Canusingpointofcarebloodtestshelpinformdecisionmakinginpatientsover65presentingwithacutefrailtysyndrome?

We aim to improve the decisionmaking for common frailty conditions by introducingpointofcare(POCT)bloodtestsintotheemergencyservices.Weaimtoimprovepatientdischargeonsceneandre-contactratesaswellasincreaseclinicianconfidence.

PROJECTLEAD:Dolly(Melinda)McPherson–SpecialistParamedicPractitioner

ClinicalSupervisor–DrDavidClarke,RoyalBerkshireHospital

WokinghamCCGUrgentCareBoard–CarolynLawson

ACPFellowshipTeam–RobWay,JulietThorogood

SouthCentralAmbulanceService–KirstinWillis,PennyMeadley

OxfordAcademicHealthScienceNetwork–JulieHart

YorkHealthEconomicsConsortium–NickHex

©OxfordAcademicHealthScienceNetworkwww.healthandwealthoxford.org

Summary

Thenational‘see,treatanddischarge’ratesforparamedicshasincreasedhowever,despitethisincreaseddemand

onparamedicdecisionmakingtherehavebeenlimitedimprovementstopre-hospitaldiagnostics.Patientsoverthe

age of 65 years presenting with acute frailty syndromes are a notably complex clinical patient group for which

informedriskstratificationinclinicalreasoningisparamount.

ThiswasasinglesitequalityimprovementprojectusingPointofCarebloodtestingtohelpinformdecisionmaking

forpatients>65presentingwithacutefrailtysyndromes.

Results fromthisquality improvementproject intotheuseofPointofCaretesting (POCT)showedaself-reported

improvedconfidenceincliniciandecision-makingandpatientdisposition.Thisconfidencewasvalidatedbyimproved

dischargeonsceneandre-contactrates.Anunintendedoutcomeoftheprojectwastheaccumulationofpractical

knowledgeontheuseofPOCTinthepre-hospitalarena.TheseresultsshowpromisefortheongoinguseofPOCTin

the pre-hospital environment, however are not without limitations. Pre hospital services wishing to implement

POCTshouldfocusoncorrectdemographicidentificationandtrainingandinterpretationofresults.

- Point of care testing is an emergent theme for emergency services but todate there is limitedpublished

evidenceonitsusewithinthisenvironment.

- Patientspresentingwithacutefrailtysyndromescanpresentclinicallycomplexdecisionsregardingonward

careandreferral.

- ThisQuality improvementproject aimed to improve clinician confidenceanddecisionmaking forpatients

presentingwithacutefrailtysyndromes.

- During its implementation many lessons were learnt regarding the use of POCT in the pre hospital

emergencycareenvironmentthatmaybeusefulforotherservicesconsideringPOCT.

- TheresultsoftheprojectshowedpromisefortheongoinguseofPOCTandthefieldoffrailty.

- Theoverall result of the roll out scenario is anet savingof £50,159. With696patients treatedover this

period,thisgivesanetsavingperpatientof£72andgivesaROIforthisscenarioof:4.6.

Introduction

Point of care blood testing (POCT) is an expanding worldwide market13 that has become an established part of

serviceimprovementproposalswithintheNHStoreduceEmergencyDepartment(ED)times,lengthofhospitalstay

andimproveillnesspreventionschemes14.IntheUnitedKingdom(UK),PointofcareInternationalNormalisedRatio

(INR)testinginprimarycarehasbeenatopicofresearchsincetheearly1990’s11andpointofcarelactatemonitors

are being trialled for early sepsis guided therapy15.UK ambulance services have been identified as a service that

wouldbenefit fromPOCTtoguidepatientmanagementandcarepathways 9.10,13however there is littlepublished

evidence on the uses, benefits and health economics of POCT in the pre-hospital environment. This paper will

discussaqualityimprovementprojectutilisingPOCTtoaiddecision-makinginpatientsovertheageof65presenting

toSouthCentralAmbulanceservicewithacutefrailtysyndromes.

