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Article

March 2018

Benefits of point-of-care testing in the Emergency Department

by Andrew St John, Christopher P. Price
Point-of-care testing Cardiac markers Natriuretic peptide
Summary

This article explores the potential benefits of point-of-care testing in the ED. Price and St. John provide a detailed description on how to approach four common aspects of point-of-care testing (POCT) in the ED, specifically, the challenges of adopting POCT, the impact of POCT on clinical decisions, the impact of POCT on operational decision making and outcomes and the impact of POCT on resource allocation decisions.

The key to successfully using POCT in the ED lies in demonstrating the diagnostic accuracy of the technology and immediately acting on the results as they become available.

 

Introduction

Overcrowding in the Emergency Department (ED) is a widely acknowledged problem that is just one of the many pressures on the ED and has arisen through a number of causes, including an aging population and increasing referrals from primary care. Overcrowding has impacts on the remainder of the hospital in which it is located but most importantly, it is associated with an adverse impact on patient mortality.

Sun et al used bootstrap sampling to study nearly one million visits to the ED and found that overcrowding was associated with increased inpatient death [1]. Singer et al reviewed 41,256 admissions from the ED, finding that mortality “generally increased with increasing boarding time, from 2.5 % in patients boarded less than 2 hours to 4.5 % in patients boarding 12 hours or more (p < 0.001)” [2].

There is an extensive literature offering solutions to this problem, including:
(i) Reducing the number of people needing to go to the ED.
(ii) Improving the efficiency of the ED.
(iii) Specifically, discharging patients from the ED more quickly [3].

Point-of-care testing (POCT) enables more rapid clinical decision making in the process of diagnosis, (rule-in or rule-out), treatment choice and monitoring, and prognosis, as well as operational decision making and resource utilization. Thus, for all of the above it is possible to consider a role for POCT to help address the pressures on the ED.

Ways to reduce the number of people presenting to the ED include providing a more integrated spectrum of services from self-help and self-care, through telephone contact, primary care and walk-in centers to hospital-based emergency departments and major trauma centers [4].

POCT could be provided in all of these care settings and enable decisions to be made more quickly if there was a potential need for referral, and the use of POCT in urgent care centers [5] and paramedical vehicles [6] has been described. It has also been suggested that urgent care centers could be used for the treatment of non-urgent conditions, thereby reducing the number of attendances at the hospital [7].

However, more attention has been directed at solutions (ii) and (iii) where the use of POCT is to facilitate earlier and more rapid decision making, which in theory should lead to a more efficient ED, such as earlier discharges, and potentially increase the capacity of the ED to treat more patients.

Challenges of adopting POCT in the ED

It is always important to determine the unmet clinical need that will be addressed by the use of any test, and how the test will actually be used in the clinical pathway. This is equally true for POCT as it is for laboratory testing. Since the whole purpose of POCT is usually to shorten the time to decision making and thus of the overall clinical pathway, then consideration must be given to how this will impact on the operation of the ED.

This point is emphasized by Rooney and Schilling who in their discussion of the effective use of POCT in the ED highlight the fact that “clinical pathways and ED logistics may need substantial modification to maximize the clinical and economic benefits of rapid TATs provided” [8].

Quality management of POCT is an important aspect of the wider quality management of services provided by the ED. It can be a challenging environment for POCT with a wide range of potential operators and the need to demonstrate competence [9]. As the range of tests employed in the ED expands, the need to maintain the equipment may also become more challenging.

The introduction of more rapid assessment, including the co-location of a primary care physician in the ED, supported by POCT can improve patient flow in the ED [10]. The practical challenges of improving patient flow can be addressed with the application of lean thinking, which also has the advantage of providing information on resource utilization, as well as helping to guide where inefficiencies occur and resources might be saved [11,12].

Furthermore, there are often perceived economic challenges with the introduction of POCT due to a fixation on just the cost of the test (almost always the POCT is more expensive than the laboratory equivalent) rather than considerations of the cost of the overall pathway which POCT can reduce [13].

Assuming these challenges can be overcome and that care pathways and associated processes can be changed within the ED to optimally use the provision of more rapid test results from POCT, then more rapid testing can impact on clinical, operational and economic outcomes.

