Use of point-of-care testing and early assessment model reduces length of stay for ambulatory patients in an emergency department

Position Statement on In-hospital/Clinic Point-of-care Coagulation Testing for Anticoagulation Monitoring in Saudi Arabia

Objectives

Hospital overload is a persistent occurrence in daily practice. Interventions such as point-of-care testing (POCT) are needed to alleviate the pressure faced by healthcare providers and administrators.

Methods

An invited panel of experts from Saudi Arabia was formed under the auspices of the Saudi Heart Association in order to discuss local treatment gaps in the management of patients receiving anticoagulation therapy. This was done in a series of meetings, which resulted in the development of official recommendations for the implementation of POCT for anticoagulation monitoring in the country. Recommendations were based on a comprehensive literature review and international guidelines taking into consideration local clinical practice, clinical gaps, and treatment/testing availabilities.

Results

Vitamin K antagonist (VKA)-based anticoagulation therapy requires routine monitoring. POCT is a promising model of care for the monitoring of International Normalized Ratio (INR) in patients receiving oral anticoagulation in terms efficacy, safety and convenience. The availability of POC INR testing should not replace the use of standard laboratory anticoagulation monitoring. However, there are several indications for implementing POCTINR monitoring that was agreed upon by the expert panel. POCT for anticoagulation monitoring should primarily be used in the warfarin (or other VKA) monitoring clinic in order to ensure treatment efficiency, cost-effectiveness of care, patient satisfaction, and quality of life improvement. The expert panel detailed the requirements for the establishment of a warfarin (or other VKA) monitoring clinic in terms of organization, safety, quality control, and other logistic and technical considerations. The limitations of POCT should be recognized and recommendations on best practices should be strictly followed. Core laboratory confirmation should be sought for patients with higher INR results (>4.7) on POCT. Proper training, quality control, and regulatory oversight are also critical for preserving the accuracy and reliability of POCT results.

Conclusions

POCT enables more rapid clinical decision-making in the process of diagnosis (rule-in or rule-out), treatment choice and monitoring, and prognosis, as well as operational decision-making and resource utilization. POCT thus can fulfill an important role in clinical practice, particularly for patients receiving VKAs.

Validation of non-invasive point of care blood content analysis using the TensorTip™ MTX device: a method comparison study

OBJECTIVES

The TensorTip™ MTX is a non-invasive device designed to determine several physiological parameters with additional analysis of haemoglobin, haematocrit and blood gas analysis by interpreting blood diffusion colour of the finger skin based on spectral analysis. The aim of our study was to investigate the accuracy and precision of the TensorTip MTX in a clinical setting in comparison with routine analysis of blood samples.

METHODS

Forty-six patients, scheduled for elective surgery, were enrolled in this study. Placement of an arterial catheter had to be part of the standard of care. Measurements were performed during the perioperative period. The measurements obtained with the TensorTip MTX were compared with the results of routine analysis of the blood samples as a reference using correlation, Bland-Altman analysis and mountain plots.

RESULTS

No significant correlation was present in the measurements. Measurement of haemoglobin with the TensorTip MTX had a mean bias of 0.4 mmol/L, haematocrit's bias was 3.0 %. Bias of partial pressure of carbon dioxide and oxygen was 3.6 and 66.6 mmHg, respectively. Calculated percentage errors were 48.2 , 48.9, 39.9 and 109.0 %. Proportional bias was present in all Bland-Altman analyses. Less than 95 % of the differences fell within the pre-set limits of allowable error.

CONCLUSIONS

Non-invasive blood content analysis with the TensorTip MTX device is not equivalent to and did not correlate sufficiently with conventional laboratory analysis. None of the parameters measured showed results within the limits of allowable error. Therefore, the use of the TensorTip MTX is not recommended for perioperative care.

Point-of-care measurement of C-reactive protein promotes de-escalation of treatment decisions and strengthens the perceived clinical confidence of physicians in out-of-hours outpatient emergency medical services

OBJECTIVES

Out-of-hours outpatient emergency medical services (OEMS) provide healthcare for patients with non-life-threatening conditions in need for urgent care when outpatient practices are closed. We studied the use of point-of-care-testing of C-reactive protein (CRP-POCT) at OEMS.

DESIGN

Cross-sectional questionnaire-based survey.

SETTING

Single centre OEMS practice in Hildesheim, Germany (October 2021 to March 2022).

PARTICIPANTS

OEMS physicians answering a questionnaire immediately after performing CRP-POCTs (CUBE-S Analyzer, Hitado) on any patients.

PRIMARY AND SECONDARY OUTCOMES

Impact of CRP-POCTs on clinical decision-making and perceived usefulness.

RESULTS

In the 6-month study period, 114 valid CRP-POCTs were performed in the OEMS practice by 18 physicians and the questionnaire was answered in 112 cases (response rate: 98.2%). CRP-POCTs were used in the diagnosis of inflammatory diseases of the gastrointestinal tract (60.0%), respiratory tract infections (17.0%), urinary tract infections (9.0%) and other non-gastrointestinal/non-specified infections (11.0%). The use of a CRP-POCT resulted in a change of the physicians' clinical decision in 83.3% of the cases. Specifically, in 13.6% and 35.1% of the cases, rapid CRP measurements led to decision changes in the (1) initiation of antimicrobial therapy and (2) other drug treatment, respectively. Notably, in 60% of all cases, the use of a CRP-POCT reportedly changed the decision on hospitalisation/non-hospitalisation of OEMS patients. In respect of antimicrobial therapy and hospitalisation, these decision changes primarily (≥73%) promoted 'step-down' decisions, that is, no antibiotic therapy and no hospital admission. In the great majority of CRP-POCT applications (≥95%), OEMS physicians reported that rapid CRP measurements increased the confidence in their diagnostic and therapeutic decision. In almost all cases (97%), physicians rated the CRP-POCT use as useful in the treatment situation.