Thenational‘see,treatanddischarge’ratesforparamedicshasincreasedsincethe‘Takinghealthcaretothepatient’

report in20058withdischargeonsceneratesrisingby4%overthe last6years18.However,despitethis increased

demand on paramedic decision-making there have been limited improvements to pre-hospital diagnostics. The

committeeondiagnosticerrorinhealthcare6identifydiagnostictestingasanintegralpartofthediagnosticpathway

andnotethataclinician’sabilitytoriskstratifycanbeaffectedbyaccesstoresults.

Patientsovertheageof65yearslivingwithfrailtyareanotablycomplexclinicalpatientgroup3forwhichinformed

riskstratification inclinical reasoning isparamount.Thispatientgroupcanpresent to theambulanceservicewith

acute frailtysyndromesthat requirecarefulassessmentandmanagement toavoid lossof independence, function

andmedical deterioration16. The combination of reduced diagnostic aids and clinical complexities in this patient

grouphaspotentialtoincreasetheriskofpoordecision-makingandnegativepatientoutcomes6.Intheambulance

service thismay translate into unnecessary admissions to the Emergency department (ED) or deterioration after

dischargeonscene.Pointofcarebloodtestingisanaturaladditiontothediagnosticrepertoireofaparamedicdue

toitscommonusewithinstandardreferralsitessuchasemergencydepartmentsandprimarycareservices.

Acutefrailtysyndromesaredefinedasseeminglybenignsymptomsthatcanmaskseriousunderlyingillness.These

areidentifiedasfalls,immobility,confusion/delirium,incontinenceandsusceptibilitytosideeffectsofmedications3.

Fallsarethemostcommonlyencounteredacutefrailtysymptomwithintheambulanceservice7.Intheolderperson,

falls are typically multifactorial and consideration should be given to environmental causes, underlying illness,

polypharmacy, neurological impairments, gait and balance decline and visual impairments16. Whilst the

comprehensive geriatric assessment and falls risks assessments can be carried out in the absence of laboratory

results4, it is important to identify health problems that may increase the risk of falling16. Altered or deranged

laboratoryresultsmayindicatemedicationssideeffectsorunderlyingillness2.

Observation from practice identifies that patients with frailty in the emergency department are commonly

investigatedwithbasicbloodtests,ECGs,observationsandphysicalexamination.Intheabsenceofbloodtestsinthe

prehospitalenvironmentstaffmaybesusceptible tooversensitivetriageof thispatientgroup,which in turncan

contributetoinappropriateadmission21.Admissiontohospitalresultsinpoorfunctionaloutcomesforpatientsliving

with frailty4 thus increasing the need to avoid unnecessary admission from the pre-hospital environment. This

knowledgeprovidedthebasisforformulationofthisqualityimprovementproject.

HorizonScanning

Resultsofapreliminaryliteraturesearchrevealedthatthereisapaucityofevidencedocumentingtheuseofpoint

ofcarebloodtestingdevicesintheoutofhospitalenvironment9,10,13.Themostnotableuseofpre-hospitalpointof

care testing is the Labkit® Near Patient Diagnostics service testedwith Surrey pathology services and South East

Coast ambulance service. This project involved a three-phase trial that researched effective functionality, pre-

hospital suitabilityand impactonpatientmanagement20, theoutcomesofwhichareunclear.Todate, therehave

beennopeer-reviewedpublicationsofthisprojecttoguidetheuseofPOCbTinfutureprojects.

Diserioetal9,10conductedtwoseparatetrialsintotheuseofPOCbTinprehospitalservicesinGermany.Thefirst

using i-STAT troponin I to facilitate the early identification of Non ST Segment Elevation Myocardial Infarction

(NSTEMI) and the second tomonitor critical care patients during Helicopter EmergencyMedical Services (HEMS)

transfertohospital.ThetroponinstudyfoundthePOCTresultstobeaccuratebutnotdiagnosticduetothecommon

requirementforserialtroponinmonitoringinhospital9.ThesecondstudyintouseofPOCTonHEMSinterhospital

transfers identified a need for transfer of real time results to achieve patient benefit10. Both studies lack

transferabilitytotheUKpre-hospitalseeandtreatmodelduetotheirfocusoncriticallyillpatientswhosetrajectory

ofcareispre-determinedbytheirpotentialorrealisedillness.

