Point-Of-Care Testing Curriculum and Accreditation for Public Health-Enabling Preparedness, Response, and Higher Standards of Care at Points of Need

Best Practices for Effective Management of Point of Care Testing

With the recent COVID-19 pandemic, point-of-care testing has gained tremendous attention, particularly in acute care settings. The point-of-care testing landscape is rapidly expanding and being contemplated for any crucial test with a central laboratory turnaround time >25% of the clinical decision time. A typical point-of-care testing program within a large hospital system encompasses a multitude of operators utilizing a wide range of devices across multiple testing sites. Thus, managing a large point-of-care testing network remains a daunting task with challenges related to staffing, standardization, quality management, training and competency assessment, and data management. This review will focus on understanding the general organization as well as the roles and responsibilities of various point-of-care testing stakeholders in addressing these challenges. More importantly, it will discuss the strategies and best practices for effective point-of-care testing management based on consensus recommendations from professional societies as well as our experience at Texas Childrens Hospital.

Assessing Third-Year Medical Students' Perspective on Point of Care Testing Boot Camp: From Bench to Bedside

BACKGROUND

Point-of-care testing (POCT), which is also known as bed side-testing, has been integrated into the healthcare system, offering faster results that can lead to improved patient outcomes. POCT was missing from the medical education curriculum in our institute.

OBJECTIVES

The primary objective of this study was to describe the development and introduce POCT training for medical students in a medical college in Pakistan.Secondary objectives were to evaluate student performance on POCT content and to assess the impact of POCT training via students' feedback.

METHODOLOGY

The boot camp experience was devised, directed, and facilitated by team constituting of Chemical Pathology faculty members, laboratory technologists and teaching assistants. The program included presentations, demonstrations of POCT instrument handling, supervised hands-on individual performance on glucometer using quality control specimens, competency assessment and sign off followed by interactive case-based discussions. A knowledge quiz via Kahoot was administered at the beginning and end of the experience and scores were compared statistically. Online evaluation and feedback were designed via virtual learning environment based on 10 questions regarding the program and methodology using on a five-point Likert Scale. Frequencies were generated and t-tests were employed to determine pre-post differences.

RESULTS

The boot camp was spread over 2 days and ran three hours each day with the third-year medical students class split into two groups (n=80). On knowledge evaluation, the mean group pre and post test scores were 45% and 95% respectively (p-value =< 0.05). On documented structured competency assessment form a score of 95 was achieved by 100% participants. Positive feedback of 4 or more was recorded on the Likert's scale by 100% respondents.

CONCLUSION

This POCT boot camp experience can be used by other institutions and can be applied at different times during the medical school curriculum and other professional education programs. This bootcamp will be helpful to educate medical students, postgraduate trainees and field workers working in rural areas and in low resource settings to deliver reliable POC tests results. Future research should examine these students' competence in achieving POCT skills when they enter in clinical practice.

Optimizing Public Health Preparedness for Highly Infectious Diseases in Central Vietnam

Our primary objectives were (a) to determine the need for and the availability of point-of-care testing (POCT) for infectious diseases and (b) to recommend point-of-care testing strategies and Spatial Care Paths^TM (SCPs) that enhance public health preparedness in the regional districts of Thua Thien Hue Province (TTHP), Central Vietnam, where we conducted field surveys. Medical professionals in seven community health centers (CHCs), seven district hospitals (DHs) and one provincial hospital (PH) participated. Survey questions (English and Vietnamese) determined the status of diagnostic testing capabilities for infectious diseases and other acute medical challenges in TTHP. Infectious disease testing was limited: six of seven CHCs (86%) lacked infectious disease tests. One CHC (14%, 1/7) had two forms of diagnostic tests available for the detection of malaria. All CHCs lacked adequate microbiology laboratories. District hospitals had few diagnostic tests for infectious diseases (tuberculosis and syphilis), blood culture (29%, 2/7), and pathogen culture (57%, 4/7) available. The PH had broader diagnostic testing capabilities but lacked preparedness for highly infectious disease threats (e.g., Ebola, MERS-CoV, SARS, Zika, and monkeypox). All sites reported having COVID-19 rapid antigen tests; COVID-19 RT-PCR tests were limited to higher-tier hospitals. We conclude that infectious disease diagnostic testing should be improved and POC tests must be supplied near patients’ homes and in primary care settings for the early detection of infected individuals and the mitigation of the spread of new COVID-19 variants and other highly infectious diseases.