CONCLUSION

Quantitative CRP-POCT promotes step-down clinical decisions and strengthens the clinical confidence of physicians in out-of-hours OEMS.

Monocyte Distribution Width, a Novel Biomarker for Early Sepsis Screening and Comparison with Procalcitonin and C-Reactive Protein

Objectives Monocyte distribution width (MDW) can be used for the early recognition of sepsis. The study compared the diagnostic accuracy of the MDW with two well-known sepsis biomarkers, procalcitonin (PCT) and C-reactive protein (CRP).

Materials and Methods A study was conducted from July 2021 to October 2021, on 111 patients admitted to the Indus Hospital and Health Network. Patients from the ages of 1 to 90 years were enrolled if hospitalized for more than 24 hours for suspected sepsis to avoid inclusion of patients who had short-term stay in the emergency department. According to the Sequential Organ Failure Assessment score, the clinical team did the characterization of cases as with sepsis or without sepsis. SPSS version 24 was used, and the diagnostic accuracy of MDW was assessed and compared using the area under the curves (AUCs) acquired from receiver operating characteristic curves. Pearson's chi-square/Fisher's exact test (as per need) was applied to determine the association. A p-value of less than 0.05 was considered significant.

Results Among 111 patients, 81 (73%) patients were labeled with sepsis and 30 (27%) were without sepsis. We have reported significantly higher MDW, PCT, and CRP levels in septic patients (p < 0.001). The AUC of MDW was comparable with PCT (0.794). Significant cutoff value for the MDW was greater than 20.24 U with 86% sensitivity and 73% specificity.

Conclusion MDW may have a predictive ability similar to PCT and CRP in terms of sepsis and, thus, can be used as a standard parameter for the timely diagnosis of sepsis.

Reducing Crowding in Emergency Departments With Early Prediction of Hospital Admission of Adult Patients Using Biomarkers Collected at Triage: Retrospective Cohort Study

BACKGROUND

Emergency department crowding continues to threaten patient safety and cause poor patient outcomes. Prior models designed to predict hospital admission have had biases. Predictive models that successfully estimate the probability of patient hospital admission would be useful in reducing or preventing emergency department "boarding" and hospital "exit block" and would reduce emergency department crowding by initiating earlier hospital admission and avoiding protracted bed procurement processes.

OBJECTIVE

To develop a model to predict imminent adult patient hospital admission from the emergency department early in the patient visit by utilizing existing clinical descriptors (ie, patient biomarkers) that are routinely collected at triage and captured in the hospital's electronic medical records. Biomarkers are advantageous for modeling due to their early and routine collection at triage; instantaneous availability; standardized definition, measurement, and interpretation; and their freedom from the confines of patient histories (ie, they are not affected by inaccurate patient reports on medical history, unavailable reports, or delayed report retrieval).

METHODS

This retrospective cohort study evaluated 1 year of consecutive data events among adult patients admitted to the emergency department and developed an algorithm that predicted which patients would require imminent hospital admission. Eight predictor variables were evaluated for their roles in the outcome of the patient emergency department visit. Logistic regression was used to model the study data.

RESULTS

The 8-predictor model included the following biomarkers: age, systolic blood pressure, diastolic blood pressure, heart rate, respiration rate, temperature, gender, and acuity level. The model used these biomarkers to identify emergency department patients who required hospital admission. Our model performed well, with good agreement between observed and predicted admissions, indicating a well-fitting and well-calibrated model that showed good ability to discriminate between patients who would and would not be admitted.

CONCLUSIONS

This prediction model based on primary data identified emergency department patients with an increased risk of hospital admission. This actionable information can be used to improve patient care and hospital operations, especially by reducing emergency department crowding by looking ahead to predict which patients are likely to be admitted following triage, thereby providing needed information to initiate the complex admission and bed assignment processes much earlier in the care continuum.

Optimization of Patient Management in the Gynecology Emergency Department Using Point-of-Care Beta hCG

Background: Point-of-care testing (POCT) provides shorter turn-around times and, in many cases, potentially improves medical decision making. The AQT90 FLEX® benchtop immunoanalyzer (Radiometer Medical ApS, Copenhagen, Denmark) allows for the determination of beta-human chorionic gonadotropin (βhCG) in 18 min. The main aim of this study was to evaluate the impact of measuring βhCG using the AQT90 analyzer in the gynecology emergency department (ED) compared to the standard practice of using central laboratory blood testing on the patient length of stay (LOS). Methods: The evaluation consisted of two parts. The first one, conducted in the central laboratory, focused on the analytical performances of the AQT βhCG assay. The second one, conducted in the ED, aimed at determining the impact of POCT βhCG implementation on the timeframe in which ED patients require βhCG assessment. Results: The within-lab imprecisions at the mean values of 17 and 287 IU/L were 2.7% and 3.7%, respectively. Using Deming regression (n = 60), the following equation was obtained in the central lab: AQT90 βhCG = 1.1 Roche βhCG—12.9 (r = 0.997). The implementation of POCT βhCG in the ED significantly reduced patient LOS (145 (90−212) min vs. 205 (155−265) with and without AQT90, respectively, p < 0.001). At the 2 IU/L decision level, a 99.7% agreement with the Roche assay was reported (kappa statistics, 0.99). Conclusions: We confirm that the analytical qualities of the AQT 90 were in line with those obtained in the central lab. The implementation of the POCT βhCG is associated with a shorter LOS in the ED due to the faster availability of the results and the faster decision-making possibilities.

Rapid Thrombolysis Protocol: Results from a Before-and-after Study

Objective

Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes.

