Do point-of-care tests to cut chest pain delays

At triage, a patient reports fatigue and shortness of breath with a history of pulmonary and cardiovascular disease. Because you don’t know the patient’s brain natriuretic peptide or troponin level, you begin treating the patient for pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure, and you start the admission process.

Or this patient could be given point-of-care (POC) testing right at triage, with no cardiac damage identified. As a result, the patient could be discharged home from the ED. POC testing for cardiac patients is done in only about 10% of EDs currently, says Cynthia Cadwell, RN, CNS, a San Diego-based consultant specializing in improving quality of care and patient throughput.

However, if you don’t perform cardiac marker testing for chest pain patients, you could be prolonging the length of stay for each patient by hours and delaying life-saving interventions, she warns.

"Getting an electrocardiogram [ECG] for a patient with chest pain is something you would never consider waiting an hour for," says Cadwell. Yet that is what EDs are doing with the non-ST elevation population, she says. "This patient population deserves immediate attention which we are not giving them."

Only about half of acute myocardial infarction cases show a pattern of ventricular injury on ECGs, and the remainder have to be identified with cardiac biomarkers, explains Cadwell.

Most chest pain patients who have delayed testing won’t die in the ED, says Cadwell. However, if treatment is not started in the ED, it often doesn’t happen until about 24 hours later, and outcomes are poorer, she explains.

"There is a huge disconnect between ED and critical care," says Cadwell. "The ED is the front door, and it has a huge impact on services downstream."

Chest pain patients are high volume and high risk, and they often are admitted because of lack of immediate information in the ED, says Cadwell. "Research has shown that if the patient’s determinations aren’t made early on, their treatment is extended and outcomes are poorer," she says. "Having the information in the ED means better patient care, shorter length of stay, and less costly care, so this is a win-win-win situation for everybody involved."

Delays cut by two hours

A study done at Stony Brook (NY) University’s ED found that bedside point-of-care testing of the cardiac marker troponin 1 cut the patient’s ED length of stay by almost two hours.1

For patients without clear-cut symptoms, ED nurses normally would have drawn blood, given a chest X-ray and ECG, and possibly given aspirin, but they would have waited up to two hours for results to come back before getting them admitted, says Julie Cangro, RN, former ED clinical coordinator at Stony Brook and currently ED educator at Brookhaven Memorial Hospital Medical Center in East Patchogue, NY.

"If we see patients have an elevated troponin level, we can call cardiology right away to work on getting them a bed," she says. "Instead of being pending, the patients get a lot more attention because you know right away."

A room was dedicated for POC testing in the ED, with nurses attending a 15-minute orientation with a return demonstration and examination to demonstrate competency, says Cangro.

The POC test results allow ED nurses to decide the next step immediately, ranging from discharge home to critical care unit admission. "It gets patients on track very quickly, similar to when you find out a patient isn’t pregnant and can send her right back to CT scan instead of waiting," she says.

One downside was that performing quality controls was additional work for nurses, says Cangro. "I ended up doing quality controls to take the burden off the nurses," she says. "It was very cumbersome and difficult to do if you are working clinically."

However, new devices are available that do quality control automatically, which frees ED nurses to focus on patient care, says Cadwell. "ED nurses don’t want to test equipment and write down a bunch of numbers," she says. "They want to take care of patients. Nurses want put the blood in and get the results."

At Baptist Memorial Hospital in Memphis, ED nurses do point-of-care testing for blood glucose monitoring, occult stools, urine Hemastix, and pH testing for amniotic fluid. This has improved patient care, patient satisfaction, and turnaround times, says Maggie Roaten, RN, ED nurse manager.

"For pediatric patients, bedside urine Hemastix enables us to get results in seconds, as opposed to sending the urine to the laboratory, which could have a turnaround time of 30 minutes," she says.

For bedside glucose monitoring, each ED nurse attends a glucose monitoring inservice and passes a written exam. "Six months after initial testing, we require a re-evaluation and, thereafter, an annual competency evaluation," says Roaten.

Patient identification is done immediately with the handheld device, she adds. "Diabetics can have their blood sugar tested and be treated quickly, often within 10 minutes, whereas sending a test to the lab could take up to 30 minutes."

One challenge was what to place in the glucose testing device to identify patients. "We resolved this by placing patients’ names in the device, or if patients can’t give us their name, we use "John Doe" in the glucose monitor for patient identification," says Roaten.

Reference

  1. Singer AJ, Ardise J, Gulla J, et al. Point-of-care testing reduces length of stay in emergency department chest pain patients. Ann Emerg Med 2005; 45:587-591.

Sources

For more information on point-of-care testing in the ED, contact:

  • Cynthia Cadwell, RN, CNS, Principal, Cadwell Consulting, 4927 Lillian St., San Diego, CA 92110. Telephone/Fax: (619) 275-2528. E-mail: cadwellconsulting@yahoo.com.
  • Julie Cangro, RN, Emergency Department Education, Brookhaven Memorial Hospital Medical Center, 101 Hospital Road, East Patchogue, NY 11772. Telephone: (631) 687-4093. E-mail: jcangro@bmhmc.org.
  • Maggie Roaten, RN, Nurse Manager, Emergency Department, Baptist Memorial Hospital-Memphis, 6019 Walnut Grove Road, Memphis, TN 38120. Telephone: (901) 226-5000.