Impact of POCT on operational decision making, and outcomes, in the ED

Rapid access to results through the adoption of POCT should, inevitability, impact operational decisions and outcomes. We consider operational outcomes as being time and setting based, examples of which are the time taken to rule in or rule out a condition or the time to discharge the patient from the ED, or avoidance of the need to attend the ED, e.g., through access to testing in primary care or an urgent care center. Reducing these times then has an obvious impact on resource utilization.

Given the relevance of these points to issues such as overcrowding, it is not surprising that the majority of evidence on the use of POCT in the ED focusses on the operational and resource utilization benefits. 

Early simulation studies of ED activity have shown that reducing the time-to-result for cardiac marker tests from 120 minutes down to 10 minutes can impact on the length of stay, average number of diversion days, average number of diversion hours per day, and percentage of diversion days, while also increasing the productivity of the ED on a daily basis [14].

Observations before and after studies of all patients presenting to the ED over a given period of time have shown a reduction in the median length of stay (from 466 to 406 minutes) with a greater effect in patients being admitted, compared to those being discharged [15].

Jarvis et al compared the process performance of a “nurse-led triage model” with samples analyzed in the laboratory to a “consultant-supported rapid assessment model” with POCT. They found a reduction in the median time for patients to be declared ready to leave the emergency department of 53 minutes (down from 129 to 76 minutes) [16].

Kankaanpää made similar observations in a larger study of an ambulatory population attending the ED, which was conducted in three phases: (i) current practice supported by laboratory testing, (ii) introducing POCT, and (iii) introducing an “early assessment team”. They found that POCT reduced the median length of stay by 29 minutes with the addition of the early assessment team reducing the total median time saved to 46 minutes (the baseline median length of stay was 3 hours 51 minutes) [17]. 

In a critical review, Holden found POCT in the ED setting led to a reduction in the length of stay, waiting time and the number of patients leaving without being seen [18]. This observation should be viewed against a backcloth of the data from a National Hospital Ambulatory Medical Care survey, covering over 360 million weighted ED visits to 364 hospitals.

The survey found that a blood test added 72 minutes to the length of stay, and imaging analyses added between 56 and 64 minutes depending on the imaging modality employed (all expressed as adjusted marginal effects). Treatment interventions added an average of 24 minutes when performing a procedure and 15 minutes when giving a medication [19].  In some cases, faster delivery of results has been achieved with the creation of a STAT laboratory within, or close to the ED [20,21], while in other instances, POCT is integrated into the ED setting. 

Interfacing POCT equipment to a clinical order communication system has also reduced the time to reporting of results, with POCT results available in 23 minutes, while laboratory results were available in 60 minutes [22]. Alternatives for providing rapid return of results from the laboratory include the use of an air tube system, although Nørgaard and Mogensen found that even in this situation POCT delivered results faster (by 46 minutes) [23]. As might be expected, the adoption of POCT requires practice and process changes in order to deliver improved outcomes.

Impact of POCT on clinical decisions in the ED

Some specific examples of the use of POCT in the ED are given in Table I; this listing makes the implicit assumption that blood electrolyte, gas and glucose measurements have an established utility in the emergency setting to assess patient status at the time of admission in a particular spectrum of patients.

Test

Stakeholder

 

Patient

Carer

Provider

Purchaser

NTpro-BNP/BNP

faster access to diagnosis

faster access to treatment

less time spent in hospital

faster access to diagnosis

faster access to treatment

greater efficiency of the care process

reduced referrals for echocardiography

reduced crowding in ED

meeting more ED efficiency targets

reduced likelihood of admissions

reduced crowding in ED

reduced cost of care

meeting more ED efficiency targets

Troponin

less time to diagnosis

less time spent in ED

less time to diagnosis

greater efficiency of the care process

reduced time to discharge

reduced length of stay in ED

reduced likelihood of admissions

reduced “cost” of diversions

reduced “cost” of diversions

reduced crowding in ED

reduced cost of care

meeting more ED efficiency targets

D-dimer

faster access to diagnosis

faster access to treatment

faster access to diagnosis

faster access to treatment

reduced referrals for ultrasonography

reduced length of stay in ED

reduced likelihood of admissions

reduced cost of care

Glucose

faster access to diagnosis

faster access to treatment

faster access to diagnosis

faster access to treatment

faster triage

reduced “cost” of diversions

reduced “cost” of diversions

reduced cost of care

Ketones

faster access to diagnosis

faster access to treatment

reduced risk of complications

faster access to diagnosis

faster access to treatment

reduced risk of complications

reduced likelihood of admission

reduced cost of care

Pregnancy test

faster access to imaging

reduced risk of adverse events

faster access to imaging

 

