This article explores the potential application of rapid access to diagnostic services to improve patient outcomes and service efficiency in emergency medicine
Over the past few decades there has been an increasing trend to more hospital-based care exemplified in the increasing numbers of patients attending the emergency department. Policy makers, commissioners and providers are seeking to reverse this trend in healthcare delivery, through strategies that broadly fall under the description of ‘care-closer-to-home’. However, the pressures on the emergency department show few signs of abating.
There are four key reasons for the increasing pressures on the emergency department: (i) an increasing (and ageing) population; (ii) an increasing prevalence of acute conditions, with an increasing proportion of patients with long-term conditions experiencing an adverse event; (iii) overcrowding in the emergency department and the consequent impact on the efficiency of the service; and (iv) poor access to primary care services.
Additional consequences of the pressures on the emergency department that can impact on the hospital, and thus may further exacerbate the problem, are: (a) readmissions within seven days of the original attendance; and (b) so-called bed blocking primarily in the elderly population due to the problems associated with discharge back to home once the patient enters the hospital system, as a consequence of the pressures on social care.1
Urgent and emergency care is now being envisaged as an integrated spectrum of services from self-help and self-care, through telephone contact, primary care and walk-in centres to hospital-based emergency departments and major trauma centres.2 In some cases there are now combinations of these modalities of care appearing, providing the opportunity for a more integrated approach to care, from both the patients’ and clinicians’ perspective.
Examples of this development have been the location of a GP-led 24-hour walk-in service adjacent to the hospital emergency department,3 and the development of emergency multidisciplinary units working with emergency departments in major hospitals, primary care physicians and paramedical units.4
Diagnostic services, including laboratory medicine services, have always played an important role in emergency medicine and as the spectrum of patients (as well as the volume of patients presenting) increases, the demands on the diagnostic services is also increasing. There have been two key developments in laboratory medicine to manage the overall increase in patient workload: (i) the advent of automated laboratory analysers integrated with automated specimen handling systems; and (ii) consolidation of laboratory services into larger units.
The major drivers for this change have been the achievement of economies of scale and critical mass of expertise, and reducing the cost per test. In many ways, this trend represents a parallel change to the trend over the years to the more hospital-based approach to patient care referred to earlier (Figure 1).
However, a serious consequence of this trend has been an increase in the time-to-result after the investigation has been requested and the specimen taken. This can be due to an increasing time to process the specimen in the laboratory, as well a greater time to get the specimen to the laboratory. The consequences of this include a delay in clinical decision-making and action, and an increase in the length of stay in the emergency department.
This article examines the current problems in emergency medicine and how more rapid access to diagnostic services offers the potential to mitigate some of these problems. Point-of-care testing (POCT) offers a means of providing rapid access to results. This can be achieved by locating a satellite laboratory service close to the emergency department or by the use of POCT technologies – at the point of care.
The latter is the more flexible approach and would enable tests to be performed across the whole spectrum of emergency care – including in the home, the community and the paramedical scenarios.5
Fig. 1: Trends in healthcare delivery and the place of POCT as the trend in care-closer-to-home evolves.
Emergency department length of stay
The length of stay in the emergency department is known to have a negative association with patient satisfaction and the quality of outcomes.6 A retrospective observational study of nine emergency departments (eight academic and one community hospital) in the United States over a period of one year identified a number of factors that are considered to adversely impact on the length of patient stay in the emergency department.7
The factors included overcrowding in the emergency department, the hospital occupancy rates, the percentage of daily admissions and the period of ambulance diversions, and it being a weekday; all of these could be considered as ‘general workload factors’. There are then ‘specific patient factors’ including patient age and patient acuity, as well as the number of patients who left the emergency department before their consultation was complete (so-called elopement).
Interestingly, and importantly in this discussion, the need for diagnostic tests and treatment are also associated with a longer length of stay. A three-year study as part of the National Hospital Ambulatory Medical Care Survey, covering over 100,000 emergency department visits to 364 hospitals, found that requiring a blood test added 72 minutes to the length of stay while imaging analyses added between 56 and 64 minutes depending on the imaging modality employed (all expressed as adjusted marginal effects).
Treatment interventions added an average of 24 minutes when performing a procedure and 15 minutes when giving a medication.8
Impact of increased length of stay and overcrowding in the emergency department
Overcrowding can lead to a greater time before the patient is seen by a physician, a situation that can be exacerbated if the patient is not monitored during that period. As a consequence of this there may be delays in administering medications, for example, antibiotics.9
An observational study involving almost a million emergency department visits found that emergency department crowding resulted in a 5% greater odds of inpatient death, a 0.8% longer hospital length of stay and a 1% increase in cost of admission.
These adverse outcomes amounted to 300 deaths, 6200 hospital days and $17 million additional costs.10 In a retrospective observational study of patients presenting to the emergency department but not admitted, a longer length of stay was associated with a greater risk in the short-term of death and admission to hospital in patients who were well enough to leave the department.11
Ways of mitigating emergency department crowding and reducing length of stay
A number of approaches have been proposed for reducing emergency department crowding by effectively diverting people away from the emergency department.
These have included improving access to primary care, the use of retail clinics and community walk-in centres, community emergency multidisciplinary units and colocation of primary care services close to the emergency department.12 The College of Emergency Medicine in their 2014 statement on emergency department crowding recommended that “investigations should be ‘front loaded’ to reduce delays to disposition decisions”.1
One example of this that is already beginning to be used is for paramedical professionals to perform POCT as part of their assessment visit as well as during transportation to the emergency department.