CurrentprojectsusingPOCTincludetheOxfordAcademicHealthScienceNetwork(AHSN)collaborationwithOxford

Health NHS Foundation Trust using POCT in the out of hours primary care environment, ambulatory units and

emergency medical units14. And numerous other pre hospital services who anecdotally report using POCT

throughouttheUKbuthavenotpublishedevidenceontheirexperiencesorfindingsforwiderlearning.

Evaluationofi-STATAlinitydevice

Oxford AHSN provided the devices and cartridgesfortheevaluation.Weassessedtheimpactonsaferdischarges, earlier disease management andincreasedclinicianconfidence.

Only trained operators used the Abbott iStat forpatientsover65presentingwithacomplaintoffallsor immobility or confusion and had an uncertaindispositionpoststandardexamination.

Theprojectaimedtoimprovepre-hospitaldiagnosticsforpatientspresentingtotheambulanceservicewithacute

frailtysyndromes. Itwashypothesizedthataccesstocertainbloodresultswould increasetheabilitytomakesafe

andconfidentdischargeswhilealsoensuringthatalteredbiochemistrycouldbeinvestigatedappropriatelyeitherby

primarycareprovidersoremergencyphysicians.

Themainobjectiveswere:

• Saferdischarges(measuredbyre-contactratesandresultsaffectingdecision-making)

• Earlierdiseasemanagement(measuredbyonwardreferralsandhospitallengthofstay)

• Increasedclinicianconfidence(measuredbyselfreportinresponsetoqualitativequestions)

ThiswasasinglesitequalityimprovementprojectimplementedfromSeptember2017toMarch2018withinanNHS

ambulance service. Four specialistparamedicsand four frailtyparamedicswere trained in theuseof theAbbot i-

STAT Alinitywith CRG4+ and CHEM8 cartridges providing Venous blood gas (VBG), Urea and Electrolytes (U&Es),

lactate,HaemoglobinandHaematocrit.

Patientswereeligibleforinclusioniftheywere>65yearsoldwithapresentingcomplaintofFallsORimmobilityOR

confusionandhadanuncertaindispositionpoststandardexamination.Patientswereexcluded fromPOCT if their

carepathwaywasclearfromstandardexaminationorincaseswherePOCTwouldnotmakeadifferencetoonward

careordecision-making.

Trained staff could use POCT during their normal duties for any patient that met the inclusion criteria or could

receivereferrals. InadditiontouseondaytodaySProtasthe i-STATAlinitywasusedweeklyonafallsandfrailty

responseserviceduetoitsabilitytoattracttherequireddemographicandincreasetheimpactoftheQIP.

Staffweretrainedintheuseandinterpretationofresultsfromthedevice.Referencerangescompatiblewithlocal

pathology services were programmed to the i-STAT Alinity with abnormal and critical results differentiated.

Abnormal ranges automatically highlighted amber whilst critical results were highlighted red. In recognition of

normallyabnormalbiochemistryandhaematology inthispatientgroup,accesstotheBerkshire IntegratedClinical

Environment(ICE)portalwasobtainedtocomparepre-existingresults.AccesstoGPadviceprovidedasafetynetto

the learning process of results interpretation and staff were encouraged to use this. Results were recorded on

ambulanceserviceelectronicpatientsrecords(EPR)withverbalhandovertohospitalorprimarycareclinicians.

StaffcompletedanonlinesurveyaftereachuseofPOCTansweringthefollowingquestions:1-Patentgender,2-

Presenting complaint, 3 -Was there uncertainty about patient disposition prior to POCT? if notwhywere bloods

done?4-DidPOCTassistdecision-making?IfNo,whynot?5-Whereanylaboratoriesabnormalitiesdiscovered?If

yes, did these require action? If yes, what action was taken? 6 - Patient disposition? Home/ED/GP referral and

home/GP referral and ED, 7 - Overall to you feel that access to POCT results improved your (or your colleagues)

confidenceindisposition?

Priortothepilot/evaluationstartdate,laboratorystaffattheJohnRadcliffeHospitalvalidatedandsetupthedevice

carried out the installation with connectivity to LIMS & EPR; full documentation was written including standard

operatingprocedures,andtrainingandestablishmentofstaffcompetency.