Materials and methods

This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay.

Results

Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98–62.31) and 34.91 minutes (95% CI 29.64–40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57–54.59) and 41.89% (95% CI 31.32–53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44–47.87) in pre-intervention group and 54.05% (95% CI 42.78–64.93) in post-intervention group had discharge mRS 0–2.

Conclusion

The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients.

How to cite this article

Verma A, Sarda S, Jaiswal S, Batra A, Haldar M, Sheikh WR, et al. Rapid Thrombolysis Protocol: Results from a Before-and-after Study. Indian J Crit Care Med 2022;26(5):549–554.

Using an electronic discharge process to improve patient experience and timeliness in a pediatric urgent care setting

BACKGROUND

Most patients in acute care settings are discharged home. Time waiting for discharge paperwork does not add value to patient experience. Quality discharge counseling is critical for patient experience and safety.

OBJECTIVE

To increase online portal enrollment in order to decrease length of stay through use of an electronic discharge (e-discharge) process.

PATIENT INVOLVEMENT

We used patient tracers to evaluate the perception of the UC discharge process at baseline, which helped identify barriers to signing up for the patient portal.

METHODS

We performed a manual audit of patient encounters twice a month (N = 1431) to determine rate of portal enrollment, e-discharge, and LOS. We calculated summary distributions of LOS for those that received hardcopy vs. e-discharge instructions. We measured the percentage of positive scores for overall experience and quality of anticipatory guidance for all completed surveys.

RESULTS

For audited encounters portal enrollment increased from 22% to 37% (p < 0.001). Encounters with e-discharge instructions had a shorter median LOS compared to patient encounters that received hardcopy instructions (55.0 vs. 68.0 min; p < 0.001). There was no difference in overall rating or perceived quality of anticipatory guidance between groups.

DISCUSSION

Patients who received e-discharge instructions had significantly shorter LOS compared to those who received hardcopy instructions. The overall rating and perceived quality of anticipatory guidance were not negatively affected by e-discharge instructions.

PRACTICAL VALUE

Enrolling children into an online portal requires additional steps to ensure that only patients and their legal guardians have access to protected patient information. However, the benefits of offering the portal include shorter LOS without impacting the perceived quality of discharge counseling.

FUNDING

Children's Mercy supported all phases of this study.

Evaluation of Preanalytical Point-of-Care Testing Errors and Their Impact on Productivity in the Emergency Department in the United States

BACKGROUND

Preanalytical errors due to poor sample quality or improper sample handling may occur with point-of-care testing (POCT).

METHODS

A retrospective analysis was conducted using deidentified records for 15 479 i-STAT® cartridges run at the Oregon Health & Science University Emergency Department (ED) between December 2015 and August 2016. Data were collected from electronic health records and device middleware for CG4+, CHEM8+, and Troponin cartridges. The frequency of POCT errors was evaluated by cartridge type. The effect of user experience on error frequency, impact of error on hospital length of stay (LOS), and test turnaround time (TAT) were all evaluated. Direct costs incurred due to Chem8+ and Troponin cartridge waste and indirect costs as avoidable nursing staff labor were estimated over 2 years.

RESULTS

A total of 935 erroneous results were identified (6.0% of all cartridges). Three hundred seventy-two (2.4%) were unusable results, and 563 (3.6%) were cartridge errors, of which 163 were classified by device error codes as poor sample quality/improper sample handling. Error rates were inversely correlated with user experience based on number of tests performed during the 9-month period. Compared to nonerroneous results, test TATs and LOS were significantly longer with erroneous results (P < 0.01). Over 2 years, direct costs incurred due to cartridge waste was $45 000, and indirect cost was estimated between 486 and 729 h in avoidable nursing labor.

CONCLUSIONS

Preanalytical POCT errors were inversely correlated with user experience and significantly impacted clinical productivity in the ED based on LOS and test TAT.

Point-of-care versus central laboratory measurements of electrolytes and hemoglobin: A prospective observational study in critically ill patients in a tertiary care hospital

Background

A blood gas analyzer is a point-of-care (POC) testing device used in the Emergency Department (ED) to manage critically ill patients. However, there were differences in results found from blood gas analyzers for hemoglobin (Hgb) and electrolytes parameters. We conducted a comparative validity study in ED in patients who had requirements of venous gas analysis, complete blood count, and electrolytes. The objective was to find the correlation of Hgb, sodium (Na⁺), and potassium (K⁺) values between the blood gas analyzer and laboratory autoanalyzer.

Methods

A total of 206 paired samples were tested for Hgb, Na⁺, and K⁺. Total 4.6 ml of venous blood was collected from each participant, 0.6 ml was used for blood gas analysis as POC testing and 4 ml was sent to the central laboratory for electrolyte and Hgb estimation.

Results

The mean difference between POC and laboratory method was 0.608 ± 1.41 (95% confidence interval [CI], 0.41-0.80; P < 0.001) for Hgb, 0.92 ± 3.5 (95% CI, 0.44-1.40) for Na⁺, and 0.238 ± 0.62 (95% CI, -0.32-0.15; P < 0.001) for K⁺. POC testing and laboratory method showed a strong positive correlation with Pearson correlation coefficient (r) of 0.873, 0.928, and 0.793 for Hgb, Na⁺, and K⁺, respectively (P < 0.001).

Conclusion

Although there was a statistical difference found between the two methods, it was under the United States Clinical Laboratory Improvement Amendment range. Hence, starting the therapy according to the blood gas analyzer results may be beneficial to the patient and improve the outcome.

