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Apr052010

Use and Abuse of Point of Care Tests in the ED by Stephen Colucciello, MD

DateMonday, April 5, 2010

Stehen Colucciello, MDBasically every Emergency Department uses Point of Care testing in some form or another.  In fact, approximately 66% of ED patients who get a test undergo a POC study.  (Point of Care 6(2):134-138, June 2007)  However, an increasing number of EDs are moving beyond the traditional “low-tech” panels (blood sugar, hemoglobin, urine pregnancy test, and dip UA) into the realm of “high-tech” hand-held analyzers that test for a variety of electrolytes or biomarkers. 

The compelling argument is that ED physicians can make faster dispositions by using POC tests compared to traditional central lab processing.  One company suggests that ED Point of Care testing provides a 50 minute head start in a 1 hour race.  While this sounds like a pretty compelling advantage, what are the realities of Point of Care (POC) testing in the Emergency Department?

 

Overview

At least one third of all ED patients get at least one blood test during their visit (CDC National Hospital Ambulatory Medical Care Survey; ED Summary).  The literature is also clear the POC tests are generally as accurate as those run in the central lab (certainly over the past decade).  Notably however, the turn-around time for POC tests is significantly shorter; generally 40 to 60 minutes less than the comparable lab process. 

This shorter turn-around time is secondary to a decrease in all three aspects of the processing cycle; the pre-analytic time (time from order to placing sample on the machine), the analytic time (actual time on machine), and post-analytic time (time results posted till the physician has them “in hand”, or is aware of the result).  The key question is, “does this 40 to 60 minutes “savings” in turn-around time translate into clinically significant outcome measures for the patient or ED flow?”

 

Quality of Care

One review article suggested that POC testing can shorten the time to critical interventions in up to 7% of patients (BMJ. 316(7137):1052-7, 1998 Apr 4) From a practical standpoint, any physician who uses point of care in daily practice will affirm that at least several times per week, a POC test prompts a major change in early patient management.  This usually relates to patients with “panic values” for glucose, hemoglobin, acidosis, hyperkalemia or a positive troponin.  These same physicians also admit that the false positive panic values are problematic as well. 

As far as the empiric data goes, the picture is mixed.  For cardiac markers, POC tests are more likely to return within the 30-60 min guidelines for turn-around time (Ann Emerg Med vol. 53, 321 - 328, 2009); however this begs the question as to whether care is actually improved.  In another study, POC troponin was associated with decreased time to anti-ischemic therapy by about three-quarters of an hour; due to a shorter time to physician notification. Still, despite these improved “benchmarks”, there were no clear difference in medical outcomes between the POC and central lab troponin groups. (Academic Emergency Medicine. 15(3):216-24, 2008 Mar.)  Another review article found fair evidence that more rapid turn-around time of ABG results, leads to improved clinical outcomes in some ED patients. (National Academy of Clinical Biochemistry (NACB); 2006. p. 30-43.)

In my own experience, I can say the more unstable and “mysterious” someone is (unclear diagnosis in an ill-appearing patient); the more often a POC test provides a quick and critically important diagnosis.

 

Length of Stay (LOS) Data

Surprisingly, the literature on POC testing’s impact on ED LOS is mixed.  Some studies show decreased ED LOS, approximately 40 to 65 minutes less, using POC testing compared to patients who get central lab testing.  (The Journal of Emergency Medicine, Vol. 17, No. 5, pp. 811–814, 1999, American Journal of Clinical Pathology. 132(3):326-31, 2009 Sep., Pediatric Emergency Care. 23(7):457-62, 2007 Jul., Archives of Pathology & Laboratory Medicine. 127(4):456-60, 2003 Apr.)  Most of these LOS benefits occur among discharged rather than admitted patients.  However, point of care testing can decrease the time from ED arrival to ordering an in-patient bed.  (Annals of Emergency Medicine. 45(6):587-91, 2005 Jun.)

Despite these studies, other trials show no significant decrease in total ED length of stay notwithstanding consistent decrease in turn-around time associated with POC testing.  This means that other ED processes need “tweaking” to leverage the benefits of the shorter testing cycle. 

A common delay occurs when POC tests are ordered in addition to central lab tests.  When this occurs, the central lab tests can become the rate-limiting step and thus the time savings of the POC tests are nullified by prolonged central lab cycle times.

 

Problems with POC

Cost versus Charge

The biggest problem with POC testing is expense.  This expense includes the infrastructure for testing (introduction of the technology, machine acquisition costs, computer interface with lab and IS system, training, etc.) and the incremental costs for each testing cartridge.   The financial picture is further muddied by the cost (to the institution) versus charge (to the patient) analysis.

The cost of a POC test or panel generally ranges from 3 to 6 times that of the central lab processing.  A single POC cartridge can cost anywhere from $5.00 to $20.00 dollars depending upon the panel.  However, the incremental costs usually go down as the volume of POC testing in the ED increases due to bulk discounts. 

As regards the charges to the patient ….. well anything goes…..  Because of the pricing structure in hospitals (markup), charges are usually many times higher than the cost; a ten fold or more markup is not uncommon.  In some hospitals, POC charges are similar to the central lab charges while in others the charges may be significantly higher.

 

Resource utilization; Staff duties

Most nurses and tech do not like expansion of point of care testing in the ED.  It diverts them from their other duties and the implementation phase may be marked by significant grumbling.  A dedicated ED phlebotomist who performs POC testing can solve most of this problem.