Results

Thequalityimprovementprojectrecruited78patientsaged65yearsto97years(Average85yearsold).Genderwas

female51.3% (n=40)andmale48.7% (n=38)with79.5% (n=62)ofpresentingcomplaintsbeingattributed to falls.

Clinicians reported uncertainty in disposition 85.6% (n=67) of the time prior to POCTwith decision-making being

improvedin84.6%(n=66)ofcasesandimprovedconfidenceindispositionreportedin75.6%(n.59)ofcases.

Resultsoutsideofreferencerangeswerefound in55.1%(n=43)of thecaseswith53.5%(n=23)of theserequiring

clinical referral or action, of which 60% (n=14) required transportation to the emergency department with the

remainderreceivingaprimarycareoroutpatient frailtyspecificreferral.Outpatient frailtyreferralsweretoa falls

clinic,Parkinson’sspecialistteamorarapidaccessclinicfortheolderperson.PatientsadmittedtotheEDwereall

subsequentlyadmittedunderspecialtyintohospitalwithameanlengthofstayof4.4days(range1-29days)whilst

thosedischargedonscenehada5.1%(n.4)rec-ontactratewithin48hours,a11.5%re-contactratewithin7days.

Discharge on scene and re-contact rates from the 2016 falls and frailty response project without POCTwere on

average49.7%fordischargeonscenewitha7dayre-contactrateof14.7%5.

CASE1

An84-year-oldfemalewithlearningdifficulties,HTNandosteoporosispresentingwithanexplainedfallintheearlyhours

of themorning. On initial assessment the patientwas uninjured, fullymobile, alert and orientatedwith a slightly raised

respiratoryrateandSP02OF88%.Initialthoughtwasgiventoprovidingoralantibioticsanddischargingonscenehowever

POCTresultswhencomparedwithresultstaken10daysearlier(viatheICEportal)revealedaNaloweredto122from136,a

Hb lowered from 128 to 82 and respiratoryacidosiswithmetabolic compromise.With thesenew findings itwas deemed

necessarytoadmitthepatienttotheemergencydepartmenttoinvestigatetheunderlyingcauseoftheseacutefindings.The

patientwassubsequentlyadmittedtothemedicalteamfromEDwhoprovidedpositivefeedbackregardinguseofPOCTon

thisjob.

CASE2A92-year-oldfemalepresentedtotheambulanceserviceafteranon-injuryfall.Shewasseenbyanambulancecrewwho

referredtothefallscarasthepatientwasaregularfalleranddidnotappeartohavehadanyinputfromthefallsteamand

didnothaveanypackageofcare.ThecrewhaddiscoveredaBPof218/98howeverthepatienthadrefusedadmission.On

examinationherBPremainedelevated,butthepatientwasasymptomaticandPOCTdiscoveredaHbof84.Thepatientwas

reportingsomefatiguebutnoheart failuresymptomsandhadnothadafullbloodcountsince2015.Areferralwasmade

backtoherGPwhoadvisedanincreaseinBPmedicationandbookedareviewofHb.Wesawthisladyagainafewmonths

laterduetoanotherfall,herBPwasnowmanagedwithinnormallimitsandherHbhadimproved.

Outcomes

Results from this quality improvement project showed a self-reported improved confidence in clinician decision-

makingandpatientdisposition.Thisconfidencewasvalidatedbyimproveddischargeonsceneandre-contactrates,

andbypatientonwardmanagementpostreferral.TheseresultsshowpromisefortheongoinguseofPOCTinthe

pre-hospitalenvironmenthoweverarenotwithoutlimitationsandshouldnotbeinterpretedatfacevalue.

Theresultsyieldedahighpercentageofreported increasedconfidenceand improveddecision-makingthroughout

theproject.Theyes/noformattomeasurementofconfidencemayoverstatetheoverallimprovementhoweveronly

limited cases reported no increase in confidence. Resultsmay also have been affected by trained staff becoming

acclimatisedtotheusePOCTandthereforebecomereliantonresultstomaintainthesamethresholdofconfidence

indischarge.

