National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Point of Care Testing, Oversight, and Administration of Cardiac Biomarkers for Acute Coronary Syndromes

Diagnostic Modalities in Critical Care: Point-of-Care Approach

The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.

Diagnostic performance of four point of care cardiac troponin I assays to rule in and rule out acute myocardial infarction

OBJECTIVE

This study evaluated the diagnostic performance of four point-of-care (POC) cardiac troponin I (cTnI) assays compared to a central laboratory cTnI assay for detecting myocardial injury and diagnosing acute myocardial infarction (AMI).

DESIGN AND METHODS

Plasma obtained at admission, 3 h, and 6 h post-admission in 169 patients presenting with symptoms suggestive of acute coronary syndrome (ACS) was studied. cTnI concentrations were measured on the Instrumentation Laboratory prototype GEM Immuno, Radiometer AQT90, Mitsubishi PATHFAST, Abbott i-STAT and the Ortho-Clinical Diagnostic Vitros assays. MI was determined based on 99th percentiles according to Universal MI guidelines.

RESULTS

For ruling in MI at presentation (0 h), the GEM Immuno (sensitivity 63%, specificity 85%) and PATHFAST (sensitivity 53%, specificity 86%) were comparable to the OCD (sensitivity 68%, specificity 81%), and significantly better (p<0.05) than the AQT90 (sensitivity 26%, specificity 93%) and i-STAT (sensitivity 32%, specificity 92%). cTnI concentrations and serial rising patterns after MI differed by each assay. Negative predictive values were >90% and ROC AUCs were >0.90 after 6h for all assays. Detection of myocardial injury in non-ischemic pathologies accounted for lower than 100% specificity for MI.

CONCLUSION

cTnI is a sensitive biomarker for detection of myocardial injury. The analytical variability that exists between POC cTnI assays demonstrates substantial diagnostic differences for ruling in and ruling out MI in patients presenting with symptoms suggestive of ACS.

Evidence-based point-of-care diagnostics: current status and emerging technologies

Point-of-care (POC) diagnostics brings tests nearer to the site of patient care. The turnaround time is short, and minimal manual interference enables quick clinical management decisions. Growth in POC diagnostics is being continuously fueled by the global burden of cardiovascular and infectious diseases. Early diagnosis and rapid initiation of treatment are crucial in the management of such patients. This review provides the rationale for the use of POC tests in acute coronary syndrome, heart failure, human immunodeficiency virus, and tuberculosis. We also consider emerging technologies that are based on advanced nanomaterials and microfluidics, improved assay sensitivity, miniaturization in device design, reduced costs, and high-throughput multiplex detection, all of which may shape the future development of POC diagnostics.

The future of point-of-care testing in emergency departments

Emergency physicians and administrators continue to face operational challenges as they attempt to increase emergency department (ED) efficiency and throughput to meet the growing demand for emergency health services. Point-of-care (POC) testing technology can provide clinicians with accurate and reliable results with at least a 50% reduction in turnaround time. Despite the near perfect alignment of POC technology goals with ED operational strategy, there has been a relatively slow adoption of comprehensive POC systems. The authors discuss current market trends for the POC products in the ED and review trends in outcomes data (including operational, clinical and financial). The authors also discuss observed managerial obstacles to implementation. The goal of this paper is to provide readers with a business psychology perspective on the current challenges that organizations face in adopting a new technology and provide an evaluation of the key drivers that influence institutional-level decisions to implement an ED-based POC system. The reader will gain an understanding of the dynamic forces that are slowing the adoption of POC technology. Also, the reader is provided with the authors' future perspectives for POC testing in emergency medicine. The current healthcare system is putting a lot of pressure on EDs to be able to provide efficient care using advanced diagnostic tests. Clinicians and administrators alike must understand the gaps between the clinician's perceived benefit of POC testing and the inconsistent literature on the operational and clinical outcomes before adopting POC systems in ED.