Point of care technology or standard laboratory service in an emergency department: is there a difference in time to action? A randomised trial

Point-of-Care Tests' Role in Time Metrics of Urgent Interventions in Emergency Department; a Systematic Review of Literature

INTRODUCTION

Point-of-Care Testing (POCT) could be helpful in clinical decisions, treatment selection, monitoring, prognostication, operational decision-making, and resource utilization. This study aimed to review the role of POCT in time metrics of performing urgent interventions in the emergency department (ED) or disposition time to proper care.

METHODS

This was a systematic review of the literature based on the PRISMA statement. PubMed, Scopus, Web of Science, and EMBASE databases were searched for studies reporting the application of the POCT in the ED with outcomes of the time to intervention or disposition.

RESULTS

After reviewing 3708 articles, 16 studies with 100,224 participants were included in this systematic review. There were 5 randomized clinical trials (RCTs), 5 retrospective cohorts, 2 prospective cohorts, and 4 before-after studies. All studies were performed in an ED setting except for one study of prehospital EMS air medical transport. Different panels, ultrasound, cardiac parameters, echocardiography, and polymerase chain reaction (PCR) POCTs were used in the studies. Regarding the outcome measures, studies with many types of patients referring to ED used different indices of time to intervention or time to disposition. Studies on different shock circumstances used the time to the first bolus of hydration or vasopressor or intravenous antibiotics for septic shock patients and central venous catheterization (CVC) placement time in one study. Time to imaging was considered as the outcome in some studies. Overall, there was a high risk of bias, especially in case of the randomization methods, and non-blinded designs in RCTs. There was lower possibility of bias in non-randomized studies but the studies did not have enough follow-ups and in case of studies using advanced panels of POCT, results do not seem to be easily applicable to public health care in many countries.

CONCLUSION

In synthesis of the evidence, all included studies were reporting the benefits of the POCT in decreasing the time to proper interventions and increasing the time to negative interventions in the last lines of critical care as well as the intubation and CVC placement.

Point-of-Care Testing for the Emergency Department Patient: Quantity and Quality of the Available Evidence

CONTEXT.—

Point-of-care test (POCT) instruments produce lab results with rapid turnaround times. Based on that fact, emergency department (ED) POCT requests are predicated on the belief that rapid test turnaround times lead to improved care, typically a decreased ED length of stay (LOS).

OBJECTIVE.—

To compile the available peer-reviewed data regarding use of POCT in the ED with an emphasis on ED-LOS.

DATA SOURCES.—

An English-language PubMed search using the following free text terms: ("EMERGENCY" AND "POINT OF CARE") NOT ULTRASOUND as well as "RAPID INFECTIOUS DISEASE TESTING." In addition, the PubMed "similar articles" functionality was used to identify related articles that were not identified on the initial search.

CONCLUSIONS.—

Seventy-four references were identified that studied POCT ED use to determine if they resulted in significant changes in ED processes, especially ED-LOS. They were divided into 3 groups: viral-influenza (n = 24), viral-respiratory not otherwise specified (n = 8), and nonviral (n = 42). The nonviral group was further divided into the following groups: chemistry, cardiac, bacterial/strep, C-reactive protein, D-dimer, drugs of abuse, lactate, and pregnancy. Across all groups there was a trend toward a significantly decreased ED-LOS; however, a number of studies showed no change, and a third group was not assessed for ED-LOS. For POCT to improve ED-LOS it has to be integrated into existing ED processes such that a rapid test result will allow the patient to have a shorter LOS, whether it is to discharge or admission.

Impact of Point-of-care Testing on Length of Stay of Patients in the Emergency Department: A Cluster-randomized Controlled Study

OBJECTIVES

Crowding is a frequent concern in the emergency department (ED). Laboratory point-of-care testing (POCT) has been proposed to decrease patients' length of stay (LOS). Our objective was to determine whether an extended panel of POCT solutions could reduce LOS.

METHODS

This was a single-center, prospective, open-label, controlled cluster-randomized study. Blood test processing was randomized into 1-week inclusion periods: interventional arm (laboratory analyses performed on POCT analyzers implemented in the ED) or control arm (central laboratory). The primary endpoint was LOS of patients in the ED. Secondary endpoints were time to result (TTR), ED crowding surrogates, and average total cost of an ED visit in each arm.

RESULTS

A total of 23,231 patients were included and 20,923 were analyzed for the main outcome measure. Mean ± SD age was 46 ± 20 years, and 7,905 (36%) underwent blood sampling. Mean ± SD LOSs were 203 ± 161 and 210 ± 168 minutes in the POCT and control arms, respectively. LOS reduction for the entire ED population was -9 minutes (95% confidence interval [CI] = -22 to 5, p = 0.22) compared to the control arm and -17 minutes (95% CI = -34.0 to 0.6, p = 0.06) for patients undergoing blood sampling. The mean ± SD TTRs were 28 ± 31 and 79 ± 34 minutes in the POCT and control arms, respectively (TTR reduction = -51 minutes, 95% CI = -54 to -48 minutes, p < 0.001).