A significant number of tests returned results outside of reference ranges but not all required clinical action or

referral.Thosethatdidnotrequireactionwereresultsthatcouldbeconfirmedasnormallyabnormalorcouldbe

explainedbypreviousmedicalhistoryandcomorbidities.Interpretationofresultsrequiredcomplexclinicaldecision-

makingandshouldbethefocusofanyfurtherprojectsutilisingpointofcarebloodsinthepre-hospitalenvironment.

Forexample,identificationofarespiratoryacidosismaybeattributedtoachronicconditionsuchasCOPDormaybe

attributabletoaseverepneumonia10eachrequiringadifferentpathwayofcare.

CASE3An 87-year-old female presentingwith her second fall within a week.Her observations and physical examinationwere

within normal limits however family were concerned about her recent increase in falls. Point of care bloods revealed a

metabolicalkalosiswithmildhyponatraemiasecondarytoindapamideuseforhypertension.ThispatientsGPwascontacted

andthepatientsindapamidestoppedforashortperiodoftimewithrepeatbloodsinthecommunityscheduled.Inaddition,

thepatients’bloodpressurewouldbereviewedwhilststoppingtheindapamide.Thispatientdidnotcontacttheambulance

servicewithinthenextmonth.

CASE4Crewreferralforpointofcarebloodtestsand‘fallsandfrailtycar’.This94year-oldfemalepatientwithdementiahadan

unknownlengthoftimeonthefloorafterbeingfoundbycarersonthefloorinthemorning.Duetoknownvasculardementia

thepatienthadno recollectionof the fall butwasuninjured,mobilisingasnormalandhadno clinicalsigns, symptomsor

history making her high risk for collapse of unknown cause. Carers stated that patient has previously not had good

experienceswithadmission.Undernormalconditionsintheabsenceofpointofcarebloodtestingthispatientwouldneed

conveyingforCK levels toexcludeacutekidney injurysecondary to rhabdomyolysis from the long lie.Pointof carebloods

enabledus to compareCreatinine levelswitha recent result (1weekearlier)andapply theRIFLE criteria foracutekidney

injury.AstherewasnoacuteriseincreatinineaGPreferralwasmadetodoarepeatsetofrenalfunctionbloodstoensure

nochangestothis.

Whilst there is a perceived improvement on discharge on scene and re-contact rates when POCTwas utilised it

wouldbedifficulttodeterminecausationduetocofoundingvariablessuchastargetedpatientselection,partnership

with the falls and frailty response scheme and advanced assessment and clinical reasoning of the specialist

paramedicrole.

Anecdotally, cases that showed the most benefit from the use of POCT were those that involved patients with

significant cognitive impairment or those that were uncooperative to thorough physical exam or history taking.

Cliniciansreportedthatthecombinationofbiochemicalandhaematologicalmarkerswithhistory,observations,ECG

and physical exam more accurately identified patient acuity thus assisting decision-making. Cases that did not

benefitfromuseofPOCTwerethosethatrequiredassessmentofinfectionandtheidentificationofsepsis.Dueto

thelackofinflammatorymarkers(WhiteCellCount(WCC)andC-ReactiveProtein(CRP))inthei-STATAlinityassays

thesecasesoftenreturnednormalresultsyethadahighre-contactrate.Lactateintheseinstanceswasnotuseful

duetoitsindicationofhypoperfusioninsteadofinflammationandassuchwasonlyraisedinsepticshock1.Dueto

thisrecurrentthemestaffwereadvisednottoutilisePOCTtoassistdecision-makinginthesecases.

Considerations

AnunintendedoutcomeoftheprojectwastheaccumulationofpracticalknowledgeontheuseofPOCTinthepre-

hospitalenvironmentfordisseminationtootherserviceswishingto implementsimilarprojects.Specificareasthat

should be considered by these services are the initial set up, maintenance of the device and cartridges, correct

demographicidentificationandtrainingandinterpretationofresults.

Initialsetupshouldensurethatactionrangesareconsistentwithlocalhospitalsandpathologylaboratoriestoavoid

inappropriate referrals. Highlighted action ranges are recommended as they assist in quick interpretation and

reductionofhumanfactorserrors.Forthebenefitofdatagatheringandavoidanceofduplicationofinvestigations

the i-STAT Alinity should have access to a networkwhen docked for chargingwith results transmitted to a local

pathology.