The Coronavirus Disease 2019 Spatial Care Path: Home, Community, and Emergency Diagnostic Portals

This research uses mathematically derived visual logistics to interpret COVID-19 molecular and rapid antigen test (RAgT) performance, determine prevalence boundaries where risk exceeds expectations, and evaluate benefits of recursive testing along home, community, and emergency spatial care paths. Mathematica and open access software helped graph relationships, compare performance patterns, and perform recursive computations. Tiered sensitivity/specificity comprise: (T1) 90%/95%; (T2) 95%/97.5%; and (T3) 100%/≥99%, respectively. In emergency medicine, median RAgT performance peaks at 13.2% prevalence, then falls below T1, generating risky prevalence boundaries. RAgTs in pediatric ERs/EDs parallel this pattern with asymptomatic worse than symptomatic performance. In communities, RAgTs display large uncertainty with median prevalence boundary of 14.8% for 1/20 missed diagnoses, and at prevalence > 33.3−36.9% risk 10% false omissions for symptomatic subjects. Recursive testing improves home RAgT performance. Home molecular tests elevate performance above T1 but lack adequate validation. Widespread RAgT availability encourages self-testing. Asymptomatic RAgT and PCR-based saliva testing present the highest chance of missed diagnoses. Home testing twice, once just before mingling, and molecular-based self-testing, help avoid false omissions. Community and ER/ED RAgTs can identify contagiousness in low prevalence. Real-world trials of performance, cost-effectiveness, and public health impact could identify home molecular diagnostics as an optimal diagnostic portal.

COVID-19 challenges: From SARS-CoV-2 infection to effective point-of-care diagnosis by electrochemical biosensing platforms

In January 2020, the World Health Organization (WHO) identified a new zoonotic virus, SARS-CoV-2, responsible for causing the COVID-19 (coronavirus disease 2019). Since then, there has been a collaborative trend between the scientific community and industry. Multidisciplinary research networks try to understand the whole SARS-CoV-2 pathophysiology and its relationship with the different grades of severity presented by COVID-19. The scientific community has gathered all the data in the quickly developed vaccines that offer a protective effect for all variants of the virus and promote new diagnostic alternatives able to have a high standard of efficiency, added to shorter response analysis time and portability. The industry enters in the context of accelerating the path taken by science until obtaining the final product. In this review, we show the principal diagnostic methods developed during the COVID-19 pandemic. However, when we observe the diagnostic tools section of an efficient infection outbreak containment report and the features required for such tools, we could observe a highlight of electrochemical biosensing platforms. Such devices present a high standard of analytical performance, are low-cost tools, easy to handle and interpret, and can be used in the most remote and low-resource regions. Therefore, probably, they are the ideal point-of-care diagnostic tools for pandemic scenarios.

Public Health Education Should Include Point-of-Care Testing: Lessons Learned from the Covid-19 Pandemic

GOAL

The goal is to present key principles of point-of-care testing (POCT) in educational curricula that meet critical needs for rapid decision-making in disasters, outbreaks of highly infectious diseases, emergency management, and complex crises.

OBSERVATIONS

The coronavirus disease 19 (COVID-19) pandemic unequivocally proved the value of POC strategies. Striking needs identified by COVID-19 challenges have yet to be entirely fulfilled. A comprehensive national survey showed absence of POCT training in public health colleges, schools, and programs. Fundamental improvements in national structuring of POC knowledge, skills, experience, training, dissemination, accreditation, and licensing are necessary, so that multidisciplinary public health teams can respond effectively and efficiently by geospatially optimizing the control and mitigation of highly infectious diseases and other critical challenges.

CONCLUSIONS

Four sets of POCT learning objectives were developed for public health and other educational institutions. Global implementation of POC diagnostics in the hands of trained personnel will help avoid untimely worldwide crises, huge economic losses, uncounted excess mortality, and sudden disruptive surges of dangerous infectious threats to personal security and cultural stability.

DIAGNOSTIC STRATEGIES FOR ENDEMIC CORONAVIRUS DISEASE 2019 (COVID-19): RAPID ANTIGEN TESTS, REPEAT TESTING, AND PREVALENCE BOUNDARIES

CONTEXT

- Coronavirus disease 2019 (COVID-19) rapid antigen tests generate intrinsically fast, inherently spatial, and immediately actionable results. They quickly confirm COVID-19, but weakly rule out infection. Test performance depends on prevalence and testing protocol. Both affect predictive values.