 

Accuracy

While numerous studies show good correlation between POC tests and central laboratory testing, this correlation is not usually reached during the first several weeks (or even months) after the implementation in a new site.  Because of operator errors, the lab needs to perform correlation studies during and after the implementation phase.  Initial errors are often technique-related, and include patient labeling issues, improper tubes, inadequate blood volumes, processing errors, machine time-outs, improper reading of controls, etc.)  The QA process should track errors systemically and by the machine operator (individual nurses) and include feedback to the individuals involved. 

An additional source of confusion may arise when the reference values for the POC test differs from that of the standard lab normals.  For this reason, it is best to use POC tests with reference values that mirror the central lab numbers.

 

Clinical Scenarios Where POC Testing May be Especially Valuable

Chest Pain Evaluation

POC cardiac biomarkers can be used for a 2 hour delta rule out.  The abbreviated chest pain workup involves an initial and subsequent set of cardiac biomarkers (2 hour delta enzymes) (Annals of Emergency Medicine 40:6 December 2002).  If there is no significant rise in the biomarkers, the patient can be stress tested or discharged for outpatient follow-up based on clinical criteria.  (Not to mention that a positive CM-MB or troponin greatly accelerates cardiology response.) 

 

Dialysis emergencies

Consider electrolytes, especially in patients who have missed dialysis, to check for hyperkalemia.

 

Need for STAT IV contrast

Consider POC renal function tests prior to IV contrast to direct pretreatment when patients need IV contrast (such as bicarbonate, N-acetylcysteine, hydration, etc.).  This is primarily a concern in older, diabetic, hypertensive patients at risk for renal insufficiency.

 

Altered Mental Status or convulsive status epilepticus

            Check for glucose and electrolyte disorders.

 

Suspected DKA

POC glucose, electrolytes plus dip UA for ketones = ready to consult/admit.  A venous blood gas may or may not be appreciated by the consultant.

 

Severe poisoning

Check for acid-base abnormalities on chem panel; see MUDPILE mnemonic (http://en.wikipedia.org/wiki/High_anion_gap_metabolic_acidosis#.22Mudpiles.22)

 

Acute GI bleed

The combination of hemoglobin plus lactate or base deficit may provide a better clue to stability than initial vital signs.

 

Blunt trauma

Low hemoglobin, high lactate or significant base deficit suggests occult blood loss and may prompt early transfer, imaging, consult, or intervention.  (Journal of Trauma-Injury Infection & Critical Care. 48(6):1101-8, 2000 Jun.)

 

Sepsis 

A point of care lactate greater than 4 may be a useful trigger for Early Goal Directed Therapy (EGDT) in severe sepsis; even if the initial blood pressure is normal.  Serial lactates may soon replace the need for central venous oxygen saturation monitors in EGDT (JAMA. 2010; 303(8):739-746.)

 

Respiratory Distress of unknown etiology

Consider POC cardiac B-naturetic peptide in patients with possible CHF (The Journal of Emergency Medicine 2006, vol. 31, no2, pp. 147-150), POC d-dimer in cases of suspected pulmonary embolism (American Journal of Clinical Pathology. 132(3):326-31, 2009 Sep.), and ABG in COPD patients at risk for CO2 narcosis placed on high flow oxygen.  Recognize that the literature is mixed on the clinical value of such “dyspnea panels” in the routine evaluation for shortness of breath.  Targeting the older patient with multiple potential etiologies of dyspnea may increase the value of these tests.

 

Bleeding in face of possible coagulopathy

POC PT/INR can trigger early administration of FFP in certain circumstances; especially the head trauma patient on Coumadin.

 

General Principles for POC Testing

When deciding to use a point of care versus central lab test, ask yourself three questions;

1.  How sick is this patient and will the POC results likely change immediate management?  

In general the unstable or clinically ill-appearing patient may benefit from POC testing; especially in the presence of an unclear diagnosis.  (The “sick as stink and I haven’t got a clue” scenario).Is the POC testing likely to significantly shorten the time to treatment, additional testing, consultation, admission, or discharge?

 

2.  Is the POC testing likely to significantly shorten the time to treatment, additional testing, consultation, admission, or discharge?

If the POC can shorten disposition or treatment time by a significant degree, get the test.

 

3.  Will other tests (apart from the POC) be necessary for the key disposition and management decisions?

If other tests are the primary “rate-limiting” steps, consider skipping the POC testing and use standard lab technology.

 

Final word

Having used hand-held POC technology for the past decade in a large urban ED, I cannot image going back to “the bad old days” where I relied exclusively on the central lab.  POC hand-held technology provides an important safety net for the critically ill and can shorten length of stay in both admitted and discharged patients; especially if you can fix other roadblocks to disposition (i.e. streamline the discharge and admission processes).

If you do not currently have this technology, it is worth getting for just about any sized ED.  When dealing with administration, base your initial arguments on patient safety and risk management.  Chances are very good that you have had at least one patient in your ED during the past year who had a bad outcome from delayed recognition of hyperkalemia or hyponatremia.  If so, you can probably make a strong argument that the morbidity or mortality would have been avoided by earlier recognition and treatment had POC testing been available. You can also audit your cardiac biomarker turn-around times.  It is likely that you are not meeting the published benchmarks of less than 60 minutes using the central lab (Archives of Pathology & Laboratory Medicine, Feb 2004)

If you already use hand-held POC technology in your ED, don’t abuse it.  Excessive reliance on POC tests can distract the nurses from other duties and can drive up costs.  Consider the primary 3 questions under “General Principles” above when choosing between standard lab and POC testing.

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