improved ED efficiency

reduced “cost” of diversions

reduced “cost” of diversions

reduced cost of care

Creatinine

reduced risk of kidney damage

reduced time to CT

reduced time to CT

reduced cost of care

Lactate

shorter time to diagnosis of sepsis

shorter time to treatment

shorter time to treatment

reduced length of stay

reduced cost of care

Influenza

shorter time to treatment

 

reduced length of stay

reduced cost of care

HIV

increased awareness of infection

increased awareness of infection

increased screening rate

increased screening rate

Blood gas and electrolytes

shorter time to establish blood gas and electrolyte status

shorter time to treatment

reduced length of stay

reduced cost of care

TABLE I. Some examples of tests employed in the ED and their potential benefits to different stakeholders 

Given that crowding in the ED can lead to an increase in time to treatment [24], it is reasonable to hypothesize that the introduction of POCT in the ED will reduce the time to treatment – and thus improve clinical outcomes. In a review of the literature covering the introduction of POCT into the ED, Rooney et al concluded that POCT “when used effectively, may alleviate the negative impacts of overcrowding on the safety, effectiveness, and person-centeredness of care in the ED” [8].

Of course, it goes without saying that, in any clinical scenario, decision making in the ED can only improve effectiveness and efficiency if the results are accessed and acted upon. Yet there are instances reported where laboratory results have not been accessed [25,26]. The lack of follow-up of test results for patients treated in the ED ranged from 1.0 % to 75 % when calculated as a proportion of tests in a review of the incidence of missing test results [26]. 

The introduction of POCT has been shown to improve the speed of access to further investigational interventions; examples have included the use of a pregnancy test to enable faster access to imaging in women of child-bearing age [20], and faster completion of IV contrast CT scanning [27]. The mean time to receipt of urea and creatinine results from the time of admission to the ED in patients being considered to receive contract media was 11.4/4.9 minutes (mean/SD) compared to 46.8/38.5 minutes when using the laboratory service [28].

Rapid access to influenza results in a pediatric ED also led to a reduction in the number of investigations as well as reduced antibiotic use, increased antiviral use and a reduction in the time to discharge [29].  

In the case of treatment interventions, the introduction of POCT for lactate in adult ED patients with suspected sepsis has been shown to reduce the time to administration of IV fluids but not antibiotics. The investigators showed a significant reduction in mortality and ICU admissions, which they concluded was “likely due, at least in part, to POC testing” [30].

Patients presenting with a constellation of symptoms, including breathlessness and chest pain, may have tests for troponin, natriuretic peptide and D-dimer. In a narrative review Nayer et al concluded that natriuretic peptide measurements were helpful in the diagnosis of patients presenting to the ED with dyspnea as well as in the management of a number of clinical conditions [31]. Bingisser et al, in another review, drew similar conclusions, but pointing out there was little data to demonstrate patient and provider benefits [32].

Pecoraro in a systematic survey of immunoassay-based POCT reported on nine studies of natriuretic peptide measurement in the ED [33], concluding that they were accurate when compared with laboratory-based tests. Rapid diagnosis of acute heart failure and prompt initiation of effective treatments, such as intravenous vasodilators, is associated with improved patient outcomes.

This requirement was highlighted in the ADHERE registry study, which showed that a delay in the treatment of heart failure was associated with a 250 % increase in acute mortality, and >150 % increase in both hospital and Intensive Care Unit length of stay [34].

There are a large number of studies reporting on the performance of troponin POCT tests in the ED, summarized in ref [35]; 16 % of the studies reported an impact of POCT on mortality. The potential value of employing troponin POCT in the ED increases as the analytical sensitivity of the assays increases, with rule-out strategies for myocardial infarction now being reported down to one hour, albeit currently only with laboratory-based assays [36].

In a critical review of the case for the use of troponin POCT in the ED, Bingisser et al concluded that “reengineering overall procedures within the emergency department setting, to take full advantage of reduced therapeutic turnaround time, has the potential to improve the flow of patients through the emergency department, to shorten discharge times, and to reduce cost” [37]. Singer et al showed a significant reduction in the length of stay in the ED in a before-and-after study of POCT for troponin in the ED [38].

