Consider pros and cons of point-of-care testing
Although there is a trend toward point-of-care testing in the ED, the practice is not without problems, according to Thomas J. Allred, MD, FCAP, FACEP, associate professor of emergency medicine and pathology and director of clinical chemistry, clinical toxicology and point-of-care testing at Medical College of Georgia in Augusta. "Is the benefit of doing point-of-care testing in the ED worth the added expense and the added regulatory hassle — both of which can be considerable?" he asks. The answer depends on your ED, says Allred. "Like most things in life, it is a trade-off," he says. "A cost-benefit analysis is the only way to arrive at the correct conclusion."
Here are some potential problems with point-of-care testing, and items to consider for each:
1. It costs more. Point-of-care testing is considerably more costly than doing the same test in the laboratory, according to Allred. "It will always be more expensive on a direct cost basis," he says. "And we are talking dollars here as opposed to pennies or dimes." Cost savings are only evident if you consider indirect ED costs, such as shorter ED stays resulting in fewer ED beds and hours of nursing care needed, he explains. You also must consider the cost of quality control, proficiency testing, and regulatory requirements, Allred adds. He acknowledges that it is difficult to assign a dollar value to shorter ED stays, improved patient flow, and increased patient satisfaction. However, if point-of-care testing improves patient flow, it can benefit patient care and your bottom line, he concludes.
2. Regulatory requirements must be met. Allred points to strict requirements for laboratory testing of the Clinical Laboratories Improvement Act that you will need to comply with. "These regulations are enforced by state inspectors, Joint Commission inspectors, and College of American Pathologists inspectors," he says. If you fail one of these inspections, it is equivalent to failing a federal inspection, Allred warns. "That puts all reimbursement from Medicare and Medicaid at risk of being stopped — for the entire hospital, not just the lab or the ED," he says. Regardless of where it’s done, a test must meet certain requirements and be done in a certain way, Allred explains. "Some point-of-care testing is classified as waived’ with minimal requirements. But most are classified as moderately complex,’" he notes. "So there are significant requirements regarding quality control, record keeping, proficiency testing, reporting, and a host of other things," he says.
3. There may be disputes over revenue. You’ll need to determine which department will receive payment for the test, says Bonnie Hansen, RN, an ED nurse at Highland Park (IL) Hospital. "If nursing has performed the test, shouldn’t they collect the revenue for their time?" she asks. "We have to maintain adequate supplies and yearly competency testing."
The lab traditionally gets the revenue, but that can be negotiated, advises Michelle Myers Glower, RN, MS, former director of emergency and trauma services for Elmhurst (IL) Hospital and a Glencoe, IL-based consultant specializing in staffing issues. "If your ED draws the blood and sends it to the lab, you may collect that lab draw money under APCs," she notes. "Otherwise the lab is charging the patient for a lab draw that you did, regardless of where the testing occurred." Still, there may be controversy, warns Glower. "An internal war may arise when it comes to dollars," she says. "A cut in revenue will mean a cut in FTEs [full-time employees]," she says. At Elmhurst Hospital’s ED, the revenues are split. "We charged for all of our draws, and the lab could charge if they drew the labs," she says. "All actual testing was done in the lab, so the lab still gets to bill."
4. Length of stay isn’t always decreased. When EDs switch to point-of-care testing, they are usually looking for one thing: to decrease turnaround times, according to Glower. "The No. 1 complaint in EDs is wait times," she says. "Many ED administrators turn to point-of-care testing to reduce delays."
However, the jury is out as to whether point-of-care testing can achieve this, according to Allred. He points to three contradictory studies: One showed a decrease in patient stays in the ED of 10 minutes with point-of-care testing, while another showed a decrease of 55 minutes on patients discharged from the ED, but not on patients who were admitted, and a third study showed no difference in overall length of stay.1-3 Consider cost issues within specific clinical contexts, Allred advises. Look at the top 10 or 20 discharge diagnoses in your ED, and determine what laboratory testing was required for diagnosis and treatment, he suggests. "With that information in hand, you can then look at how quicker testing might influence the care given," says Allred. "If significantly better care can be given with point-of-care testing, as with hypoglycemic coma or with starting thrombolysis for a myocardial infarction, then its use is clearly justified, regardless of the cost."
1. Parvin L, Deuser W, Lewis S. Impact of point-of-care testing on patient’s length of stay in a large emergency department. Clinical Chemistry 1996; 42(5):711-717.
2. Murray RP, Leroux M, Sabga E, et al. Effect of point-of-care-testing on length of stay in an adult emergency department. J Emerg Med 1999; 17: 811-814.
3. Kendall J, Reeves B, Clancy M. Point of care testing: randomised controlled trial of clinical outcome. British Medical J 1998; 316:1,052-1,057.
For more information about point-of-care testing, contact: Thomas J. Allred, MD, FCAP FACEP, Associate Professor of Emergency Medicine and Pathology, and Pathology, Medical College of Georgia, BI-2022A, 1120 15th St., Augusta, GA 30912. Telephone: (706) 721-0746. Fax: (706) 721-7837. E-mail: firstname.lastname@example.org.