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

A Case Study

How to lose a year of your life but come out

smiling.

What is POC testing?

• Test processing at/near the patient

• Present in some form for many years

– glucometers, urine dipsticks

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

The evidence

• Tests have variable accuracies and utilities

• Commercially funded studies very positive but

selective

• Independent studies have more marginal results

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

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

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

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

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?

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?

The answers

• Some pre-determined

• Others by consultation

Available tests

• Abbott iSTAT

– Electrolytes, renal function, blood gases, glucose, Hb

• Radiometer AQT 90

– Troponin T (HS), betaHCG

• Sysmex pocH 100i

– FBE

Our POC Lab

Abbott iSTAT

Radiometer AQT 90

Sysmex pocH 100i

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

Budget

• Kept within laboratory budget

• Easier to study overall costs

• Extra ED staff time unbudgeted

Results reporting and storage

• Directly from machines

– Displays and printers

• Downloaded to health service’s laboratory

results site

Maintenance

• Daily checks by laboratory staff

• On-line QA and maintenance

• Some clinical staff involvement

Non-POC tests

• Other campus laboratory capability enhanced

(marginally)

• Regular courier service

• Irregular taxi service

• System for storage of non-urgent specimens

Location

• Area cleared near Resus bays

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

Effect on NEAT

• Significant deterioration

• Counter to previous trend

• March 2013 = 71%

• May 2013 = 66%

Effect on clinical management

• Difficult to quantify other than delays

What went wrong?

• (quite a lot)

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

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

Standardizing work

Results handling

• Printer failures

• Connectivity problems

• POC results separate and hard to find

• NATA inspection required

Maintenance

• Desk-based machines less reliable than

expected

• Frequent calls and recall of scientists and

technicians

Non-POC tests

• Courier services not frequent enough

• Taxis expensive

• Results delayed by about 2 hours

Blood products

• Lengthy consultation process

• Generally successful

• Increased blood wastage

• Change in surgical practice

Review

• No overall savings

– Individual tests expensive

– Tests duplicated

– Transport costs

– Scientist call-back

• Decreased NEAT performance

• Staff dissatisfaction

Solutions

• Hours extended, not overnight

• Limited POC in-hours to speed decision-

making

Current status

• NEAT improved

– May 2013 = 66%

– May 2014 = 81%

• Costs reduced

• Staff satisfaction increased

• Back-up system for laboratory failure

Other POC applications

• Other tests

• Other settings

Other tests

• CRP, LFTs, D-dimer, CK-MB, myoglobin,

PT/INR, BNP, urinalysis

• Lipids, A1c

• HIV, syphilis, influenza, pneumococcus,

legionella

• Breast cancer biomarkers

Other settings

• Rural and remote, prehospital

• Flinders International Centre for Point of

Care Testing

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