Role of POCT in reducing emergency department length of stay and crowding: existing evidence
The time-to-result clearly has an impact on the clinical and operational decisions made in the emergency department.8 Simulation studies of emergency department activity has shown that reducing the time-to-result for cardiac marker tests from 120 minutes down to 10 minutes can impact on the length of stay, average number of diversion days, average number of diversion hours per day, and percentage of diversion days, while also increasing the number of patients seen in the emergency department on a daily basis.13
Point-of-care testing is seen as a potential solution to improving the throughput of patients in the emergency department and reducing crowding.12
Modelling of patient flow and throughput in the emergency department has shown that the turnaround time of laboratory test results has an impact on the efficiency of the emergency department.13,14 There have been a number of studies that have indicated that rapid delivery of results in the emergency setting can reduce the time to decision-making, reducing time to treatment initiation and clinical outcomes, reducing time to discharge in appropriate patients, and reducing the overall length of stay in the emergency department.15
The range of tests that have figured in reported studies of the impact of diagnostic testing on the length of stay in the emergency department are given in Table 1, accompanied by the decision pathway in which they were used.
Conclusions
Point-of-care testing can, by definition reduce the time-to-result, and therefore time to decision-making. In the case of the emergency department, this may be time to treatment initiation or patient disposition decisions, including discharge. In the paramedical setting, this may help to further reduce the time to decision-making, which may further reduce the time spent in the emergency department or enable the patient to be managed at home or in a community setting. Similarly, access to POCT in primary care may enable patients to be managed locally and reduce the need for an urgent referral to the hospital emergency department.
The potential benefits to this more integrated approach to urgent care would be to improve the effectiveness and efficiency of emergency care, as well as improving patient experience and patient satisfaction. However there are challenges involved – as in any case where there is going to be a change in practice. Technically, it is important that the equipment is robust and performs well, and that attention is paid to operator training and quality control.
It is a challenge for the technology developers to minimise the complexity of operation of POCT technology to minimise the risk of errors. Investment will be required in the technology and the supporting infrastructure wherever the technology is deployed, but this can be achieved through the savings made in resource utilisation elsewhere in the care pathway, for example, emergency department time saved. However, rapid access to results alone will not lead to improved health outcomes – clinical, operational or economic.
It is important to stress the need to pay attention to the practical aspects, for example timings, of the clinical pathway recognising that faster access to results will require earlier availability to make decisions, as well as the speed with which decisions can be made. This may also impact on other activities within the emergency scenarios (including unintended consequences) with which staff must also be aware. There are always apocryphal stories of rapid testing being introduced, but the results not being acted upon because the routine of the clinical team has not changed.
The scale of the change in practice highlights an important complementary technological innovation to that of POCT technologies, that being communication technologies. The breadth of access to emergency services is likely to embrace the spectrum from homes to major trauma centres; however, this is only possible if they are ‘digitally connected’. The majority of developments in POCT technologies today encapsulate some form of communication technology; this connectivity has to include all of those involved in the care of the patient – and in all of the settings, again from home to major trauma unit.
The scale and breadth of the unmet clinical need has been demonstrated quite clearly, and the operational changes required to meet that need have also been identified. The POCT technologies are now becoming available to address these needs through the rapid access to diagnostic services. More studies are now required to explore the necessary system reengineering to demonstrate the benefits of POCT and the impact on patient outcomes and on service provision.
This article presents independent research funded by the National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Oxford. The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health. The study sponsors had no role in the design, analyses or reporting of the study. The researcher retained complete independence in the conduct of this study.
References
- The College of Emergency Medicine. Crowding in emergency departments (revised June 2014). Available at: www.rcem.ac.uk/code/document.asp?ID=6296. Last accessed March 2016.
- Ham C. Emergency department pressures need to be tackled through integrated urgent and emergency care. BMJ 2015;350:h322.
- Arain M, Nicholl JP, Campbell M. Patients’ experience and satisfaction with GP led walk-in centres in the UK; a cross sectional study. BMC Health Serv Res 2013;13:142.
- Webb M, Campbell K. Innovating care in the community. Br J Healthcare Manag 2014;20:330–2.
- St John A, Price CP. Existing and emerging technologies for point-of-care testing. Clin Biochem Rev 2014;35:155–67.
- Sayah A et al. Minimizing ED waiting times and improving patient flow and experience of care. Emerg Med Int 2014;2014:981472.
- Wiler JL et al. Predictors of patient length of stay in 9 emergency departments. Am J Emerg Med 2012;30:1860–4.
- Kocher KE et al. Effect of testing and treatment on emergency department length of stay using a national database. Acad Emerg Med 2012;19:525–34.
- Sikka R et al. ED crowding is associated with an increased time to pneumonia treatment. Am J Emerg Med 2010;28:809–12.
- Sun BC et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med 2013;61:605–11.
- Guttmann A et al. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011;342:d2983.
- Boyle A et al. Emergency department crowding: time for interventions and policy evaluations. Emerg Med Int 2012;2012:838610.
- Storrow AB et al. Decreasing lab turnaround time improves emergency department throughput and decreases emergency medical services diversion: a simulation model. Acad Emerg Med 2008;15:1130–5.
- Paul JA, Lin L. Models for improving patient throughput and waiting at hospital emergency departments. J Emerg Med 2012;43:1119–26.
- Rooney KD, Schilling UM. Point-of-care testing in the overcrowded emergency department – can it make a difference? Crit Care 2014;18:692.