CONCLUSIONS

The implementation of an extended panel of POCT solutions in an ED did not significantly reduce the LOS, but reduced the TTR.

The cost of time: A randomised, controlled trial to assess the economic impact of upfront, point-of-care blood tests in the Emergency Centre

Introduction

Time and cost constraints abound in the Emergency Centre (EC). These resource-constraints are further magnified in low- and middle-income countries (LMIC). Almost half of all patients presenting to the EC require laboratory tests. Unfortunately, access to laboratory services in LMIC is commonly inadequate. Point-of-Care (POC) tests may assist to avert this shortcoming. The aims of this study were to evaluate the cost effectiveness of upfront POC blood tests performed prior to doctor assessment compared to the standard EC workflow.

Methods

A secondary analysis was performed on data from a prospective, randomised, controlled trial where patients with abdominal/chest symptoms or generalised body pain/weakness followed either the normal EC workflow pathway or one of two enhanced workflow pathways with POC tests (i-STAT with and without a complete blood count (CBC)) prior to doctor evaluation. The incremental cost effectiveness ratio (ICER) was used to perform the cost effectiveness analysis.

Results

There were 248 patients enrolled in the study. The use of the two upfront, POC test pathways significantly exceeded the primary outcome measure of a 20% reduction in treatment time. In the i-STAT + CBC group, the 31 min. time-saving translated into cost-saving of US$14.96 per patient (IECR 0.27) whereas the 21 min. time-saving in the i-STAT only group only had an additional net cost of US$3.11 per patient (IECR 0.90).

Conclusion

Upfront, POC blood tests can be utilised in the resource-constrained EC to manage patients more efficiently by saving time. This time-saving can, in fact, be more cost effective than traditional EC workflow making it an economically viable option for implementation in LMIC.

Doctors' perceptions of the impact of upfront point-of-care testing in the emergency department

Objectives

Special investigations (e.g. blood tests, electrocardiograms, x-rays) play an integral role in patient management in the emergency department (ED). Having results immediately available prior to assessing a patient may lead to improved efficiency. This could be instituted by utilizing point-of-care (POC) testing with an alternative ED workflow, but the implementation would be dependent on acceptance by the end-users. The aim of this study was to assess doctors’ perceptions of POC testing in the ED when the normal treatment pathway was modified to use upfront POC tests performed prior to doctor evaluation in an effort to decrease treatment times.

Methods

A prospective, randomized, controlled trial was performed in the ED where medical patients received either the normal ED workflow pathway or one of the enhanced workflow pathways with POC tests in various combinations prior to doctor evaluation. At the end of the study period, doctors were invited to participate in an anonymous survey to gauge their opinions on the implementation of the early POC testing.

Results

Overall, the doctors surveyed were very satisfied with use of upfront POC in the ED. One hundred per cent of the 28 doctors surveyed found it helpful to assess patients who already had test results available and would want it to be permanently available. Normalized satisfaction scores were more favorable for combinations of 3 or more tests (0.7–1.0) as opposed to combinations with 2 or less tests (0.3–0.7). There was a preference for combinations that included comprehensive blood results.

Conclusion

The implementation of workflow changes to assist doctors in the ED can potentially make them more productive. End-user buy-in is essential in order for the change to be successful. Upfront, protocolised, POC testing is a low-input, high-yield intervention that decreased treatment time and satisfied doctors.

Can point-of-care testing shorten hospitalization length of stay? An exploratory investigation of infectious agents using regression modelling

This retrospective study investigates the potential benefits from the introduction of point-of-care tests for rapid diagnosis of infectious diseases. We analysed a sample of 441 hospitalized patients who had received a final diagnosis related to 18 pathogenic agents. These pathogens were mostly detected by standard tests but were also detectable by point-of-care testing. The length of hospital stay was partitioned into pre- and post-laboratory diagnosis stages. Regression analysis and elementary queueing theory were applied to estimate the impact of quick diagnosis on the mean length of stay and the utilization of healthcare resources. The analysis suggests that eliminating the pre-diagnosis times through point-of-care testing could shorten the mean length of hospital stay for infectious diseases by up to 34 per cent and result in an equal reduction in bed occupancy and other resources. Regression and other more sophisticated models can aid the financing decision-making of pilot point-of-care laboratories in healthcare systems.

A Randomized Controlled Trial to Assess the Impact of Upfront Point-of-Care Testing on Emergency Department Treatment Time

OBJECTIVES

To compare standard emergency department (ED) workflow to a protocolized pathway using upfront point-of-care (POC) tests performed prior to doctor evaluation to determine if this could produce a significant reduction in treatment time.

METHODS

We performed a prospective, randomized, controlled trial. Patients were randomized to receive the standard of care or one of the enhanced workflow pathways with POC tests.

RESULTS

There were 1,044 patients enrolled. All workflows, except electrocardiogram and low-dose x-ray (LODOX), exceeded the outcome measure (20% reduction in treatment time). It was significantly shorter compared with the control workflow if the patient received any (i-STAT + CBC)-containing workflows (P = .0001, P = .020, P = .0009, P = .011), as well as the i-STAT + LODOX workflows (P = .0001, P = .034).