In a randomized trial Goodacre et al demonstrated an increase in the number of patients discharged home using a panel of cardiac markers including troponin I [39]. Slagman et al in a comparison of a conventional POCT assay for troponin T compared with a high-sensitivity troponin T assay concluded that with the POCT assay “….a 99th percentile cut-off may be useful for rule-out of NSTEMI, but seems limited for routine rule-in strategies” [40].

POCT for D-dimer, together with the Wells score has been shown to have comparable diagnostic accuracy to a laboratory-based service in patients with suspected venous thromboembolism, enabling a quick decision to be made for patients requiring ultrasound scanning [41]. This can lead to a reduction in the length of stay in the ED, and fewer hospital admissions [42].

Finally, a number of POCT tests have been reported in the ED for use in screening patients for drugs of abuse and infectious diseases [43]. POCT for HIV has been considered as a way to reduce the proportion of the population who are unaware of their HIV status.

Impact of POCT on resource allocation decisions in the ED

While the literature on the cost effectiveness of POCT in the ED is limited, with concerns generally being expressed about the increasing cost of the test compared with its laboratory counterpart, it is now being recognized that the economic benefits of POCT are more likely to be realized through improving the efficiency of the ED, and the wider impact across the care pathway [13].

Thus, Asha et al investigated the cost effectiveness of introducing POCT in the ED, focusing on the time to disposition and showed that while the mean cost of POCT was greater ($12 (95 % CI $7 to $18)), the incremental cost-effectiveness ratio was $113 per hour saved in time to disposition decision for POCT, when compared with tests being sent to the central laboratory [46]. Clearly, savings will be greater if admissions to hospital can be avoided; however, there are clearly major challenges in realizing these savings.

Conclusions

There are considerable pressures on the ED, which contribute to crowding and poorer patient outcomes. The evidence would suggest that POCT, as well as the availability of other diagnostic modalities, can contribute to reducing the burden on the ED. While there may be benefits simply by introducing POCT in order to make results accessible more quickly, greater benefits to patient flow, as well as a broader range of health outcomes, will accrue from combining POCT with other changes in the organization of the ED workflow.

The effects can also be enhanced through triage in the primary care setting by: (i) better signposting of patients with acute or urgent problems in primary care [47], (ii) the establishment of urgent care or emergency multidisciplinary units in the community [3,48], or (iii) integration of primary care physicians into the ED setting [10]. It is likely that these solutions will help to reduce the crowding in the ED and both general practitioners and paramedics are now thinking about POCT in the community setting [49-51].

Intuitively the benefits from using POCT in the ED all derive from the rapid access to test results. However, the key to successful use of POCT in the ED lies in demonstrating the diagnostic accuracy of the technology, robust quality management of the POCT technology, acting on the results immediately the results become available and making the operational process changes to improve the efficiency and effectiveness of the care process.