OBJECTIVES

- To use original mathematics and visual logistics for interpreting COVID-19 rapid antigen test performance patterns, gauge the influence of prevalence, and evaluate repeated testing.

DESIGN

- Mathematica and open access software helped graph relationships, perform recursive computations, and compare performance patterns. PubMed retrieved articles addressing endemic COVID-19.

RESULTS

- Tiered sensitivity/specificity comprise: T1) 90%/95%; T2) 95%/97.5%; and T3) 100%/≥99%, respectively. Performance of self- and home antigen tests with Food and Drug Administration Emergency Use Authorization peaks in low prevalence. Fall-off in performance appears with increasing prevalence because suboptimal sensitivity creates false negatives. The rate of false omissions limits clinical use because of prevalence boundaries based on tolerance for risk. Mathematical analysis supports testing twice to improve predictive values and extend prevalence boundaries nearly to levels of herd immunity.

CONCLUSIONS

- COVID-19 is quickly becoming endemic. Suboptimal sensitivity of rapid antigen tests limits performance in high prevalence. Risk of contagion in packed spaces (e.g., airplanes) might be avoided with dual testing 36 hours apart, allowing time for viral load to increase. Awareness of community prevalence and proof of improved performance with repeated testing will help manage COVID-19 risk, while meeting rapid decision-making needs for highly contagious and new variants (e.g., Delta). New COVID-19 variants call for high quality, low cost, readily accessible, fast, user friendly, and ubiquitous point-of-care testing.

The Impact of Increasing Disease Prevalence, False Omissions, and Diagnostic Uncertainty on Coronavirus Disease 2019 (COVID-19) Test Performance

CONTEXT.—

Coronavirus disease 2019 (COVID-19) test performance depends on predictive values in settings of increasing disease prevalence. Geospatially distributed diagnostics with minimal uncertainty facilitate efficient point-of-need strategies.

OBJECTIVES.—

To use original mathematics to interpret COVID-19 test metrics; assess US Food and Drug Administration Emergency Use Authorizations and Health Canada targets; compare predictive values for multiplex, antigen, polymerase chain reaction kit, point-of-care antibody, and home tests; enhance test performance; and improve decision-making.

DESIGN.—

PubMed/newsprint-generated articles documenting prevalence. Mathematica and open access software helped perform recursive calculations, graph multivariate relationships, and visualize performance by comparing predictive value geometric mean-squared patterns.

RESULTS.—

Tiered sensitivity/specificity comprised: T1, 90%, 95%; T2, 95%, 97.5%; and T3, 100%, ≥99%. Tier 1 false negatives exceeded true negatives at >90.5% prevalence; false positives exceeded true positives at <5.3% prevalence. High-sensitivity/specificity tests reduced false negatives and false positives, yielding superior predictive values. Recursive testing improved predictive values. Visual logistics facilitated test comparisons. Antigen test quality fell off as prevalence increased. Multiplex severe acute respiratory syndrome (SARS)-CoV-2)*influenza A/B*respiratory syncytial virus testing performed reasonably well compared with tier 3. Tier 3 performance with a tier 2 confidence band lower limit will generate excellent performance and reliability.

CONCLUSIONS.—

The overriding principle is to select the best combined performance and reliability pattern for the prevalence bracket. Some public health professionals recommend repetitive testing to compensate for low sensitivity. More logically, improved COVID-19 assays with less uncertainty conserve resources. Multiplex differentiation of COVID-19 from influenza A/B-respiratory syncytial virus represents an effective strategy if seasonal flu surges next year.

Training and Competency Strategies for Point-of-Care Testing

The increased availability and use of POCT are being influenced by many factors, such as; industry trends to move towards patient-centered care and healthcare decentralization, the increasing prevalence of infectious diseases also including the current use of Rapid SARS-CoV-2 Testing, a growing incidence of lifestyle diseases such as diabetes, heart disease, and hypertension, as well as advances in in-vitro diagnostic medical technologies. The use of POCT can increase the efficiency of services and improve outcomes for patients. However, the variability of the testing environment and conditions as well as the competency of staff performing the tests may have a significant impact on the quality and accuracy of POCT results. A majority of the staff who perform POCT are not trained laboratory staff and may not be as knowledgeable about the processes involved in testing, such as patient preparation, sample collection, management of equipment and supplies, instrument calibration and maintenance, the performance of the test, quality control, interpretation of the results, and reporting/documentation of results in each patient's context. Therefore, staff performing POCT must have the proper training and experience to ensure test results are accurate and reliable. This short communication outlines the specific requirements for staff training based on international standards which need to be considered to ensure the quality of test results and describes competency criteria required for compliance with POCT.

