Ronald's story illustrates how undiagnosed medical issues led to repeated falls and eventual loss of independence. The project aimed to use point-of-care blood testing (POCBT) by paramedics on elderly patients presenting with acute frailty syndromes to inform safe hospital avoidance, enable earlier disease management, and increase clinician confidence. Initial results found POCBT improved discharge rates and recontact rates compared to previous frailty projects, and case studies showed it supported earlier disease identification and management. While more research is needed, the quality improvement project demonstrated POCBT's potential positive impact on assessing and treating elderly patients experiencing acute frailty.
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UK Diagnostics
1. POINT OF CARE BLOOD TESTING (POCBT)
FOR PATIENTS >65 YEARS PRESENTING
WITH ACUTE FRAILTY SYNDROMES.
Using diagnostics to improve clinician confidence in discharge
of patients presenting with acute frailty syndromes.
3. RONALD’S STORY
Fall 1:
• Ambulance
• Non Injury
• Non urgent
falls referral
Fall 2:
• 111 - GP
• Non Injury
• Not seen
Fall 3:
• Ambulance
• Non Injury
• No referral
made
Fall 4:
• Neck of Femur #
• Loss of independence
• Complaint from hospital
Hb 75 g/L
4. BIOCHEMICAL AND
HAEMATOLOGICAL
CONTRIBUTORS TO FALLS WHO epidemiology of falls
Cognitive deficit
hypercalcaemia,
hyponatraemia,
hypo/ hyperglycaemia
Renal failure
hypoxia from respiratory failure,
Muscle weakness
Anaemia,
Hypocalcaemia
Hypokalaemia/ hyperkalaemia
5. THE PROJECT
1 x iSTAT alinity
CRG4+ and CHEM8 Cartridges
4 Specialist Paramedics + 4 Frailty Paramedics
Patients >65 years presenting with acute frailty
syndromes
11. DEPLOYMENT AND
REFERRALS
Device used on specialist Paramedic car
plus falls and frailty response vehicle
Deployment
Self deployment
Specialist Paramedic Hub
Referrals
Crew referrals
12. SAFETY NETS
• Standard Operating
procedures
• Team training
• Access to previous
results
• GP telephone triage
and advice
• Multiple PDSA cycles
13. RESULTS
78 patients involved
Improvement in reported
clinician confidence
Improved discharge on
scene and recontact
rates (when compared
with frailty specific
project)
Case studies support
earlier disease
management.
19. KEY LEARNINGS
Learning
Cost vs benefit Patient demographic selection is vital
Targeted use of device on selected resources
Access to
previous results
Recognition of the normally abnormal
ICE (Integrated Clinical Access) access
Appropriate
training of the
team
Initial group training run by qualified ACP
Monthly 1-2-1 sessions with team
Senior support – GP or Medical team
Use in
prognosticating
infection
Lactate alone is not sufficient to identify early sepsis
Logistics Temperature management
Cartridge management
21. CONCLUSION
Whilst formal research is required
to validate its use, this
QIP showed POCbT to have a
positive impact on all stated
aims. The projects results,
whilst taken from a small sample
size and of limited transferability,
show promise for POCbT
in both the pre-hospital environment
and in the field of frailty.
Introduction to the project
My background is as a specialist paramedic with south central ambulance and I am currently training as an advanced clinical practitioner at the University hospital Southampton. Last year I was fortunate enough to be on a HEETV funded program for trainee ACPs which gave me the opportunity to develop a quality improvement plan aimed at improving diagnostics for the frail older person.
About 10% of people with a hip fracture die within 1 month and about 30% within 12 months – NICE
In sept 2017 – March 2018 I trained 4 Sps and 4 frailty paramedics in the use of the iSTAT Alinity device with CRG4+ and CHEM8 Cartridges.
Specialist Paramedics are Paramedics who have gone on to do masters modules to specialise in critical or urgent care and frailty paramedics are Paramedics who work on the falls and frailty car and have a special interest in frailty.
We targeted Patients >65 years old presenting to the ambulance service with acute frailty syndromes and in whom their disposition is unclear – Just to explain that – In the ambulance service once assessing a patient we must make a decision about their best treatment location – For some it is very clear that definitive care should be provided in hospital, for others it is abundantly clear that either primary care management (or no management at all) is required. However often patients sit in an area of uncertainty between the two which can cause a great deal of anxiety among a paramedic who is often working without senior support. In particular, the frail older person – through no fault of their own, commonly falls into this group of unclear disposition.
Rationale
Specialist Paramedics are currently used within the south central ambulance service to make advanced decisions regarding hospital admission, treatment and referral. They do this utilising a range of advanced assessment skills and treatment skills however have no additional diagnostic tools. It stood to reason that a workforce trained in advanced diagnostics could utilise PoCT bloods to assist their decision making and perhaps enable more appropriate treatment and referral thus preventing deterioration of illness and or avoidable hospital admissions. Observation from practice identified that patients with frailty in the emergency department are commonly investigated with basic blood tests, ECGs, observations and physical examination. In the absence of blood tests in the pre hospital environment staff may be susceptible to over sensitive triage of the frail older person which in turn can contribute to inappropriate admission21. Admission to hospital results in poor functional outcomes for patients living with frailty4 thus increasing the need to avoid unnecessary admission from the pre-hospital environment. This knowledge provided the basis for formulation of this quality improvement project.
