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