Synergy Between Point-of-Care Testing and Laboratory Consolidations

Central or area laboratories will offer an improved number of diagnostic testing services, where drivers for change will involve chronic disease clinical care for an increasingly older population, new emerging diagnostic technologies and personalized medicine. Higher automation quality and ever more diagnostic field integration will lead to higher productivity by means of an improved throughput. At the same time Point of Care Testing (POCT) site of patient care allows for timely medical assessment, which can lead to improved patient outcomes, more effectiveness and patient satisfaction. POCT test introduction in clinical practice should be assessed by an outcome-based policy to avoid adverse events, failure to diagnose providing appropriate timed treatment. The use of POCT devices does not only require technological considerations for the production and management of acceptable tests possibly managed by central laboratory, but also implicates a shift in diagnostic practice across all health organizations. The interaction between laboratory professionals and clinicians will be enriched with new methods of evaluation of patient needs in the internet of things and mobile Health worlds, where boundaries between POCT and central laboratory or hospital and primary healthcare will no longer exist and where all data can be shared and disseminated among stakeholders in the healthcare system.

Emergency severity level-3 patient flow based on point-of-care testing improves patient outcomes

BACKGROUND

Overcrowding of the Emergency Department is rapidly becoming a global challenge and a major source of concern for emergency physicians. The desire to improve Emergency Department throughput requires novel approaches to patient flow.

MATERIALS AND METHODS

We conducted a prospective and cluster-randomized study, to evaluate the impact in patient outcomes of a new patient flow based on Point-of-Care Testing (POCT). A total of 380 Emergency Severity Level-3 patients were enrolled and studied in two different groups, interventional arm (laboratory analyses performed on POCT analyzers implemented in the Emergency Department) or control arm (central laboratory). The primary outcome was the Emergency Department length of stay. Secondary outcome included the time to first medical intervention, the laboratory turnaround time and the time to disposition decision. Readmission within the 7 days after discharge was also calculated.

RESULTS

Length of stay significantly decreased by 88.50 min (from 247.00 to 158.50), time to disposition decision by 89.00 min (from 192.00 to 103.00) and laboratory turnaround time by 67.11 min (from 89.84 to 22.73) in the POCT group. No increase in readmission was found.

CONCLUSION

Our strategy based on POCT represents a good approach to optimize patient flow in the Emergency Department and it should be seen as a starting point for further studies focusing on improving throughput.

Monocyte Distribution Width, Neutrophil-to-Lymphocyte Ratio, and Platelet-to-Lymphocyte Ratio Improves Early Prediction for Sepsis at the Emergency

(1) Background: Sepsis is a life-threatening condition, and most patients with sepsis first present to the emergency department (ED) where early identification of sepsis is challenging due to the unavailability of an effective diagnostic model. (2) Methods: In this retrospective study, patients aged ≥20 years who presented to the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were included. The SIRS, sequential organ failure assessment (SOFA), and quick SOFA (qSOFA) scores were obtained for all patients. Routine complete blood cell testing in conjugation with the examination of new inflammatory biomarkers, namely monocyte distribution width (MDW), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), was performed at the ED. Propensity score matching was performed between patients with and without sepsis. Logistic regression was used for constructing models for early sepsis prediction. (3) Results: We included 296 patients with sepsis and 1184 without sepsis. A SIRS score of >2, a SOFA score of >2, and a qSOFA score of >1 showed low sensitivity, moderate specificity, and limited diagnostic accuracy for predicting early sepsis infection (c-statistics of 0.660, 0.576, and 0.536, respectively). MDW > 20, PLR > 9, and PLR > 210 showed higher sensitivity and moderate specificity. When we combined these biomarkers and scoring systems, we observed a significant improvement in diagnostic performance (c-statistics of 0.796 for a SIRS score of >2, 0.761 for a SOFA score of >2, and 0.757 for a qSOFA score of >1); (4) Conclusions: The new biomarkers MDW, NLR, and PLR can be used for the early detection of sepsis in the current sepsis scoring systems.

Implementation of point-of-care blood gas testing at a large community hospital: Cost analysis, sepsis bundle compliance, and employee engagement

INTRODUCTION/BACKGROUND

Point-of-care testing (POCT) platforms support patient-centered approaches to health care delivery and may improve patient care. We evaluated implementation of a POCT platform at a large, acute care hospital in the Midwestern United States.

METHODS

We used lactate testing as part of a sepsis bundle protocol to evaluate compliance and mortality outcomes. Respiratory team members were surveyed to assess perception of efficiency, ease of use, timely patient care, and overall engagement with the POCT system. Annualized cost per test of a benchtop analyzer and a POCT platform were compared across 3 years for each platform.

RESULTS

Lactate testing volume increased from 61% to 91%, which was associated with improved sepsis bundle protocol compliance. Employees reported high levels of engagement, improvements in efficiency and time savings, and better patient care with POCT. Average cost per test was $10.02 for the benchtop system and $6.21 for the POCT platform. POCT saved our institution $88,476 annually in labor costs.

DISCUSSION

Combined with a robust training program emphasizing the use of lactate testing in the context of the overall clinical picture, POCT enabled adherence to the sepsis bundle protocol and may have contributed to lower mortality. Additionally, the COVID-19 pandemic has provided us with unanticipated benefits of using POCT; it has enhanced our ability to deal with stringent infectious disease protocols, saving time and minimizing patient and staff exposure.

CONCLUSIONS

Implementation of a POCT platform was associated with improved compliance to our sepsis protocol, reduced sepsis mortality, high employee engagement, and cost savings.

Health Economic Evidence of Point-of-Care Testing: A Systematic Review

OBJECTIVE

Point-of-care testing (POCT) has become an essential diagnostic technology for optimal patient care. Its implementation, however, still falls behind. This paper reviews the available evidence on the health economic impact of introducing POCT to assess if poor POCT uptake may be related to lacking evidence.

