Early point-of-care testing in ED improves and speeds patient care

Decreased resources coupled with increased demand represents a major problem for healthcare providers that is most publicly manifest in overstretched hospital emergency room (ER) departments around the world. Prolonged waiting times and extended periods of overcrowding in ER, which are increasingly the norm, result in delay in diagnosis and treatment, with potentially worse patient outcomes.

ER nurse-led triaging of patients, which aims to speedily identify those unstable critically/acutely ill patients most at risk of delay in diagnosis and treatment, certainly mitigates the problem, but there remains an urgent need for novel ways of improving the rate of patient flow though ER to address the general problem of overcrowding and its attendant risks. 

Advances in technology have allowed an increasing number of laboratory tests to be performed rapidly at the patient’s beside rather than in the central laboratory. This so-called point-of-care testing (POCT) has real potential to be part of the solution to prolonged waiting times and overcrowding in ER.

Numerous studies have provided evidence that the use of POCT in ER decreases turnaround time (TAT) of test results, when compared with central laboratory testing; and some have demonstrated that the use of POCT in ER can expedite patient diagnosis and disposition in particular clinical contexts, including: acute coronary syndrome (ACS), venous thromboembolism and sepsis/septic shock. 

The precise way(s) in which POCT can be best exploited in ER remain the object of continuing research. A collaborative group of US emergency medicine researchers based at Stony Brook University Hospital in New York and George Washington University Hospital in Washington have been investigating the use of POCT at the time of ER triage, which is prior to ER physician assessment of patients. The latest of several studies by the group examining the value of this ER nurse-led POCT-use strategy is recently published.

In essence, this study was designed to compare length of ER care time (defined as the time between patient arrival in ER and physician decision regarding patient disposition) in stable patients receiving POCT at triage with length of ER care time in matched control-triaged patients whose blood tests were conventionally performed in the central laboratory following initial physician evaluation. They also sought to determine the extent to which POCT results at nurse triage escalated patients to a more urgent triage level; did some apparently stable patients receive physician attention more rapidly because of their triage POCT results?

The study population comprised 52 study patients and 52 matched control patients; matched for age, gender, clinical condition and main clinical complaint. Study patients/controls were selected for study if they presented in a stable state at triage with prespecified conditions (chest pain, abdominal pain, syncope, generalized weakness, infection/sepsis, GI bleed) that warranted defined blood/urine tests.

The stable condition indicated that they did not need to be triaged to the most urgent triage level and would therefore have to wait for physician assessment. Patients who at triage were judged to need immediate physician evaluation were excluded from this study.

The 52 study patients were submitted for POCT at the time of triage; blood testing of the 52 control patients was delayed until physician assessment, and conducted at the central laboratory. The median length of time between triage and initial physician assessment was essentially the same in both study and control patients (3.1 hours versus 3.2 hours).

However, study patients who were submitted for POCT at triage had a significantly shorter overall ED care time (median 7.6 hours, interquartile range of 5.1-9.5 hours) than matched control patients (median 8.5 hours, interquartile range of 6.2-11.3 hours). 

The triage level of three study patients was escalated to a more urgent level because of POCT results; two had a raised serum troponin and were subsequently diagnosed with non-ST elevation myocardial infarction (NSTEMI); and one had a low hemoglobin (ctHb 6 g/L) that warranted red-cell transfusion. 

Survey of physicians caring for study patients revealed that a majority (56 %) of responders felt that the availability of POCT results at the time of their initial patient evaluation was helpful and that it improved patient care. 

In short, study results suggest that POCT at triage reduces ED care time by around 1 hour and has the potential to improve patient care because of the improved triage decision making that availability of POCT results allows.