Duringprojectdevelopment,thetargetdemographicshouldbecarefullyconsideredtomaximisehealtheconomics.

Thisprojectaimedto facilitatedischargeonsceneand/orearlierdiseaserecognitiontoreducetheoverallcostof

care.Withtheinitialfinancialoutlayofdevicecostandtheongoingcostsofcartridgesitisunlikelythattheaddition

ofanyPOCTdevicetoallambulancevehicleswithouttargeteddemographicswillbearealisticfutureaim.Theuse

of specialist services suchas specialistparamedics, team leaders, clinicalmentorsor critical careparamedicsmay

targetitsusesufficientlywithoutdefiningthepatientdemographictooclosely.

Maintenance of the device, cartridges and project pose logistical challenges for pre-hospital services. The i-STAT

Alinity requires a device temperature of >15 degrees Celsius to operate which can cause some delays on scene

duringthewintermonths.Inaddition,cartridgesmustbekeptstrictlybetween2-8degreesCelsiusforstorageand,

oncewarmedtoroomtemperaturepriortouse,haveareducedexpirytime(CRG4=2months,CHEM8+=14days)

and cannot be returned to cold storage. This could pose problems for ambulance stations whomay not have a

securetemperaturemonitoredfridgethatcouldbeused.

Finally, appropriate training and interpretation of results significantly affects the outcomes of patients and the

project.Accesstopre-existingresults is invaluabletotheadequate interpretationofpatientsresultsandclinicians

shouldhaveaccesstoseniormedicaladviceduringtheuseofPOCT.

Economicanalysis

YorkHealthEconomicsConsortium(YHEC)carriedoutaneconomicanalysisofthispilot.Theaimofthisevaluation

is to informabusinesscase todemonstrate thevalueofPOCTto the localClinicalCommissioningGroups (CCGs).

The evaluation is a cost-consequences analysis with results expressed as cost savings per patient. A return on

investmentwasalsocalculated,basedupontheincrementalcostsoftheintervention.

Methods

The Specialist Paramedic Practitioner (SPPs) participating in the POCT pilot filled in a data capture form for each

patient. This formwas designedby SCAS to providedata for the evaluationof thepilot, including the economic

evaluation.

ThekeymeasuresthatindicateabenefitfromtheuseofPOCTweredefinedas:

• Hospital avoidance – measured as the number of times POCT confirmed discharge when clinicians were

unsureinpriorassessment;

• Saferdischarge–measuredasreductioninre-contactrates(48hoursand30days)andreductioninhospital

stays;

• Earlier disease management – measured as the number of detected abnormalities requiring correction

(presumedtobemissedintheabsenceofPOCT);

• Clinicianconfidence–measuredasimprovedreportedconfidencelevelswhenusingtheiSTATdevice.

Oncompletionof thepilot, the full datawereprovided toYHECwhohaveundertakenananalysis to identify the

impacton these indicatorsand toassignappropriateeconomicvalues to them. Theeconomicvalueswere taken

fromrecognisedsources,suchasthenationalPaymentbyResultstariffsforEDattendancesandhospitaladmissions

andstaffcostsreportedbythePSSRUUnitCostsofHealthandSocialCare.

In the case of hospital avoidance, it is assumed that this includes avoidance of ED attendance and avoidance of

hospitaladmissionsthatmayresultfromEDattendance. Inthecaseofsaferdischarge,re-contactswererecorded

duringthepilotasoccurringwithin48hoursand1week,asopposedto48hoursand30days,asspecified inthe

original statementof indicators, citedabove.Forcomparisonwith standardpractice,datawereprovidedbySCAS

from the Reading, Newbury & Bracknell area, on patients who presented with falls, from December 2016 and

February 2018. These data include categorisation of the number of patients treated on scene and the number

conveyed. Forthesameperiod,thenumberofpatientswhore-contactedtheservicearealso included. Toavoid

thepotentialbiasfromincludingtwowinterperiods,oneyearofdatawasusedintheanalyses(February2017to

February2018).DatawasalsoprovidedbySCASonaFallsandFrailtyResponsepilot,which involvedSPPsandan

OccupationalTherapistandwhichtargetedpatientsover65whohadhadfalls.Thedataonthispilotwerereported

inAugust2016.Dataon thecostsof running thepilot, including thecostsof thePOCTdeviceand thecartridges,

wereobtainedfromSCAS.