STUDY DESIGN

The Scopus and PubMed databases were searched to identify publications describing a health economic evaluation of a point-of-care (POC) test. Data were extracted from the included publications, including general and methodological characteristics as well as the study results summarized in either cost, effects or an incremental cost-effectiveness ratio. Results were sorted into six groups according to the POC test's purpose (diagnosis, screening or monitoring) and care setting (primary care or secondary care). The reporting quality of the publications was determined using the CHEERS checklist.

RESULTS

The initial search resulted in 396 publications, of which 44 met the inclusion criteria. Most of the evaluations were performed in a primary care setting (n = 31; 70.5%) compared with a secondary care setting (n = 13; 29.5%). About two thirds of the evaluations were on POC tests implemented with a diagnostic purpose (n = 28; 63.6%). More than 75% of evaluations concluded that POCT is recommended for implementation, although in some cases only under specific circumstances and conditions. Compliance with the CHEERS checklist items ranged from 20.8% to 100%, with an average reporting quality of 72.0%.

CONCLUSION

There were very few evaluations in this review that advised against the implementation of POCT. However, the uptake of POCT in many countries remains low. Even though the evaluations included in this review did not always include the full long-term benefits of POCT, it is clear that health economic evidence across a few dimensions of value already indicate the benefits of POCT. This suggests that the lack of evidence on POCT is not the primary barrier to its implementation and that the low uptake of these tests in clinical practice is due to (a combination of) other barriers. In this context, aspects around organization of care, support of clinicians and quality management may be crucial in the widespread implementation of POCT.

Diagnostic Tests for COVID-19

The diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has ramifications on both an individual level and a public health level. The use of appropriate testing mechanisms is paramount to preventing transmission, along with offering treatment to those who are infected and show appropriate symptomatology. The choice of employing a specific test often relies on laboratory capabilities, including the abilities of the medical technologists, the cost of testing platforms, and the individual quirks of each test. This chapter intends to discuss the relevant issues relating to diagnostic testing for SARS-CoV-2, including specimen types and collection methods, viral detection methods, and serological testing.

Impact of Rapid Medical Evaluation on Patient Flow in an Urban Emergency Department

Rapid Medical Evaluation (RME) is a new Emergency Department (ED) process that initiates testing while patients are in the Waiting Room. Primary goal of this study is to assess the effectiveness of RME pathway on the patient flow through the ED. This was a retrospective, single site, cohort study of patients presenting to the ED 12 months before (PRE group) and 12 months after (POST group) RME implementation. The POST group was divided into those that underwent RME and those managed using standard care pathway (SCP). Data was collected from Electronic Health Record (EHR) database using SQL and consisted of time stamp data for discrete ED patient events. The following metrics were calculated for all ED encounters: Active ED Room Time, Boarding Time, Total ED Room Time, Total ED Time, and Door-to-Provider Time. Patients undergoing RME on average spent 90-min less in ED Treatment Room compared to SCP group and were evaluated by a provider 151 min earlier than if they had waited for an available ED Treatment Room. Implementation of RME helped reduce time patients spend in ED Treatment Room, improved patient throughput, and decreased Door-to-Provider time during the busiest times in the ED.

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.

Current Status of Clinical Application of Point-of-Care Testing

CONTEXT.—

The clinical applications of point-of-care testing (POCT) are gradually increasing in many health care systems. Recently, POCT devices using molecular genetic method techniques have been developed. We need to examine clinical pathways to see where POCT can be applied to improve them.

OBJECTIVE.—

To introduce up-to-date POCT items and equipment and to provide the content that should be prepared for clinical application of POCT.

DATA SOURCES.—

Literature review based on PubMed searches containing the terms point-of-care testing, clinical chemistry, diagnostic hematology, and clinical microbiology.

CONCLUSIONS.—

If medical resources are limited, POCT can help clinicians make quick medical decisions. As POCT technology improves and menus expand, areas where POCT can be applied will also increase. We need to understand the limitations of POCT so that it can be optimally used to improve patient management.

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.

Impact of point-of-care panel tests in ambulatory care: a systematic review and meta-analysis

OBJECTIVES

This article summarises all the available evidence on the impact of introducing blood-based point-of-care panel testing (POCT) in ambulatory care on patient outcomes and healthcare processes.

DESIGN

Systematic review and meta-analysis of randomised-controlled trials and before-after studies.

DATA SOURCES

Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, Database of Abstracts of Reviews and Effects, Science Citation Index from inception to 22 October 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies were based in ambulatory care and compared POCT with laboratory testing. The primary outcome was the time to decision regarding disposition that is, admission/referral termed disposition decision (DD) time. Secondary outcomes included length of stay (LOS) at the ambulatory care unit/practice and mortality.

RESULTS

19 562 patients from nine studies were included in the review, eight of these were randomised-controlled trials, and one was a before-after study. All the studies were based in either emergency departments or the ambulance service; no studies were from primary care settings. General panel tests performed at the POCT resulted in DDs being made 40 min faster (95% CI -42.2 to -36.6, I2=0%) compared with the group receiving usual care, including central laboratory testing. This in turn resulted in a reduction in LOS for patients who were subsequently discharged by 34 min (95% CI -63.7 to -5.16). No significant difference in mortality was reported.

DISCUSSION

Although statistical and clinical heterogeneity is evident and only a small number of studies were included in the meta-analysis, our results suggest that POCTs might lead to faster discharge decisions. Future research should be performed in primary care and identify how POCTs can contribute meaningful changes to patient care rather than focusing on healthcare processes.

PROSPERO REGISTRATION NUMBER

CRD42016035426.

Emergency department overcrowding : Analysis and strategies to manage an international phenomenon

Overcrowding in emergency departments is a common and worldwide phenomenon, which is widely reported even in the lay press. Strategies to address this incriminating situation for patients, nurses, physicians and hospital administrators are urgently needed. The current review presents an analysis of the overcrowding problem as well as strategies to answer overcrowding situations.

