Here’s how to make point-of-care testing a success
A patient is discharged with chest pain, a normal electrocardiogram, and a normal first set of enzymes. Later, you find out that that the lab made an error reporting the results. Has this occurred in your ED? "Many EDs experiences this scenario, and it’s a physician’s nightmare," says 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.
She acknowledges that an ED should never send a patient out without seeing the labs, especially enzymes. "However patients may be discharged with lab errors due to many variables, especially when to many people are handling the specimen," says Glower.
She notes that with point-of-care testing, a single nurse or technician is handling the specimen, running the test, and getting the results. "Most errors happen when too many cooks spoil the brew," Glower says. "I have also seen ED patients not waiting for results and negotiating with the physician to leave because the patient has no history, is young, and has a normal EKG." This is setting yourself up for a lawsuit, she says. "Calling the patient back in for admission is risky business, if he or she hasn’t already arrested," Glower says.
Don’t put patients in wrong bed
Point-of-care testing can help you discharge patients appropriately, according to Glower. She points to an internal study that showed that ED physicians were able to make a quicker and more accurate disposition by having lab results within 15 minutes. "It gave the physician the information needed to admit the patient in the ICU," Glower says. "This is especially important when the patient’s history is unremarkable and you may have discharged the patient instead of admitting."
As a result, ED staff are able to accurately place patients in the right bed, says Glower. A chest pain patient who is stable does not necessarily get admitted to the ICU; instead, he or she can go to a telemetry stepdown unit, she says. "If the first set of enzymes are normal and you are admitting all these patients to the ICU, it is a waste of resources and lost revenue," says Glower. "The last thing you want to hear from is the utilization review department asking why a patient is in the ICU with normal enzymes."
EDs are increasingly using point-of-care testing for blood glucose, rapid strep, urine dipsticks for blood or leukocytes, urine pregnancy, hemocue, electrolytes, arterial blood gases, and cardiac markers, says Glower. There are many new products on the market for point of-care-testing, she reports. "Many vendors are coming out with instrumentation the size of a fax machine for the most frequently ordered tests in EDs," says Glower. (See "Resources" at the end of this article for list of manufacturers.)
Quicker results mean a patient’s workup in the ED, such as X-rays, labs, computed tomography scans, and ultrasounds, can be started sooner, says Bonnie Hansen, RN, an ED nurse at Highland Park (IL) Hospital. The hospital’s lab turnaround time is about an hour, notes Hansen. "For a urine pregnancy test that takes us four minutes, or a rapid strep that takes 10 minutes, that means a time saving of 40 to 50 minutes," she says.
Glower says there can be a significant decrease in the wait time for disposition. "This adds to patient satisfaction because they are getting information sooner," she explains. "It may also prevent them from leaving against medical advice, which can possibly prevent a bad outcome."
Here are ways to effectively implement point-of-care testing in your ED:
• Be ready for Joint Commission surveys. At high volume EDs, surveyors from the Oakbrook Terrace-based Joint Commission on Accreditation of Healthcare Organizations will be on the lookout for incomplete quality control and test reporting based on time and staffing constraints, says Glower. "At low-volume EDs, they will look for inability to maintain quality and proficiency testing records due to lack of familiarity with the protocols," she adds.
• Select the right equipment. Glower recommends using the following attributes as a guide when purchasing a point-of-care instrument:
- a system with multiple test panel disposables;
- a system with an internal quality control;
- a system that is user-friendly;
- a system that is compliant with the Clinical Laboratories Improvement Act (CLIA);
- a system that gives quantitative results;
- a system that is cost-effective.
• Involve the right people. Before asking for capital dollars to purchase a point-of-care instrument, Glower recommends getting buy-in from following individuals: the ED medical director, ED manager, vice president of patient care services, laboratory director, laboratory point-of-care coordinator, and vice president of finance. "Administrators don’t want to hear the arguments between you and the lab. They want a proposal showing how they will benefit," she says. "All of them need to be on board to hash out the differences from revenue to quality control, before implementation."
Here is a partial listing of products used for point-of-care testing in the ED:
• Alpha Dx Point of Need System delivers whole blood cardiac marker profiles in less than 18 minutes for myoglobin, creatine kinase (CK), isoenzyme of creatine kinase with muscle and brain subunits (CK-MB), and cardiac troponin I. Serial patient tests, referenced to symptom onset, are displayed in a graphical format. The system requires no calibration, and bi-level quality controls are automatically run with every sample. For more information, contact Winnie Subramaniam, First Medical, 530 Logue Ave., Mountain View, CA 94043. Telephone: (800) 634-5654 ext. 7821 or (650) 903-5974 ext. 7821. Fax: (650) 903-9040. E-mail: email@example.com. Web: www.firstmedical.com.
• Signify Strep A is a test waived by the Clinical Laboratories Improvement Act (CLIA) for the detection of Group A Streptococcal antigen from throat swabs or confirmation of presumptive Group A Streptococcal colonies recovered from culture. The cost for a packet of 30 tests is $113.44. For more information, contact: Abbott Laboratories, Diagnostics Division, 100 Abbott Park Road, Abbott Park, IL 60064-3500. Telephone: (800) 323-9100 or (847) 937-6100. Fax: (847) 937-3130. Web: www.abbott.com.
• Sure-Vue hCG Stat Test Kits are visual, one-step tests for the qualitative determination of human chorionic gonadotropin (hCG) in serum or urine to aid in early detection of pregnancy, with results within 4-5 minutes. The cost for a 50-test kit is $170. For more information, contact: Fisher HealthCare Customer Service, P.O. Box 1546, 9999 Veterans Memorial Drive, Houston, TX 77038. Telephone: (800) 640-0640 or (281) 820-9898. Fax: (800) 290-0290 or (281) 405-4075. Web: www.fishersci.com.