Costs

AtotalofeightSPPsweretrainedintheuseoftheiSTATdevice.Formaltrainingisestimatedtotakeabouthalfa

day. SCASprovidedacostof£18perhour forSPPs. However,as staffonBand6of theAgenda forChangepay

scales,thefullcost,includingsalaryoncostsandoverheads,isgivenelsewhereas£43perhour.Othercostsforthe

pilotare:theiSTATdevice;thetwotypesofcartridge;andafridge.Thecartridgesarepurchasedinbatchesof25,

butthecostpercartridgedoesnotchangewiththenumberofbatchespurchased.Thesecostsareincorporatedin

thetable1,showingthefullestimatedcostsofthepilot.

Table1. CostsofthePOCTpilot

Unitcost(£) No.ofunits Total(£)

iSTATdevice 6,500.00 1 6,500.00

Fridge 100.00 1 100.00

Chem8Cartridges 5.48 77 421.96

CRG4+Cartridges 3.32 77 255.64

Sub-totaldevicecosts 7,277.60

Training8SPPsa 1,204.00

Totalcostofpilot 8,481.60

Thisgivesacostpereligiblepatientseeninthepilotof£110.15.Itisassumedthatallofthesepatientsweretested

usingPOCT,despitesevencaseswhereitisstatedthattherewasnouncertaintyaboutpatientdispositionpriorto

testing.

Outcomes

EconomiccostsandbenefitsforincreasingnumbersofSPPs:

ThispilotwascarriedoutbythreeSPPs,whereaseighthadbeentrained,indicatingthatalargerscalerolloutofthe

programmewouldbesoughtinfuture.Usingthecostsandbenefitsidentifiedinthispilot,itispossibletocalculate

whattheresultswouldbeofapilotwithlargernumbersofSPPs,butwithallotherelementsthesame.

Thebenefits fromgreater scale canbeexpected to increase in linear fashion,witha stablebenefitper SPP. The

costs,ontheotherhand,willnotallvaryinthesameway.Runningcosts(suchasChem8andCRG4+cartridges)will

increaseinalinearfashion,buttheset-upcosts(theiSTATdevice,thefridgeandthetraining)willnot.TheProject

LeadinSCAShasindicatedthatoneiSTATdevicecanbeusedby4-6SPPs.AssuminganaverageoffiveSPPscanuse

eachdevice,anewonewillhavetobepurchasedforeachsixthuser.TheiSTATdeviceisthehighestcostiteminthe

projectset-upresultinginamarkedsteppedcostprofileasthepilotincreasesinsize.AstheiSTATdeviceisshared

bymoreSPPs,thecostperusedecreasestothepointthatbreak-evenisjustaboutreached,beforeanewdevicehas

tobepurchasedtocontinueincreasingthesizeofthepilot.

Economiccostsandbenefitsforincreasingpilotlength:

Thepilotranfrom25/09/2017to06/03/2018,whichmeansthatthestart-upcostswereapportionedoveraperiod

ofjustundersixmonths.Ifthepilotwereextendedoveralongertimeperiod,theapportioningofthesecostswould

result in a lower cost per case. This indicates that, with the same resources used in the pilot, the result would

becomeanetsaving,onceithadbeenunderwayforaroundelevenmonths.Thisisdueentirelytoapportioningthe

start-upcostsoveralongerperiodand,consequently,agreaternumberofpatients.

Economiccostsandbenefitsforincreasingpatientcontacts:

TheaveragenumberofpatientsseenperSPPperweekinthispilotwas1.12.Thismaybelowerthanthenumberof

relevantpatientsthataSPPwouldtypicallyseeforanumberofreasons.Pilotsoftentaketimetobedinandworkat

theleveltheywouldwhenaprogrammeisfullyrolledoutandestablished.Thisindicatesthatthepilotwouldhave

producedanetsavingfromapatientcontactlevelof2.3patientsperSPPperweek,onaverage.Inotherwords,ifa

totalof159patientshadbeenseeninthepilot.