The cost-effectiveness of upfront point-of-care testing in the emergency department: a secondary analysis of a randomised, controlled trial

Background

Time-saving is constantly sought after in the Emergency Department (ED), and Point-of-Care (POC) testing has been shown to be an effective time-saving intervention. However, when direct costs are compared, these tests commonly appear to be cost-prohibitive. Economic viability may become apparent when the time-saving is translated into financial benefits from staffing, time- and cost-saving. The purpose of this study was to evaluate the cost-effectiveness of diagnostic investigations utilised prior to medical contact for ED patients with common medical complaints.

Methods

This was a secondary analysis of data from a prospective, randomised, controlled trial in order to assess the cost-effectiveness of upfront, POC testing. Eleven combinations of POC equivalents of commonly-used special investigations (blood tests (i-STAT and complete blood count (CBC)), electrocardiograms (ECGs) and x-rays (LODOX® (Low Dose X-ray)) were evaluated compared to the standard ED pathway with traditional diagnostic tests. The economic viability of each permutation was assessed using the Incremental Cost Effectiveness Ratio and Cost-Effectiveness Acceptability Curves. Expenses related to the POC test implementation were compared to the control group while taking staffing costs and time-saving into account.

Results

There were 897 medical patients randomised to receive various combinations of POC tests. The most cost-effective combination was the i-STAT+CBC permutation which, based on the time saving, would ultimately save money if implemented. All LODOX®-containing permutations were costlier but still saved time. Non-LODOX® permutations were virtually 100% cost-effective if an additional cost of US$50 per patient was considered acceptable. Higher staffing costs would make using POC testing even more economical.

Conclusions

In certain combinations, upfront, POC testing is more cost-effective than standard diagnostic testing for common ED undifferentiated medical presentations – the most economical POC test combination being the i-STAT + CBC. Upfront POC testing in the ED has the potential to not only save time but also to save money.

Trial registration

ClinicalTrials.gov: NCT03102216.

Improving Emergency Department Management of Diabetic Ketoacidosis in Children

BACKGROUND

Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions and prolonged ED length of stay (LOS), especially in patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA). At our institution, baseline DKA determination time (arrival to diagnosis) was 86 minutes, and 61% of patients did not meet DKA criteria. Subsequently, intravenous (IV) placement occurred in 85% of patients without DKA. We aimed to use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months.

METHODS

Four key interventions (POC tests, order panels, provider guidelines, and nursing guidelines) were tested by using plan-do-study-act cycles. DKA determination time was our primary outcome, and secondary outcomes included the percentage of patients receiving IV placement and ED LOS. Process measures included the rate of use of POC testing and order panels. All measures were analyzed on statistical process control charts.

RESULTS

Between January 2015 and July 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all 4 interventions, DKA determination time decreased from 86 to 26 minutes (P < .001). In patients without DKA, IV placement decreased from 85% to 36% (P < .001). ED LOS decreased from 206 to 186 minutes (P = .009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively.

CONCLUSIONS

Using quality-improvement methodology, we achieved a meaningful reduction in DKA determination time, the percentage of IV placements, and ED LOS.

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.

Implementation of point-of-care testing in a pediatric healthcare setting

Point-of-care testing (POCT) refers to testing performed outside the clinical laboratory near the patient or at the site of patient care. This could be in critical care settings like the intensive care unit (ICU) and emergency department (ED) or primary care settings like physician offices where testing is performed by nonlaboratory personnel. POCT circumvents several steps in central laboratory testing including specimen transportation and processing resulting in faster turnaround times. Provider access to rapid test results at the site of patient care allows for prompt medical decision making which can lead to improved patient outcomes, operational efficiencies, patient satisfaction, and even cost savings in some cases. In addition to providing results rapidly, POCT devices have small specimen volume requirements compared to central laboratory tests making POCT particularly attractive for pediatric healthcare settings. The availability of published reports on the impact of POCT implementation in pediatric care are helpful resources when evaluating the clinical necessity of POCT prior to implementation. Even though several studies have shown advantages to implementing POCT in different pediatric settings, it is important to note that limitations exist that might limit the utilization of certain POCTs in some pediatric populations. So, it is important that these limitations and the analytical performance of a test are considered while keeping the target patient population in mind. Since POCTs are performed by non-laboratory staff who are not trained laboratory personnel, one challenge with POCT is maintaining regulatory compliance and quality assurance. It is therefore important that regulatory and quality assurance programs be put in place prior to implementing POCT in the pediatric hospital. With advances in POCT technology, most POCT devices have the capability to interface to the laboratory information system (LIS) and electronic medical record (EMR). POCT device interfacing allows for improved compliance to regulatory and quality assurance standards. Maintaining a cost efficient POCT program is becoming increasingly important as hospitals and healthcare systems are undergoing consolidation and harmonization. This includes assessing the clinical and operational benefit of POCT before implementation and inventory management to ensure minimal reagent wastage. This review discusses these different considerations when implementing POCT with a focus on the pediatric healthcare setting.

Use of data mining techniques to classify length of stay of emergency department patients

Emergency departments (EDs) are the largest departments of hospitals which encounter high variety of cases as well as high level of patient volumes. Thus, an efficient classification of those patients at the time of their registration is very important for the operations planning and management. Using secondary data from the ED of an urban hospital, we examine the significance of factors while classifying patients according to their length of stay. Random Forest, Classification and Regression Tree, Logistic Regression (LR), and Multilayer Perceptron (MLP) were adopted in the data set of July 2016, and these algorithms were tested in data set of August 2016. Besides adopting and testing the algorithms on the whole data set, patients in these sets were grouped into 21 based on the similarities in their diagnoses and the algorithms were also performed in these subgroups. Performances of the classifiers were evaluated based on the sensitivity, specificity, and accuracy. It was observed that sensitivity, specificity, and accuracy values of the classifiers were similar, where LR and MLP had somehow higher values. In addition, the average performance of the classifying patients within the subgroups outperformed the classifying based on the whole data set for each of the classifiers.

Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis

OBJECTIVE

The aim of this review was to collate all available evidence on the impact of point-of-care C reactive protein (CRP) testing on patient-relevant outcomes in children and adults in ambulatory care.

DESIGN

This was a systematic review to identify controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services. Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, DARE, Science Citation Index were searched from inception to March 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services, measuring a change in clinical care, including but not limited to antibiotic prescribing rate, reconsultation, clinical recovery, patient satisfaction, referral and additional tests. No language restrictions were applied.

DATA EXTRACTION

Data were extracted on setting, date of study, a description of the intervention and control group, patient characteristics and results. Methodological quality of selected studies and assessment of potential bias was assessed independently by two authors using the Cochrane Risk of Bias tool.

RESULTS

11 randomised controlled trials and 8 non-randomised controlled studies met the inclusion criteria, reporting on 16 064 patients. All included studies had a high risk of performance and selection bias. Compared with usual care, point-of-care CRP reduces immediate antibiotic prescribing (pooled risk ratio 0.81; 95% CI 0.71 to 0.92), however, at considerable heterogeneity (I2=72%). This effect increased when guidance on antibiotic prescribing relative to the CRP level was provided (risk ratios of 0.68; 95% CI 0.63 to 0.74 in adults and 0.56; 95% CI 0.33 to 0.95 in children). We found no significant effect of point-of-care CRP testing on patient satisfaction, clinical recovery, reconsultation, further testing and hospital admission.

CONCLUSIONS

Performing a point-of-care CRP test in ambulatory care accompanied by clinical guidance on interpretation reduces the immediate antibiotic prescribing in both adults and children. As yet, available evidence does not suggest an effect on other patient outcomes or healthcare processes.

PROSPERO REGISTRATION NUMBER

CRD42016035426; Results.

Comparison of the use of comprehensive point-of-care test panel to conventional laboratory process in emergency department

BACKGROUND

In this study, we hypothesized that point of care testing (POCT) would reduce length of stay (LOS) in emergency department (ED) when compared to central laboratory testing and be a factor in patient discharge destination.

METHODS

A single centre observational study was performed in ED non-ambulatory patients. Blood testing was performed either with POC instruments for blood gases and chemistry panel, full blood count, and CRP, or at central laboratory, or as a combination of both. Blood draw and POCTs were performed by experienced nurses.

RESULTS

During the 4-week study period, 1759 patients underwent sample testing (POCT: n = 160, central lab: n = 951; both n = 648). Median waiting time for blood sampling was 19 min less in POCT than central laboratory (0:52 (95% confidence interval (CI) 0:46-1:02) vs. 1:11 (95% CI 1:05-1:14), p < 0.001). POCT results were available faster in both discharge groups, as expected. When imaging was not required, patients in POCT group were discharged home 55 min faster (4:57 (95% CI 3:59-6:17) vs. 5:52 (95% CI 5:21-6:35), p = 0.012) and 1 h 22 min faster when imaging was performed (5:48 (95% CI 5:26-6:18) vs. 7:10 (95% CI 6:47-8:26), p = 0.010). Similar reduction in sampling time and LOS was not seen among those admitted to hospital.

CONCLUSIONS

POCT shortened the laboratory process and made results available faster than the central lab. This allowed patients to be discharged home quicker. Thus, with proper training and education of the ED care team, POCT can be used as an effective tool for improving patient flow.

Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians

STUDY OBJECTIVE

Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician-based protocol when no stroke neurologist is available.

METHODS

This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization.

RESULTS

A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval -8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization.

CONCLUSION

Implementation of a stroke protocol with emergency physician-directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.

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.

The Utility of Point-of-Care Testing at Emergency Department Triage by Nurses in Simulated Scenarios

We developed and tested simulated patient scenarios to assess how normal or abnormal point-of-care (POC) test results at triage change prioritization decisions. This was a cross-sectional study where our team developed simulated scenarios and presented them to triage nurses from 3 academic medical centers. Twenty-four scenarios were constructed on the basis of 12 clinical indications from a protocol previously developed by our team. In each scenario, nurses were presented with 2 patients with the same Emergency Severity Index Version 4 (ESI v.4; Agency for Healthcare Research and Quality, Rockville, MD) triage level (Level 2 or Level 3). One of the patients met the inclusion criteria for POC testing under the protocol (cases), whereas the other patient did not (controls). Nurses were asked which of the 2 patients to prioritize first in 3 separate rounds: first without any POC test results, once with abnormal POC test results for case patients, and once with normal POC test results for case patients. Prioritization decisions that changed on the basis of abnormal POC results were defined as "up-triage" and prioritization decisions that changed on the basis of normal results were defined as "down-triage." A total of 39 nurses completed 468 scenarios. In scenarios without any POC test results, 42.3% of case patients were prioritized first. When POC test results were abnormal, 71.6% of cases were prioritized first. When POC test results were normal, 32.7% of case patients were prioritized first. An abnormal POC test resulted in up-triage in 32.5% of the scenarios. When POC test results were normal, there was down-triage in 18.6% of the scenarios. Up- and down-triage rates varied considerably by scenario and clinical indication. Point-of-care testing at emergency department triage results in reasonably high rates of up- and down-triage in simulated scenarios; however, POC tests for specific indications appear to be more useful than others.

