Manager, Point of Care Testing,
Partnership Pathology Services,
Frimley Park and Royal Surrey County
Hospitals, Guildford, Surrey
The use of point-of-care testing devices for blood gas analysis and for blood glucose monitoring is well established, so the concept of near-patient testing is familiar to clinicians working in the secondary care environment. Following the rationalisation of pathology services across the UK, the ‘Hub and Spoke’ service delivery approach is gaining in popularity as pathology departments consolidate, merging departments across sites and across trusts to gain economic advantage. This is set against a backdrop of an ever-increasing menu of diagnostic tests available on benchtop or handheld devices that have been designed for use by non-scientifically trained staff.
Whilst the use of point-of-care devices is growing in popularity throughout the trusts whose pathology services are delivered by Partnership Pathology Services (PPS), the requirement for vigilant management has never been greater. The Point-of-Care Testing Policy in use throughout our hospitals was ratified in 2002 and at that time we managed blood gas analysers, blood glucose meters and urinalysis devices. Following the recommendations described in the Carter report, and the market growth of new technologies offering a diverse range of point-of-care tests, we now support devices covering all disciplines of pathology. Without exception, all point-of-care testing carries a greater risk of obtaining an inaccurate result than the same test performed under standard conditions in the laboratory. This risk must be weighed against the threat to the service delivery in the ward or clinic of not using point-of-care testing, before the decision to go down the point-of-care testing route is made.
The complexity of the analysers we manage varies but the risks involved can be mitigated within a standard approach. Obviously, device maintenance and quality control are essential, but even the most tightly controlled analyser can produce misleading results in the hands of an incompetent user, so training and competency checking are an essential and relentless part of the service we provide throughout our hospitals.
Expansion of point-of-care testing
In the current economic climate the drive for cost efficiencies has never been greater. Intelligent marketing strategies have been developed to address the drive for cost improvements by selling economic outcomes to commissioners, thus replacing the traditional route of targeting clinicians with a view to selling point-of-care testing devices. This approach has resulted in the acceptance of fetal fibronectin testing in the maternity departments of the trusts throughout Surrey, where the original business case outlining savings in the management of pre-term delivery throughout the South East of England was produced by the Strategic Health Authority (SHA). Having identified the potential cost benefits, the SHA released the funding for the test, throwing the onus of responsibility for achieving the potential savings onto the participating maternity departments.
Recent changes to quality targets have focused attention on the patient experience in the Accident and Emergency Department, where the use of point-of-care testing is being reviewed as an option to decrease waiting times for pathology results and facilitate an efficient service.
The central laboratory service provision at PPS is via an automated track system both in blood sciences and bacteriology. The capacity of these systems provides a cost-effective service but the turnaround times are dependent upon phlebotomy services, sample transport provision, efficient specimen registration and the speed of the track system, so there is a growing requirement for point-of-care testing ‘Hot Labs’ providing timely laboratory quality results throughout the hospital acute departments. The extent of the point-of-care testing service we provide is heavily dependent on the ethos of the lead clinician who guides the shape of the service delivery. At Frimley Park Hospital, the Accident and Emergency Department has benefited from the ability to access a laboratory standard full blood count using the Pentra 60C+ analyser to provide a count with five-part differential, blood gases, creatinine, electrolytes and metabolites from a Radiometer ABL 827, d-dimer from a Radiometer AQT90 and a Troponin I using the Siemens Stratus CS. Developments in the connectivity and functionality of available software for many point-of-care analysers has enabled a service provision where the prevalence of poor quality results is no greater than that of the laboratory.
Following the success of this service, the Lead Consultant in Accident and Emergency at Frimley Park Hospital is keen to expand the point-of-care testing available in his department to cover a wider range of analytes including LFTs and amylase. Device evaluations covering all required analytes will be carried out by the point-of-care testing team before a final decision is made to install a preferred analyser. The consensus view in A+E is that the impact of point-of-care testing on the efficiency of the performance of the A+E department and the ability to achieve government targets is beyond doubt. This enthusiasm is not necessarily shared in other trusts where skepticism surrounding accuracy of results, duplication of testing and silo budgeting issues still exists and may temper attitudes.