References
  1. Sun BC, Hsia RY, Weiss RE et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med 2013; 61: 605-11
  2. Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011; 18: 1324-29
  3. Salway RJ, Valenzuela R, Shoenberger JM, Mallon WK, Viccellio A. Emergency department (ED) overcrowding: evidence-based answers to frequently asked questions. Rev Med Clin Condes 2017; 28: 213-19
  4. Ham C. Emergency department pressures need to be tackled through integrated urgent and emergency care. BMJ 2015; Jan 20; 350: h322. doi: 10.1136/bmj.h322
  5. Weinick RM, Burns RM, Ateev Mehrotra A. How many Emergency Department visits could be managed at urgent care centers and retail clinics? Health Aff (Millwood) 2010; 29: 1630-36
  6. Di Serio F, Lovero R, Leone M, De Sario R, Ruggieri V, Varraso L, Pansini N. Integration between the tele-cardiology unit and the central laboratory: methodological and clinical evaluation of point-of-care testing cardiac marker in the ambulance. Clin Chem Lab Med 2006; 44: 768-73
  7. Corwin GS, Parker DM, Brown JR. Site of treatment for non-urgent conditions by Medicare beneficiaries: is there a role for urgent care centers? Am J Med 2016; 129: 966-73 
  8. Rooney KD, Schilling UM. Point-of-care testing in the overcrowded emergency department - can it make a difference? Crit Care 2014; 18:692. doi: 10.1186/s13054-014-0692-9
  9. Larsen A, Greig-Pylypczuk R, Huisman A. The state of point-of-care testing: a European perspective. Upsala J Med Sci 2015; 120: 1-10
  10. Jarvis PR. Improving emergency department patient flow. Clin Exp Emerg Med 2016; 3: 63-68
  11. Silvester K, Price CP. Lean thinking and a role for point-of-care testing. In Price CP, St John A, Kricka LJ. (Eds). Point-of-Care Testing. Needs, Opportunity and Innovation. Third Edition, Washington DC, AACC Press, 2010: 157-79
  12. White BA, Chang Y, Grabowski BG, Brown DF. Using lean-based systems engineering to increase capacity in the emergency department. West J Emerg Med 2014; 15: 770-76 
  13. St John A, Price CP. Economic evidence and point-of-care testing. Clin Biochem Rev 2013; 34: 61-74
  14. Storrow AB, Zhou C, Gaddis G et al. Decreasing lab turnaround time improves emergency department throughput and decreases emergency medical services diversion: a simulation model. Acad Emerg Med 2008; 15: 1130-35
  15. Singer AJ, Viccellio P, Thode HC et al. Introduction of a stat laboratory reduces Emergency Department length of stay. Acad Emerg Med 2008; 15: 324-28
  16. Jarvis P, Davies T, Mitchell K et al. Does rapid as¬sessment shorten the amount of time patients spend in the emergency department? Br J Hosp Med (Lond) 2014; 75: 648-51
  17. Kankaanpää M, Raitakari M, Muukkonen L et al. Use of point-of-care testing and early assessment model reduces length of stay for ambulatory patients in an emergency department. Scand J Trauma Resusc Emerg Med 2016; 24, 1: 125
  18. Holden RJ. Lean thinking in emergency departments: A critical review. Ann Emerg Med 2011; 57: 265-78
  19. Kocher KE, Meurer WJ, Desmond JS et al. Effect of testing and treatment on emergency department length of stay using a national database. Acad Emerg Med 2012; 19: 525-34
  20. Lee-Lewandrowski E, Corboy D, Lewandrowski K et al. Implementation of a point-of-care satellite laboratory in the Emergency Department of an academic medical center. Arch Pathol Lab Med 2003; 127: 456-60
  21. Singer AJ, Viccellio P, Thode HC et al. Introduction of a stat laboratory reduces Emergency Department length of stay. Acad Emerg Med 2008; 15: 324-28
  22. Gilkar A, Fink R, Eardley P, Barron C. The effect of on-line POCT on patient waiting times in an Accident and Emergency Department. BMJ Qual Improv Rep 2013; Apr 12; 2(1). pii: u201027.w685. doi: 10.1136/bmjquality.u201027.w685. eCollection 2013
  23. Nørgaard B, Mogensen CB. Blood sample tube transporting system versus point of care technology in an emergency department: effect on time from collection to reporting? A ran¬domised trial. Scand J Trauma Resusc Emerg Med 2012; 20: 71. doi: 10.1186/1757-7241-20-71
  24. Sikka R, Mehta S, Kaucky C, Kulstad EB. ED crowding is associated with an increased time to pneumonia treatment. Am J Emerg Med 2010; 28: 809-12
  25. Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ 2001; 322(7294): 1101-03
  26. Callen J, Georgiou A, Li J, Westbrook JI. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf. 2011; 20: 194-99 
  27. Singer AJ, Williams J, Taylor M et al. Comprehensive bedside point of care testing in critical ED patients: a before and after study. Am J Emerg Med 2015; 33: 776-80
  28. You JS, Chung YE, Park JW et al. The usefulness of rapid point-of-care creatinine testing for the prevention of contrast-induced nephropathy in the emergency department. Emerg Med J 2013; 30: 555-58 