Acute frailty syndromes
Acute frailty syndromes, like the proverbial tip of the iceberg, are seemingly benign symptoms that can mask serious underlying injury. It is vital we go looking for the cause.
Aims
When I started out with this project I had three main aims. These were:
Safer discharges - measured by recontact rates and results affecting decision making
Earlier disease management - measured by onward referrals and hospital length of stay
Increased clinician confidence - measured by self report in response to qualitative questions
However as I began to do background research and even more so as the project commenced another aim developed and this was to increase the knowledge of Point-of -care-blood-testing in the pre hospital environment.
The reason for this final aim was that despite a fairly robust literature search there seemed to be a significant lack of published evidence in its use.
Evidence
The most notable use of pre-hospital point of care testing I found was the Labkit® Near Patient Diagnostics service tested with Surry pathology services and South East Coast ambulance service. This project involved a three phase trial that researched effective functionality, pre-hospital suitability and impact on patient management20, the outcomes of which are unclear. Whilst promotional material for the study reported positive outcomes I was unable to find a full peer reviewed publication of the study.
There were two pre-hospital studies carried out in Germany, the first looking at using the i-STAT troponin I to facilitate the early identification of Non ST Segment Elevation Myocardial Infarction and the second to monitor critical care patients during Helicopter Emergency Medical Services (HEMS) transfer to hospital.
The troponin study found the POCT results to be accurate but not diagnostic due to the common requirement for serial troponin monitoring in hospital9. The second study into use of POCT on HEMS inter hospital transfers identified a need for transfer of real time results to achieve patient benefit. Whist interesting, both studies lack transferability to the UK pre-hospital see and treat model due to their focus on critically ill patients whose trajectory of care is pre-determined by their potential or realised illness.
It seemed to me that I was hearing of many NHS services ranging from OOH primary care to emergency services and secondary care using POCbT but that no-one seemed to be sharing their learning.
So, In addition to trying to use this diagnostic tool to facilitate the assessment and management of acute frailty syndromes I hoped to generate knowledge that could be disseminated on pre-hospital POCbT.
Project - iSTAT
So how did the project actually work?
Firstly we used the iSTAT alinity device – this is an example of it here and I also have one that I will pass around the room for you to look at.
The iSTAT device is a handheld device that uses only a small sample of blood inserted into single use cartridges producing a result within minutes. This met the requirements of the pre-hospital environment for a number of reasons. Firstly it was small enough to carry around (has anyone seen the amount of kit a paramedic carries into any job – trust me a small lightweight device was essential), secondly it was quick (when we are asked to make a transport decision with 30 minutes on scene it is vital that results return quickly) and finally it was simple to use. (Vital because it was me using it!!)
We chose the CRG4+ and CHEM8 cartridges as they most closely resembled routine bloods carried out in the hospital environment and could identify common causes of acute frailty syndromes such as anaemia, electrolyte disturbances and altered respiratory or metabolic function.
The device was placed on the Reading specialist paramedic car during the week and the falls and frailty response car Saturday – Monday.
Project – Patient selection and referrals
Patient were identified through a number of means – the most common was specialist paramedic selection once with the patient or via the CAD system as jobs came in.
We also used the specialist paramedic hub to notify of us of any jobs in the area presenting with acute frailty syndromes
And we also received crew referrals from other paramedics and technicians who were with a patient and were unsure of their disposition.
Once with the patient, informed consent was obtained and the patient outcome later followed up through the ambulance CAD system or hospital notes.
Safety netting
Of course the introduction of a new diagnostic tool is not without its risks so it was important to put some safety nets in place.
Standard Operating procedures were written up and reviewed by specialist paramedic managers and staff were given training in both the use of the iSTAT and the interpretation of blood results.
I was able to establish access to the Integrated Clinical Environment (ICE) which gave us access to our patients most recent blood results – this was done in recognition of the fact that this patient group often has normally abnormal blood results and we needed to know when to act on abnormal results.
As paramedics we have access to GP telephone triage (which if there are any GPs in the room we are eternally grateful for!!). All staff trained on the iSTAT were encouraged to discuss abnormal results with the patients GP or OOH GP if there was any difficulty interpreting these.
And finally the project was subject to multiple PDSA cycles with changes being made to improve safety throughout as learning increased.
Results:
The quality improvement project recruited 78 patients aged 65 years to 97 years
There was an even split between male and female
The majority of presenting complaints were falls – I think this is for two reasons – firstly the use of the falls and frailty response car pre-disposed clinicians to this presenting complaint but secondly falls are a very common presenting complaint to the ambulance service and would be more common and easier to identify that other acute frailty syndromes.