The financial aspects of point-of-care testing are a hot topic for debate, with many arguments against point-of-care testing made on the basis of the cost per test against a similar one carried out in the laboratory.
The impact of the point-of-care test result must include end-to-end costs based on the overall patient journey, patient management and outcomes, decrease in the laboratory workload, transport and phlebotomy services. Other financial aspects include clinician time, bed costs and achievement of government targets. The 18-week target is a case in point because the patient may require pathology tests to confirm the diagnosis resulting in several visits to the consultant prior to commencement of treatment. If the use of point-of-care testing can provide the clinician with the pathology results during a ‘one-stop shop’, the time and effort involved in organising repeat appointments can be curtailed and the patient journey can be streamlined.
We use Hemocue haemoglobin analysers to assess the postnatal patient prior to discharge. The predictable turnaround time for the result facilitates the process and prevents unnecessary bed blocking. Point-of-care INR testing is growing in popularity in the secondary care setting, both as a check prior to discharge and also in theatre and endoscopy departments where the effective management of warfarin is paramount to the optimal clinical management of the patient. We are also in the process of evaluating the thromboelastography analysers currently available for theatres to achieve savings by reducing the inappropriate use of blood products during surgical procedures.
The cardiac catheter laboratory measures activated clotting time to determine the half-life of heparin to prevent bleeding following sheath withdrawal, while ICUs use the same test to monitor the haemofiltration patient to achieve optimal heparin activity during dialysis.
The use of point-of-care testing cardiac markers is well documented. For many years we have offered this test using the Stratus CS analyser with a testing protocol for chest pain patients on admission and at 12 hours in line with current local guidelines. Following a prospective audit, we hope to adopt a six-hour protocol that may further reduce dependence on audit results.
The Pentra 60C+ full blood count analyser is utilised not only in the Accident and Emergency Department, but also enables efficient management of chemotherapy in the Oncology units on three sites and facilitates the patient journey in the haematology clinics that are run out of remote facilities by secondary care teams.
Other benefits of point-of-care testing
The ability to remotely access the Pentra 60C+ and the Radiometer blood gas analysers offers the laboratory results in real time and monitoring of the performance, not only of the analysers, but also the users. Observing remote use of the analyser allows a degree of competency checking because performance can be viewed as it happens. The password protection facility instantly identifies the user who may be unaware that their performance is being monitored. In my view, this gives us the opportunity to evaluate competency without the user ‘putting on their best performance’ and gives a truer vision of the behaviour of the users.
Chronic disease management has leached from secondary to primary care as point-of-care technologies have enabled the testing to follow the patient. However, clinics are still serviced from both the Royal Surrey County and the Frimley Children’s Centre where the use of the DCA Vantage analysers provides an HbA1c result within the allocated consultation time enabling a ‘one-stop shop’ service in the diabetes clinics.
To ensure optimal performance of benchtop devices, members of the point-of-care testing team maintain the devices daily, building a comprehensive daily log for each analyser. This ensures that team competencies are maintained and builds strong relationships with the staff using the equipment. Training is delivered daily throughout the hospital on an ad hoc basis, during induction or via formal sessions, in an attempt to maintain competency for the individual needs of over 4000 staff.
Currently the point-of-care equipment maintained by the Point-of-Care Testing team totals over 25 different devices, each placed to resolve a unique requirement where the patient pathway is time dependent and turnaround times cannot be resolved by any other means.
The proposed changes in health service funding streams in the UK are offering the new GP Commissioning Consortia the opportunity to manage the patient pathway in a different way and point-of-care testing is being seen as an essential requirement to the provision of primary care triage centres. This change in service provision aims to offer patients a faster service, reducing the burden on the Accident and Emergency Departments of the District General Hospitals with the inherent savings obvious from this approach.
The requirement for instant access to information has driven the development of the silicon chip, the world wide web, the mobile phone, among other innovations. Clinicians are comfortable using their iPhones to access information on the internet, with the underlying risks involved in standardisation of information. This is illustrated in the calculation of eGFR: several different equations are available and the clinician is rarely aware of the correct one for their facility.
The drive to deliver the right result to the right person at the right time enabling clinicians to gain access to answers while the questions first form in their minds is the impetus required to ensure that the market for point-of-care testing is set to expand.