  29. Bonner AB, Monroe KW, Talley LI et al. Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial. Pediatrics 2003; 112: 363-67
  30. Singer AJ, Taylor M, LeBlanc D et al. ED bedside point-of-care lactate in patients with suspected sepsis is associated with reduced time to iv fluids and mortality. Am J Emerg Med 2014; 32: 1120-24
  31. Nayer J, Aggarwal P, Galwankar S. Utility of point-of-care testing of natriuretic peptides (brain natriuretic peptide and n-terminal pro-brain natriuretic peptide) in the emergency department. Int J Crit Illn Inj Sci 2014; 4: 209-15
  32. Bingisser R, Cairns CB, Christ M et al. Measurement of natriuretic peptides at the point of care in the emergency and ambulatory setting: current status and future perspectives. Am Heart J 2013; 166: 614-21
  33. Pecoraro V, Banfi G, Germagnoli L, Trenti T. A systematic evaluation of immunoassay point-of-care testing to define impact on patients’ outcomes. Ann Clin Biochem 2017; 54: 420-31
  34. Di Somma S, Zampini G, Vetrone F et al. Opinion paper on utility of point-of-care biomarkers in the emergency department pathways decision making. Clin Chem Lab Med 2014; 52: 1401-07
  35. Pecoraro V, Germagnoli L, Banfi G. Point-of-care testing: where is the evidence? A systematic survey. Clin Chem Lab Med 2014; 52: 313-24
  36. St John A, Cullen L, Jülicher P, Price CP. Developing a value proposition for high-sensitive troponin testing. Clin Chim Acta. 2017 Dec 6. pii: S0009-8981(17)30492-8. doi: 10.1016/j.cca.2017.12.007. [Epub ahead of print]
  37. Bingisser R, Cairns C, Christ M et al. Cardiac troponin: a critical review of the case for point-of-care testing in the ED. Am J Emerg Med 2012; 30: 1639-49
  38. Singer AJ, Ardise J, Gulla J, Cangro J. Point-of-care testing reduces length of stay in Emergency Department chest pain patients. Ann Emerg Med 2005; 45: 587-91           
  39. Goodacre SW, Bradburn M, Cross E et al. The randomised assessment of treatment using panel assay of cardiac markers (RATPAC) trial: a randomised controlled trial of point-of-care cardiac markers in the emergency department. Heart 2011; 97: 190-96
  40. Slagman A, von Recum J, Möckel M. Diagnostic performance of a high-sensitive troponin T assay and a troponin T point of care assay in the clinical routine of an Emergency Department: A clinical cohort study. Int J Cardiol 2017; Mar 1; 230: 454-60
  41. Sen B, Kesteven P, Avery P. Comparison of D-dimer point of care test (POCT) against current laboratory test in patients with suspected venous thromboembolism (VTE) presenting to the emergency department (ED). J Clin Pathol 2014; 67: 437-40 
  42. Lee-Lewandrowski E, Nichols J, Van Cott et al. Implementation of a rapid whole blood D-dimer test in the emergency department of an urban academic medical center: Impact on ED length of stay and ancillary test utilization. Am J Clinical Pathol 2009; 132: 326-31
  43. Lager PS, Attema-de Jonge ME, Gorzeman MP et al. Clinical value of drugs of abuse point of care testing in an emergency department setting. Toxicology Reports 2018; 5: 12-17
  44. Rob Stenstrom, R, Ling D, Grafstein E et al. Prevalence of HIV infection and acceptability of point-of-care testing in a Canadian inner-city emergency department. Can J Public Health 2016; 107: e291–e5
  45. Becker ML, Thompson LH, Pindera C et al. Feasibility and success of HIV point-of-care testing in an emergency department in an urban Canadian setting. Can J Infect Dis Med Microbiol 2013; 24: 27-31
  46. Asha SE, Chan AC, Walter E et al. D Impact from point-of-care devices on emergency department patient processing times compared with central laboratory testing of blood samples: a randomised controlled trial and cost-effectiveness analysis. Emerg Med J 2014; 31: 714-19
  47. Thompson MI, Lasserson D, McCann L, Thompson M, Heneghan C. Suitability of emergency department attenders to be assessed in primary care: survey of general practitioner agreement in a random sample of triage records analysed in a service evaluation project. BMJ Open 2013; 3:e003612. doi: 10.1136/bmjopen-2013-003612.
  48. Webb M, Campbell K. Innovating care in the community. British Journal of Healthcare Management 2014; 20: 330-32
  49. Turner PJ, Van den Bruel A, Jones CH et al. Point-of-care testing in UK primary care: a survey to establish clinical needs. Fam Pract. 2016; 33: 388-94
  50. Kip MMA, Noltes AM, Koffijberg H et al. Improving early exclusion of acute coronary syndrome in primary care: the added value of point-of-care troponin as stated by general practitioners. Prim Health Care Res Dev. 2017; 18: 386-97
  51. Kip MMA, Koffijberg H, Moesker MJ et al. The cost-utility of point-of-care troponin testing to diagnose acute coronary syndrome in primary care. BMC Cardiovasc Disord 2017; 17:213. doi: 10.1186/s12872-017-0647-6
     