Results outside of reference ranges were found in 55.1% of the cases with only half of these requiring clinical action or referral.
Only 14 of the 73 patients required transport to the emergency department as a result of abnormal blood results and all of these were subsequently admitted under specialty into hospital. Patients who returned abnormal blood results but that were not transported to hospital received an outpatient frailty specific referral such as falls clinic, Parkinson’s specialist team or a rapid access clinic for the older person
Clinicians reported improved decision making and confidence in >75% of the cases however in some circumstances clinicians felt that blood results actually confused them further.
And finally the project showed to have improved discharge on scene rates and reduced recontact rates when compared with a similar frailty specific project the previous year.
It is important to note when hearing these results that further formal research is required to validate these results but it does show promise for the use of POCbT both pre-hospital and in the field of frailty.
Case examples
Case 1: Brenda was an 84 year old female with learning difficulties, HTN and osteoporosis presenting with an explained fall in the early hours of the morning. On initial assessment the patient was uninjured, fully mobile, alert and orientated with a slightly raised respiratory rate and SP02 of 88% in the presence of sever kyphosis. The clinician was unsure if this respiratory rate and oxygen saturations were normal for her due to her severe kyphosis and Initial thought was given to providing oral antibiotics and discharging on scene. When POCbT results returned and were compared with results taken 10 days earlier she was found to have a new severe hyponatraemia and respiratory acidosis. With these new findings it was deemed necessary to admit the patient to the emergency department to investigate the underlying cause of these acute findings. The patient was subsequently admitted to the medical team with a diagnosis of pneumonia and hyponatraemia from ED and the receiving medical doctor provided positive feedback regarding its use on this job.
Case 2: 94 year old male who had fallen but due to advanced dementia could not remember how. He had last been seen by his carers late the evening before and was found first thing on the morning beside his bed. Clinical examination was able to rule out significant head injury or acute illness but in these patients a creatine kinase is usually required to exclude acute kidney injury. However due to the availability of urea and creatinine through the iSTAT and access to recent results we could apply the RIFLE and AKIN criteria for acute kidney injury and refer the patient to GP for follow up bloods to ensure no further progression.
Case 3: Dot was an 86 year old lady who had been recently discharged from hospital on furosemide for fluid overload secondary to heart failure. She had been doing well at home up until the last couple of days when her mobility started to progressively worsen. Family had called 999 because they were due to go home and were concerned about her ability to safely mobilise around the flat. The patient was observed to mobilise safely however fatigued easily and complained of muscle cramps. One member of the ambulance crew felt the patient was safe to discharge on scene whilst the other remained unsure. POCbT revealed a furosemide induced metabolic alkalosis with a hypokalaemia of 2.3. This knowledge when combined with the patients significant cardiac history made the decision to admit the patient to hospital the safest option and possibly avoided a significant adverse event.
Case 4: 92 year old Bob presented to the ambulance service after a non-injury fall however was noted to have been experiencing increased falls over the last month. In addition to interventions put in place by the falls and frailty team, POCbT discovered a new Hb of 84. The patient was reporting some fatigue but no heart failure symptoms and had not had a full blood count since 2015. A referral was made back to her GP who booked a review of her anaemia with her own GP. This patients regularity of falls decreased once her anaemia was addressed and it is hoped that an injury and or admission was avoided.
Learnings:
As I mentioned earlier, an initially unintended aim of the project was to develop learnings in the practical implementation of pre-hospital point of care blood testing. So I just wanted to talk through some of these.
Cost vs benefit: When considering point of care diagnostics for any environment it is important to consider the cost vs benefit ratio. I felt that in order to justify the cost of POCbT it needed to have the ability to alter decision making and determine the trajectory of the patient journey. To my mind it is pointless doing a test that will only be repeated in a patient that is already destined for hospital. It was also vital to target the device to selected resources not only to optimise training and safety but also to be able to target a patient demographic.
Access to previous results and staff training: As mentioned earlier – this patient group often has normally abnormal results so it was incredibly important to have access to old results and the appropriate training of staff is vital to the success of the project.
I found that due to the lack of WCC or CRP the device was least useful in the assessment of infection for the purposes of hospital avoidance. Whilst lactate is available, a raised lactate indicates hypoperfusion in the presence of sepsis which can typically be identified by SIRS criteria without this. For this reason staff were encouraged not to use the device to assist decision making if the patient had been recently diagnosed with infection of gave a history of infective symptoms.
Logistics: As you might imagine the ambulance service isn’t the most controlled environment with most of our kit being exposed to the elements and the occasional clumsy hand. The iSTAT device didn’t work under 16 degrees which during the winter months proved tricky but It did warm up quickly when in a warm house or warmed against the body so it didn’t prevent us using it. The cartridges also have a strict storage temperature and once warmed had an accelerated expiry date so a fridge on the ambulance station was required.
Thanks
I do need to take this time to thank some of the participating trusts and companies who provided time, money or support to the project. These things are never achieved by a single person!