Designing and Interpreting Coronavirus Disease 2019 (COVID-19) Diagnostics: Mathematics, Visual Logistics, and Low Prevalence

CONTEXT.—

Coronavirus infectious disease-19 (COVID-19) diagnostics require understanding of how predictive values depend on sensitivity, specificity, and especially, low prevalence. Clear expectations, high sensitivity and specificity, and manufacturer disclosure will facilitate excellence of tests.

OBJECTIVES.—

To derive mathematical equations for designing and interpreting COVID-19 tests, assess US Food and Drug Administration (FDA) Emergency Use Authorization and Health Canada minimum requirements, establish sensitivity and specificity tiers, and enhance clinical performance in low prevalence settings.

DESIGN.—

PubMed and other sources generated articles on COVID-19 testing and prevalence. EndNote X9.1 consolidated references. Mathematica and open access software helped prove equations, perform recursive calculations, graph multivariate relationships, and visualize patterns, including a new relationship, predictive value geometric mean-squared.

RESULTS.—

Derived equations were used to illustrate shortcomings of COVID-19 diagnostics in low prevalence. Visual logistics helped establish sensitivity/specificity tiers. FDA/Canada's 90% sensitivity, 95% specificity minimum requirements generate excessive false positives at low prevalence. False positives exceed true positives at prevalence lower than 5.3%, or if sensitivity is improved to 100% and specificity to 98%, at prevalence lower than 2%. Recursive testing improves predictive value. Three tiers emerged from these results. With 100% sensitivity, physicians can select desired predictive values, then input local prevalence, to determine suitable specificity.

CONCLUSIONS.—

Understanding low prevalence impact will help health care providers meet COVID-19 needs for effective testing. Laypersons should receive clinical performance disclosure when submitting specimens. Home testing needs to meet the same high standards as other tests. In the long run, it will be more cost-effective to improve COVID-19 point-of-care tests rather than repeat testing multiple times.

Geospatial Hotspots Need Point-of-Care Strategies to Stop Highly Infectious Outbreaks

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.

Geospatial Science and Point-of-Care Testing: Creating Solutions for Population Access, Emergencies, Outbreaks, and Disasters

Objectives: (a) To understand how to integrate geospatial concepts when implementing point-of-care testing (POCT); (b) to facilitate emergency, outbreak, and disaster preparedness and emergency management in healthcare small-world networks; (c) to enhance community resilience by using POCT in tandem with geographic information systems (GISs) and other geospatial tools; and (d) to advance crisis standards of care at points of need, adaptable and scalable for public health practice in limited-resource countries and other global settings.

Content: Visual logistics help integrate and synthesize POCT and geospatial concepts. The resulting geospatial solutions presented here comprise: (1) small-world networks and regional topography; (2) space-time transformation, hubs, and asset mapping; (3) spatial and geospatial care paths™; (4) GIS-POCT; (5) isolation laboratories, diagnostics isolators, and mobile laboratories for highly infectious diseases; (6) alternate care facilities; (7) roaming POCT—airborne, ambulances, space, and wearables; (8) connected and wireless POCT outside hospitals; (9) unmanned aerial vehicles; (10) geospatial practice—demographic care unit resource scoring, geographic risk assessment, and national POCT policy and guidelines; (11) the hybrid laboratory; and (12) point-of-careology.

Value: Small-world networks and their connectivity facilitate efficient and effective placement of POCT for optimal response, rescue, diagnosis, and treatment. Spatial care paths™ speed transport from primary encounters to referral centers bypassing topographic bottlenecks, process gaps, and time-consuming interruptions. Regional GISs position POCT close to where patients live to facilitate rapid triage, decrease therapeutic turnaround time, and conserve economic resources. Geospatial care paths™ encompass demographic and population access features. Timeliness creates value during acute illness, complex crises, and unexpected disasters. Isolation laboratories equipped with POCT help stop outbreaks and safely support critically ill patients with highly infectious diseases. POCT-enabled spatial grids can map sentinel cases and establish geographic limits of epidemics for ring vaccination.

Impact: Geospatial solutions generate inherently optimal and logical placement of POCT conceptually, physically, and temporally as a means to improve crisis response and spatial resilience. If public health professionals, geospatial scientists, and POCT specialists join forces, new collaborative teamwork can create faster response and higher impact during disasters, complex crises, outbreaks, and epidemics, as well as more efficient primary, urgent, and emergency community care.