Emergency medicine for 25 Years in Iceland - history of the specialty in a nutshell

After the early implementation of Emergency Medicine (EM) 25 years ago, Iceland became the first Nordic country to nationally realize the benefits of this specialty. However, the road has been rocky as in many other countries. The early years of EM in Iceland were characterized by a significant shortage of resources, particularly a lack of medical staff dedicated to EM and properly trained for the services required. The main task for the first couple of decades was to build the infrastructure of an operational emergency department based primarily on the model of EM. Although these efforts eventually led to a critical number of specialists becoming certified in EM, recruiting more people remains a priority in order to fully meet the need for specialty trained emergency physicians in Iceland. A key step towards achieving this goal was the initiation of a two-year residency program for specialty training in EM in year 2002. The program was based on a curriculum produced by the Icelandic Society for Emergency Medicine, which had been founded in year 2000. This training program is currently being redeveloped and the curriculum of the Royal College of Emergency Medicine in the UK will be adopted for use in Iceland. Another important milestone was the appointment of the first faculty member dedicated to EM at the University of Iceland. This created an opportunity to teach medical students EM and advance training at the graduate level. Also, conditions for scientific research in EM have been improved, following the establishment of an EM research institute in 2010.

Other Nordic countries may be able to benefit from lessons learned and experiences gained from the development of emergency medicine in Iceland during the past quarter of a century.

Diagnostic performances of the Xpert® Flu PCR test and the OSOM® immunochromatographic rapid test for influenza A and B virus among adult patients in the Emergency Department

BACKGROUND

New rapid influenza diagnostic tests (RIDT) are available but their clinical utility in adults has not been validated.

OBJECTIVES

To evaluate the diagnostic performances of OSOM^® Ultra Flu A&B a RIDT on viral strains of influenza A/B from the last epidemic season, and its feasibility by Emergency Department (ED) physicians and nurses.

STUDY DESIGN

Of the 1099 patients admitted to the ED with suspected influenza, all having a nasopharyngeal swab tested by the Xpert^® Flu PCR and then stored at -20 °C; 500 were selected at random and their samples were tested using the RIDT. Two experts reviewed ED and hospital medical records and all virological data to define influenza cases. Intra- and inter-observer variability were calculated.

RESULTS

Of the 500 patients included 45% were ≥75 years, 122 (24.4%) presented with influenza based on clinical and virological criteria. PCR test performances (%) were Se 98.4 (95% CI 93.6-99.7), Spe 99.7 (98.3-100), PPV 99.2 (94.8-100) and NPV 99.5 (97.9-100); and RIDT performances were Se 95.1 (89.2-97.9), Spe 98.4 (96.4-99.4), PPV 95.1 (87.2-99.9) and NPV 98.4 (96.4-98). There was no difference in test performance between influenza A and B virus nor between the influenza A subtypes. Intra- and inter-observer variability of RIDT were 0.94 (0.89-0.99) and 0.96 (0.92-1).

CONCLUSION

Our results show that the Xpert^® Flu PCR and the OSOM^® Ultra Flu A&B Test perform very well in diagnosing strains of circulating virus in adults and elderly. Our results also confirm the feasibility of this RIDT at point-of-care by ED staff.

Point-of-care testing (POCT) and evidence-based laboratory medicine (EBLM) - does it leverage any advantage in clinical decision making?

Point-of-care testing (POCT) is the analysis of patient specimens outside the clinical laboratory, near or at the site of patient care, usually performed by clinical staff without laboratory training, although it also encompasses patient self-monitoring. It is able to provide a rapid result near the patient and which can be acted upon immediately. The key driver is the concept that clinical decision making may be delayed when samples are sent to the clinical laboratory. Balanced against this are considerations of increased costs for purchase and maintenance of equipment, staff training, connectivity to the laboratory information system (LIS), quality control (QC) and external quality assurance (EQA) procedures, all required for accreditation under ISO 22870. The justification for POCT depends upon being able to demonstrate that a more timely result (shorter turnaround times (TATs)) is able to leverage a clinically important advantage in decision making compared with the central laboratory (CL). In the four decades since POCT was adapted for the self-monitoring of blood glucose levels by subjects with diabetes, numerous new POCT methodologies have become available, enabling the clinician to receive results and initiate treatment more rapidly. However, these instruments are often operated by staff not trained in laboratory medicine and hence are prone to errors in the analytical phase (as opposed to laboratory testing where the analytical phase has the least errors). In some environments, particularly remote rural settings, the CL may be at a considerable distance and timely availability of cardiac troponins and other analytes can triage referrals to the main centers, thus avoiding expensive unnecessary patient transportation costs. However, in the Emergency Department, availability of more rapid results with POCT does not always translate into shorter stays due to other barriers to implementation of care. In this review, we apply the principles of evidence-based laboratory medicine (EBLM) looking for high quality systematic reviews and meta-analyses, ideally underpinned by randomized controlled trials (RCTs), looking for evidence of whether POCT confers any advantage in clinical decision making in different scenarios.

Overcrowding in emergency departments: A review of strategies to decrease future challenges

Emergency departments (EDs) are the most challenging ward with respect to patient delay. The goal of this study is to present strategies that have proven to reduce delay and overcrowding in EDs. In this review article, initial electronic database search resulted in a total of 1006 articles. Thirty articles were included after reviewing full texts. Inclusion criteria were assessments of real patient flows and implementing strategies inside the hospitals. In this study, we discussed strategies of team triage, point-of-care testing, ideal ED patient journey models, streaming, and fast track. Patients might be directed to different streaming channels depending on clinical status and required practitioners. The most comprehensive strategy is ideal ED patient journey models, in which ten interrelated substrategies are provided. ED leaders should apply strategies that provide a continuous care process without deeply depending on external services.