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References
  1. Sun BC, Hsia RY, Weiss RE et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med 2013; 61: 605-11
  2. Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011; 18: 1324-29
  3. Salway RJ, Valenzuela R, Shoenberger JM, Mallon WK, Viccellio A. Emergency department (ED) overcrowding: evidence-based answers to frequently asked questions. Rev Med Clin Condes 2017; 28: 213-19
  4. Ham C. Emergency department pressures need to be tackled through integrated urgent and emergency care. BMJ 2015; Jan 20; 350: h322. doi: 10.1136/bmj.h322
  5. Weinick RM, Burns RM, Ateev Mehrotra A. How many Emergency Department visits could be managed at urgent care centers and retail clinics? Health Aff (Millwood) 2010; 29: 1630-36
  6. Di Serio F, Lovero R, Leone M, De Sario R, Ruggieri V, Varraso L, Pansini N. Integration between the tele-cardiology unit and the central laboratory: methodological and clinical evaluation of point-of-care testing cardiac marker in the ambulance. Clin Chem Lab Med 2006; 44: 768-73
  7. Corwin GS, Parker DM, Brown JR. Site of treatment for non-urgent conditions by Medicare beneficiaries: is there a role for urgent care centers? Am J Med 2016; 129: 966-73 
  8. Rooney KD, Schilling UM. Point-of-care testing in the overcrowded emergency department - can it make a difference? Crit Care 2014; 18:692. doi: 10.1186/s13054-014-0692-9
  9. Larsen A, Greig-Pylypczuk R, Huisman A. The state of point-of-care testing: a European perspective. Upsala J Med Sci 2015; 120: 1-10
  10. Jarvis PR. Improving emergency department patient flow. Clin Exp Emerg Med 2016; 3: 63-68
  11. Silvester K, Price CP. Lean thinking and a role for point-of-care testing. In Price CP, St John A, Kricka LJ. (Eds). Point-of-Care Testing. Needs, Opportunity and Innovation. Third Edition, Washington DC, AACC Press, 2010: 157-79
  12. White BA, Chang Y, Grabowski BG, Brown DF. Using lean-based systems engineering to increase capacity in the emergency department. West J Emerg Med 2014; 15: 770-76 
  13. St John A, Price CP. Economic evidence and point-of-care testing. Clin Biochem Rev 2013; 34: 61-74
  14. Storrow AB, Zhou C, Gaddis G et al. Decreasing lab turnaround time improves emergency department throughput and decreases emergency medical services diversion: a simulation model. Acad Emerg Med 2008; 15: 1130-35
  15. Singer AJ, Viccellio P, Thode HC et al. Introduction of a stat laboratory reduces Emergency Department length of stay. Acad Emerg Med 2008; 15: 324-28
  16. Jarvis P, Davies T, Mitchell K et al. Does rapid as¬sessment shorten the amount of time patients spend in the emergency department? Br J Hosp Med (Lond) 2014; 75: 648-51
  17. Kankaanpää M, Raitakari M, Muukkonen L et al. Use of point-of-care testing and early assessment model reduces length of stay for ambulatory patients in an emergency department. Scand J Trauma Resusc Emerg Med 2016; 24, 1: 125
  18. Holden RJ. Lean thinking in emergency departments: A critical review. Ann Emerg Med 2011; 57: 265-78
  19. Kocher KE, Meurer WJ, Desmond JS et al. Effect of testing and treatment on emergency department length of stay using a national database. Acad Emerg Med 2012; 19: 525-34
  20. Lee-Lewandrowski E, Corboy D, Lewandrowski K et al. Implementation of a point-of-care satellite laboratory in the Emergency Department of an academic medical center. Arch Pathol Lab Med 2003; 127: 456-60
  21. Singer AJ, Viccellio P, Thode HC et al. Introduction of a stat laboratory reduces Emergency Department length of stay. Acad Emerg Med 2008; 15: 324-28
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May contain information that is not supported by performance and intended use claims of Radiometer's products. See also Legal info.

Andrew St John

 

ARC Consulting
Perth
Western Australia
Australia

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Christopher P. Price

 

Department of Primary Care Health Sciences
University of Oxford
Oxford
United Kingdom

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