Point of Care Testing(POCT)

Rawene Hospital 2009

Rawene Hospital

• Part of Hauora Hokianga Trust

• Integrated Health service ( PHO NGO)

• Care across the primary –secondary

interface

• Fragmented funding

• Docs are generalists ( GPs/RHD)

Rawene Hospital 2

• 24/7 acute service

• 10 acute beds 4 maternity beds

• Base Hospital at Whangarei 2hrs

• 750 acute admissions, 25% transfer WBH

• No lab, Xray Mon-Fri

• 70 % Maori

• Deprivation index 9-10

• High prevalence of cardiac disease,

renal disease, diabetes mellitus,

COPD, cancer…

POCT

• Portable

• Stand alone

• good evidence that POCT is reliable with quality control systems

POCT analysers in NZ:

• Used in several NZ rural hospitals in conjunction with an on site laboratory

• Use in a small rural hospital with no on-site laboratory ?

• The planned introduction of POCT at Rawene = an opportunity…

Before POCT

• Laboratory service on a “send away”

basis : to Whangarei Mon-Fri

• From 10am Friday until 10 am Monday no

lab at all

• Turn around Time (TAT) : 8-72 hours

Most standard guidelines for medical

emergencies include basic lab tests as part

of the initial assessment and management

and to guide ongoing care…

Where we saw an urgent need for

POCT:

• Acute emergency presentations needing

resuscitation /stabilisation and transfer

• Patients with the potential to become

acutely unwell

The Impact of Point-of-care-testing

on Decision Making by General

Practitioners in a Small Rural

Hospital

Rural Innovation Fund Grant

Objectives:

• Assess the impact of POCT on patient management

• Assess the acceptability of POCT to clinicians

• Quality Assurance

• To evaluate costs vs benefits

• Part I : a prospective observational

study

• Part II : Clinician Interviews

• Part III: Implementation of Quality

Control programme

• Part IV: Cost-benefit analysis

Collaboration…

• Hauora Hokianga

• University Otago

• Senior Clinicians at Whangarei Hospital

• Laboratory services, POCT co ordinator

Whangarei Hospital

Methods part I

• Doctors completed a standard pro-forma each time they ordered a POCT

• Disposition

• Differential Diagnosis

• Management

pre and post- POCT

Methods part II

• Semi- structured interviews with doctors,

nurses, community health workers,

management

• Interviews recorded, transcribed, analysed

• Thematic analysis

• Computer assisted qualitative data

analysis software package

Tests available

• CHEM8: sodium , potassium , chloride , glucose , creatinine,

ionised calcium, urea, Haematocrit, Haemoglobin

• CG8: blood gas, sodium,potassium, glucose, Haematocrit ,

Haemoglobin

• TnI: troponin I

• BNP: B- natriuretic peptide

• INR: international normalised ratio

What did we find ?

• Over 6 months POCT was undertaken on

177 patients.

• POCT used for around 70% of

admissions

• POCT used much more often at weekends

• Chem 8 used most often followed by

Troponin. CG8( ABG) used least

Impact of patient transfer

decisions

….there was a statistically

significant difference in the

disposition of patients before and

after testing (Fisher’s Exact test 29.656:

p<0.001).

Impact on patient transfer decisions

Changes in Disposition pre- and post-test: All cases

admitted

discharged

transferred

0

20

40

60

80

100

120

140

pre-test post test

N patien

ts

• POCT altered disposition for 43 % of

patients (75 of 176, Fisher’s Exact test 29.656: p<0.001).

• Transfer admit (77%).

• Admit discharge (22%).

• Admit transfer ( 6%)

2 ways that POCT influenced

transfer decisions

Avoiding unnecessary transfer:

“ … a patient with renal failure … creatinine

in the mid 300‟s ….the fact that we knew

we could take his creatinine on Saturday

made it a lot easier to manage him here so

we changed his medication… and on

Saturday it had dropped down to 200 so

we knew we were heading in the right

direction… (Doctor)”

Expediting Transfer

POCT has enabled transfer decisions to be made earlier than they otherwise would have which has often meant that treatment can begin immediately …

• “..patient with a really high potassium …she came in quite symptomatic … when we did the blood test it confirmed that… we were able to start the treatment prior to transferring her out. So she actually got immediate treatment rather than having to wait two hours prior to [arrival at Whangarei hospital] – at least two hours really, so I thought that was a really good call.” (Doctor)

… if you have a test result to go with

them… that gives you a more definite

reason to transfer someone as well…

Diagnostic Certainty

• There was a significant reduction in the number

of diagnoses considered as part of the post test

differential compared to the pre test differential.