CONCLUSIONS

The full benefit of POC testing can be realized if it is implemented prior to doctor evaluation, as part of a standardized procedure in the ED. This allows for a more rapid availability of investigation results subsequently leading to decreased treatment times.

A systematic evaluation of immunoassay point-of-care testing to define impact on patients' outcomes

Background Point-of-care testing has been developed to provide rapid test results. Most published studies focus on analytical performance, neglecting its impact on patient outcomes. Objective To review the analytical performance and accuracy of point-of-care testing specifically planned for immunoassay and to evaluate the impact of faster results on patient management. Methods A search of electronic databases for studies reporting immunoassay results obtained in both point-of-care testing and central laboratory scenarios was performed. Data were extracted concerning the study details, and the methodological quality was assessed. The analytical characteristics and diagnostic accuracy of six points-of-care testing: troponin, procalcitonin, parathyroid hormone, brain natriuretic peptide, C-reactive protein and neutrophil gelatinase-associated lipocalin were evaluated. Results A total of 116 scientific papers were analysed. Studies measuring procalcitonin, parathyroid hormone and neutrophil gelatinase-associated lipocalin reported a limited impact on diagnostic decisions. Seven studies measuring C-reactive protein claimed a significant reduction of antibiotic prescription. Several authors evaluated brain natriuretic peptide or troponin reporting faster decision-making without any improvement in clinical outcome. Forty-four per cent of studies reported analytical data, showing satisfactory correlations between results obtained through point-of-care testing and central laboratory setting. Half of studies defined the diagnostic accuracy of point-of-care testing as acceptable for troponin (median sensitivity and specificity: 74% and 94%, respectively), brain natriuretic peptide (median sensitivity and specificity: 82% and 88%, respectively) and C-reactive protein (median sensitivity and specificity 85%). Conclusions Point-of-care testing immunoassay results seem to be reliable and accurate for troponin, brain natriuretic peptide and C-reactive protein. The satisfactory analytical performance, together with an excellent practicability, suggests that it could be a consistent tool in clinical practice, but data are lacking regarding the patient outcomes.

Perceptions of point-of-care infectious disease testing among European medical personnel, point-of-care test kit manufacturers, and the general public

BACKGROUND

The proper development and implementation of point-of-care (POC) diagnostics requires knowledge of the perceived requirements and barriers to their implementation. To determine the current requirements and perceived barriers to the introduction of POC diagnostics in the field of medical microbiology (MM)-POC a prospective online survey (TEMPOtest-QC) was established.

METHODS AND RESULTS

The TEMPOtest-QC survey was online between February 2011 and July 2012 and targeted the medical community, POC test diagnostic manufacturers, general practitioners, and the general public. In total, 293 individuals responded to the survey, including 91 (31%) medical microbiologists, 39 (13%) nonmedical microbiologists, 25 (9%) employees of POC test manufacturers, and 138 (47%) members of the general public. Responses were received from 18 different European countries, with the largest percentage of these living in The Netherlands (52%). The majority (>50%) of medical specialists regarded the development of MM-POC for blood culture and hospital acquired infections as "absolutely necessary", but were much less favorable towards their use in the home environment. Significant differences in perceptions between medical specialists and the general public included the: (1) Effect on quality of patient care; (2) Ability to better monitor patients; (3) Home testing and the doctor-patient relationship; and (4) MM-POC interpretation. Only 34.7% of the general public is willing to pay more than a€10 ($13) for a single MM-POC test, with 85.5% preferring to purchase their MM-POC test from a pharmacy.

CONCLUSION

The requirements for the proper implementation of MM-POC were found to be generally similar between medical specialists and POC test kit manufacturers. The general public was much more favorable with respect to a perceived improvement in the quality of healthcare that these tests would bring to the hospital and home environment.

Blood sample tube transporting system versus point of care technology in an emergency department; effect on time from collection to reporting? A randomised trial

Background

Time is a crucial factor in an emergency department and the effectiveness of diagnosing depends on, among other things, the accessibility of rapid reported laboratory test results; i.e.: a short turnaround time (TAT). Former studies have shown a reduced time to action when point of care technologies (POCT) are used in emergency departments. This study assesses the hypothesis, that using Point of Care Technology in analysing blood samples versus tube transporting blood samples for laboratory analyses results in shorter time from the blood sample is collected to the result is reported in an emergency department.

Methods

The study was designed as a randomised controlled trial with consecutive allocation into two groups and rated 1:1. Blood samples were collected on all included patients and then randomised into either POCT analyses or tube transporting for central laboratory analyses.

Results

Blood samples from a total of 319 patients were included.

The mean time from collecting to reporting was 24 minutes for the POCT analysis and 70 minutes for the tube transported analysis. An unpaired Students t-test showed a significant reduction in time from collecting to reporting using POCT (p<.0001).

Conclusion

We found a significantly reduced time from collecting to reporting using Point of Care Technology (POCT) in an emergency department compared to tube transported blood samples for central laboratory analyses.