Graeme Thomson, Angliss Hospital - Point of Care Testing, Not a Simple Solution

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Graeme Thomson delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit: http://bit.ly/edmanagement14

Published in: Health & Medicine
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Graeme Thomson, Angliss Hospital - Point of Care Testing, Not a Simple Solution

  1. 1. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Point of Care Testing Graeme Thomson, Angliss Hospital
  2. 2. A Case Study How to lose a year of your life but come out smiling.
  3. 3. What is POC testing? • Test processing at/near the patient • Present in some form for many years – glucometers, urine dipsticks
  4. 4. Why use POC? • Rapid results • Early clinical decision-making • Early interventions • Reduced test usage by limiting options • Improved clinical outcomes • Improved NEAT performance • No laboratory access
  5. 5. The evidence • Tests have variable accuracies and utilities • Commercially funded studies very positive but selective • Independent studies have more marginal results
  6. 6. Local evidence • St George Hospital study – Some improvement in Time to Decision-Making – Some reduction in ED LOS for some patient groups – Possibly reduced costs – Greater for discharged group seen by senior doctors – The Integrated Point of Care Testing (IPoCT) Project in the ED, Chan A et al, 2012
  7. 7. Best practice example • Massachusetts General Hospital • Comprehensive parent laboratory • Satellite POC laboratory in ED • Staffed 24/7 by laboratory technicians • 10 minutely rounds to collect specimens • Demonstrated decreased time to result availability
  8. 8. Angliss pre-POC • Urban district hospital • Part of Victoria’s second largest health service • ED with 40,000+ attendances • Obstetric unit with 2000+ deliveries • Other general inpatient services • 24-hour laboratory with rapid turnaround times • Some microbiology and complex tests sent away
  9. 9. POC introduction • Limitation of laboratory hours to reduce costs • No on-site service from early evenings (week) and early afternoons (weekend) • POC testing in ED • Limited POC in Theatre, HDU, SCN • Non-POC tests sent away or deferred
  10. 10. The big questions • What POC tests would be available? • Who would do the testing? • Who would pay for the tests? • How would test results be stored? • Who would maintain the machines? • How long would non-POC tests take?
  11. 11. The big questions • Where would the machines be located? • How would Blood Bank operate? • What would be the effects on clinical management, NEAT and the budget?
  12. 12. The answers • Some pre-determined • Others by consultation
  13. 13. Available tests • Abbott iSTAT – Electrolytes, renal function, blood gases, glucose, Hb • Radiometer AQT 90 – Troponin T (HS), betaHCG • Sysmex pocH 100i – FBE
  14. 14. Our POC Lab
  15. 15. Abbott iSTAT
  16. 16. Radiometer AQT 90
  17. 17. Sysmex pocH 100i
  18. 18. Testers • ED nurses and doctors • Limited number of nurses from other units • Trained and credentialed on 3 machines • Given individual operator IDs • Superusers and trainers
  19. 19. Budget • Kept within laboratory budget • Easier to study overall costs • Extra ED staff time unbudgeted
  20. 20. Results reporting and storage • Directly from machines – Displays and printers • Downloaded to health service’s laboratory results site
  21. 21. Maintenance • Daily checks by laboratory staff • On-line QA and maintenance • Some clinical staff involvement
  22. 22. Non-POC tests • Other campus laboratory capability enhanced (marginally) • Regular courier service • Irregular taxi service • System for storage of non-urgent specimens
  23. 23. Location • Area cleared near Resus bays
  24. 24. Blood bank • Major concern • On-site 10 units uncrossmatched blood in separate fridge • System for provision of crossmatched blood from central laboratory • On-call scientist for massive transfusions
  25. 25. Effect on NEAT • Significant deterioration • Counter to previous trend • March 2013 = 71% • May 2013 = 66%
  26. 26. Effect on clinical management • Difficult to quantify other than delays
  27. 27. What went wrong? • (quite a lot)
  28. 28. Test limitations • Tests not available – CRP, lipase, LFTs, INR • Reliability of results – Inaccuracies, mostly due to sample preparation errors – Troponin analysis not identical to laboratory analysis – Duplicate testing common
  29. 29. Staff issues • Initial training complicated • Skill retention difficult • Difficult to train and credential new staff • Left to a small number of key staff • Night staff felt abandoned • Distracted staff from other duties
  30. 30. Standardizing work
  31. 31. Results handling • Printer failures • Connectivity problems • POC results separate and hard to find • NATA inspection required
  32. 32. Maintenance • Desk-based machines less reliable than expected • Frequent calls and recall of scientists and technicians
  33. 33. Non-POC tests • Courier services not frequent enough • Taxis expensive • Results delayed by about 2 hours
  34. 34. Blood products • Lengthy consultation process • Generally successful • Increased blood wastage • Change in surgical practice
  35. 35. Review • No overall savings – Individual tests expensive – Tests duplicated – Transport costs – Scientist call-back • Decreased NEAT performance • Staff dissatisfaction
  36. 36. Solutions • Hours extended, not overnight • Limited POC in-hours to speed decision- making
  37. 37. Current status • NEAT improved – May 2013 = 66% – May 2014 = 81% • Costs reduced • Staff satisfaction increased • Back-up system for laboratory failure
  38. 38. Other POC applications • Other tests • Other settings
  39. 39. Other tests • CRP, LFTs, D-dimer, CK-MB, myoglobin, PT/INR, BNP, urinalysis • Lipids, A1c • HIV, syphilis, influenza, pneumococcus, legionella • Breast cancer biomarkers
  40. 40. Other settings • Rural and remote, prehospital • Flinders International Centre for Point of Care Testing
  41. 41. Recommendations • Do not assume that POC can replace laboratory services at the moment, except during low demand periods • Do not expect improvement in overall NEAT unless you fund your POC system very well • Use POC as an adjunct for selected patient groups when it will aid decision-making and that will translate to improved throughput or clinical care

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