ramljak
- IKFE Institute for Clinical Research and Development, Mainz, Germany
| | | | | | - Petra B. Musholt
- IKFE Institute for Clinical Research and Development, Mainz, Germany
| | - Thomas Forst
- IKFE Institute for Clinical Research and Development, Mainz, Germany
| | - Martha Lyon
- Department of Pathology and Laboratory Medicine, University of Alberta, Alberta, Canada
| | - Andreas Pfützner
- IKFE Institute for Clinical Research and Development, Mainz, Germany
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Preliminary Evaluation of a Point-of-Care Blood Gas–Electrolyte Analyzer Potentially Robust in Cold During Emergencies and Disasters. POINT OF CARE 2012. [DOI: 10.1097/poc.0b013e318265f3a3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kost GJ, Sakaguchi A, Curtis C, Tran NK, Katip P, Louie RF. Enhancing crisis standards of care using innovative point-of-care testing. Am J Disaster Med 2011; 6:351-68. [PMID: 22338316 PMCID: PMC3434883 DOI: 10.5055/ajdm.2011.0074] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify strategies with tactics that enable point-of-care (POC) testing (medical testing at or near the site of care) to effectively improve outcomes in emergencies, disasters, and public health crises, especially where community infrastructure is compromised. DESIGN Logic model-critical path-feedback identified needs for improving practices. Reverse stress analysis showed POC should be integrated, responders should be properly trained, and devices should be staged in small-world networks (SWNs). First responder POC resources were summarized, test clusters were strategized, assay environmental vulnerabilities were assessed, and tactics useful for SWNs, alternate care facilities, shelters, point-of-distribution centers, and community hospitals were designed. PARTICIPANTS AND ENVIRONMENT: Emergency-disaster needs assessment survey respondents and Center experience. OUTCOMES Important tactics are as follows: a) develop training/education courses and '"just-in-time" on-line web resources to ensure the competency of POC coordinators and high-quality testing performance; b) protect equipment from environmental extremes by sealing reagents, by controlling temperature and humidity to which they are exposed, and by establishing near-patient testing in defined environments that operate within current Food and Drug Administration licensing claims (illustrated with human immunodeficiency virus-1/2 tests); c) position testing in defined sites within SWNs and other environments; d) harden POC devices and reagents to withstand wider ranges of environmental extremes in field applications; e) promote new POC technologies for pathogen detection and other assays, per needs assessment results; and f) select tests according to mission objectives and value propositions. CONCLUSIONS Careful implementation of POC testing will facilitate evidence-based triage, diagnosis, treatment, and monitoring of victims and patients, while advancing standards of care in emergencies and disasters, as well as public health crises.
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Affiliation(s)
- Gerald J. Kost
- UC Davis Point-of-Care Technologies Center and the POCT•CTR, Pathology and Laboratory Medicine, School of Medicine, UC Davis
- Affiliate Faculty, Chulalongkorn University
| | - Ann Sakaguchi
- John A. Burns School of Medicine, University of Hawaii
| | - Corbin Curtis
- UC Davis Point-of-Care Technologies Center and the POCT•CTR, Pathology and Laboratory Medicine, School of Medicine, UC Davis
| | - Nam K. Tran
- UC Davis Point-of-Care Technologies Center and the POCT•CTR, Pathology and Laboratory Medicine, School of Medicine, UC Davis
| | | | - Richard F. Louie
- UC Davis Point-of-Care Technologies Center and the POCT•CTR, Pathology and Laboratory Medicine, School of Medicine, UC Davis
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Abstract
OBJECTIVE: The goal of this paper is to identify strategies for connectivity that will optimize point-of-care testing (POCT) organized as small-world networks in disaster settings. METHODS: We evaluated connectivity failures during the 2010 Haiti Earthquake, applied small-world network concepts, and reviewed literature for point-of-care (POC) connectivity systems. RESULTS: Medical teams responding to the Haiti Earthquake faced connectivity failures that affected patient outcomes. Deploying robust wireless connectivity systems can enhance the efficiency of the disaster response by improving health care delivery, medical documentation, logistics, response coordination, communication, and telemedicine. Virtual POC connectivity education and training programs can enhance readiness of disaster responders. CONCLUSIONS: The admirable humanitarian efforts of more than 4000 organizations substantially impacted the lives of earthquake victims in Haiti. However, the lack of connectivity and small-world network strategies, combined with communication failures, during early stages of the relief effort must be addressed for future disaster preparedness.
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Brock TK, Mecozzi DM, Sumner S, Kost GJ. Evidence-based point-of-care tests and device designs for disaster preparedness. Am J Disaster Med 2010; 5:285-294. [PMID: 21162410 PMCID: PMC3074570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To define pathogen tests and device specifications needed for emerging point-of-care (POC) technologies used in disasters. DESIGN Surveys included multiple-choice and ranking questions. Multiple-choice questions were analyzed with the chi2 test for goodness-of-fit and the binomial distribution test. Rankings were scored and compared using analysis of variance and Tukey's multiple comparison test. PARTICIPANTS Disaster care experts on the editorial boards of the American Journal of Disaster Medicine and the Disaster Medicine and Public Health Preparedness, and the readers of the POC Journal. RESULTS Vibrio cholera and Staphylococcus aureus were top-ranked pathogens for testing in disaster settings. Respondents felt that disaster response teams should be equipped with pandemic infectious disease tests for novel 2009 H1N1 and avian H5N1 influenza (disaster care, p < 0.05; POC, p < 0.01). In disaster settings, respondents preferred self-contained test cassettes (disaster care, p < 0.05; POC, p < 0.001) for direct blood sampling (POC, p < 0.01) and disposal of biological waste (disaster care, p < 0.05; POC, p < 0.001). Multiplex testing performed at the POC was preferred in urgent care and emergency room settings. CONCLUSIONS Evidence-based needs assessment identifies pathogen detection priorities in disaster care scenarios, in which Vibrio cholera, methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and Escherichia coli ranked the highest. POC testing should incorporate setting-specific design criteria such as safe disposable cassettes and direct blood sampling at the site of care.
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Affiliation(s)
- T Keith Brock
- UC Davis-LLNL Point-of-Care Technologies Center, Department of Pathology and Laboratory Medicine, School of Medicine, University of California, Davis, USA
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Kost GJ, Hale KN, Brock TK, Louie RF, Gentile NL, Kitano TK, Tran NK. Point-of-care testing for disasters: needs assessment, strategic planning, and future design. Clin Lab Med 2010; 29:583-605. [PMID: 19840690 PMCID: PMC7115727 DOI: 10.1016/j.cll.2009.07.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Gerald J Kost
- Department of Pathology and Laboratory Medicine, UC Davis-LLNL Point-of-Care Technologies Center [NIBIB, NIH], Point-of-Care Testing Center for Teaching and Research (POCT*CTR), School of Medicine, University of California, Davis, CA 95616, USA.
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