• Diagnoses pre test: 2.5

• Diagnoses post test: 1.3 ( paired t-tests p< 0.001)

• POCT narrowed the differential diagnosis for

94% of patients.

Respondents considered that POCT had

made an enormous impact on their

ability to diagnose challenging

patients.

Change in Management

POCT resulted in a substantial change in

treatment in 75% of cases, some change in

22% of cases and no change in 3% of cases.

“.. I think for me, the bigger thing is keeping somebody with confidence as opposed to keeping them and thinking, „oh should I or shouldn‟t I‟. There is that uncertainty ” ( doctor)

We would be flying by the seat of our pants from Friday 10.30 until Monday at five o‟clock… it sounds terrible doesn‟t it. But I–have lived with that for – I have been here since 1977 so you use clinical judgment and skills. (Doctor)

“It made you feel much more confident in

managing them here or ….in transferring

them, or discussing them with a

consultant. It really should be part of the

routine management when they present

acutely and I guess we hadn‟t been doing

that before. (Doctor)”

POCT enabled clinical staff to feel better

about patients returning to relatively

isolated homes across the harbour

particularly as the ferry only sails during

daylight hours.

The Challenge

• Increased workload

• Higher standard of practice

• Upskilling

• Time-consuming

• Over-testing

Increased workload ?

• … our ability to manage more and more

people here...anything new that you can

do changes the boundaries in what we

do… and we are doing …. very long

weekends when we are covering a ward

that can have some quite sick people plus

we are doing outpatients and A&E at the

same time. So it is a bit of a challenge

Up skilling :

“….having that blood result means that you

have got to have the capacity to interpret

it. POCT has forced me to go back to the

books and read up about pH and all that

kind of thing again to make sure that I can

interpret it so you are confronted with that,

yes.” ( doctor)

Time consuming …

“….in the middle of the night when it is just

me and the nurse and a really sick

person… All our hands are full trying to put

lines in and do all the other things ….

(POCT) is going to take an extra – ten

minutes of the nurses time – away from

the patient… where do you fit it into an

emergency situation and what priority do

you give it?” ( doctor)

Over-testing

“You have the younger doctors, who come

in and… do tests on everyone…

whereas some of the experienced doctors

here have learnt to function without them

( blood tests) and there is something good

about that as well” (Doctor)

Part III Quality Assurance Systems

The lab staff is YOU !

• Training and certification of Staff

• Procedure documentation

• Quality Control Programmes

• Cost

Costs

• Equipment

• Consumables

• Quality programme

• Staffing

• Training

• Overheads

Tangible Benefits

• RH admission : $4000

• WBH admission $5000

• Transfer $1900

• Savings to DHB: cost of transfer, lab

services, admissions to WBH

• Overall cost saving to Northland

Improved access to appropriate care for rurally isolated and high-needs Maori community

Improved job satisfaction for

rural clinicians

• Although POCT has proved more

expensive to run than initially anticipated,

sources for future funding are being

explored by Hauora Hokianga because the

service is considered to be of significant

benefit..

• At the time this talk was drafted there was

increasing optimism that the Northland

DHB would fund the continuation of this

service

Transferability

Key factors:

The travel time from Rawene Hospital to

base hospital and its laboratory service

demographics of the population

Make up of clinical staff

Rural areas : blurred boundaries

• Primary vs Secondary Care: both can be rural

• Specialist vs Generalist

• GP practice vs A&M clinic vs Hospital ED etc

• Rural Hospitals

….affects funding

Should quick easy access to basic lab

tests not be a core service for all

NZers presenting with acute

emergency medical problems ?