Impactofdifferentpercentagesofadmissionsthatareemergencyimpatientadmissions:

ThecostofadmissionsfromEDattendancesusedwas£617,basedon‘non-electiveshortstay’.Ingeneral,avoidable

admissionsarelikelytobeshortstay,butinthecaseofolderpeople,evenarelativelyminorcauseforadmissioncan

resultinalongerstayinhospital.Asaresult,aproportionoftheseadmissionsarelikelytohaveahighercost.To

test the impactof this,apercentageofadmissions fromEDareassumed tobe ‘emergency inpatientadmissions’,

whichhaveacostpercaseof£3,058.Thisfigureindicatesthatthepilotwouldproduceanetsavingifjustunder25%

of admissions from ED were emergency impatient admissions, with the remainder being non-elective short stay

admissions.

NetEconomicImpactofaRoll-outScenario:

To assess the combined impact of the parameters that have been tested above, a scenario has been created to

understandthecombinedimpactoncostsandbenefits. Thissimulateswhattherolloutoftheprogrammemight

look like,usingwhatwebelieve tobe realistic, but conservative, values for eachof these fourparameters,while

maintainingallothercharacteristics stable.Using thesevalues, the rolloutscenariowould result ina totalof696

relevantpatientsbeingseenovertheyear.

Parameter Valueusedinthescenario

Rationale

Sizeoftheprogramme 8SPPs Theoriginalintentionofthepilotwastouse8SPPs

Lengthoftheprogramme 1year Aconservativetimeperiodoverwhichbudgetsavingsmaybesought

PatientcontactsperSPPperweek 1.5patients Aconservativeincrementonthenumberinthepilot

PercentofadmissionsfromEDthatare‘emergency’

15% Aconservativeestimategiventhatpatientsareelderly

Thesamecostsandbenefitsanalysishasbeenundertakenon this scenarioaswasdone for thepilot.Theoverall

resultofthisscenarioisanetsavingof£50,159.With696patientstreatedoverthisperiod,thisgivesanetsaving

perpatientof£72.Usingthecostsandsavingsabove,thisgivesaROIforthisscenarioof:4.6.

SavingsfromavoidedEDattendances £77,265

Savingsfromsaferdischargea -£13,174

Totalsavings £64,091

Totalcostofthescenario £13,932

Netresult £50,159

TheresultsfromthepilotofthePOCTusedbySPPsshowamoderateimprovementintheavoidanceEDvisits.There

isamoderatedecreaseinsaferdischarge,althoughthereislesscertaintyabouttherobustnessofthis.Combining

thesewiththecostsofthepilotresultsinasmallnetcost,withaROIof0.54.

Modifyingsomeoftheparametersinthepilot,toaconservativeestimationofwhatwouldhappeniftheprogramme

wasrolled-out,resultsinanetsavingandaROIof4.6.Theresultswouldmostlikelyshowaneteconomicbenefit

withreasonableincreasesonanyoneofthreeoutofthefourparameterstested:thedurationofthepilot;thelevel

ofpatientcontacts;andtheproportionofhospitaladmissionsthatwouldbeemergencies.Theimpactofchanging

thefourthparameter(thesizeofthepilot)variesaccordingtotheexactvalueoftheparameter,butdoesnotshow

anoverallimprovementorworseningoverthelongterm.

Ithasnotbeenpossibletocalculatetheeconomicbenefitsofearlierdiseasemanagement.Physicianconfidencehas

clearlyincreased,butthereisno,immediate,economicbenefittothis.

Thescenarioforrolloutwasdesignedtobeplausible. However,thehigh levelofattritionofSPPsmaymakethis

uncertain. At the least, there may be higher training costs than used here to account for attrition. These are

modest,however,andwouldnotchangetheoverallnetbenefitofthisscenario.

Thebiggestuncertainties,whichmayhavea significant impacton the result, are thepercentageof EDvisits that

result inadmissionsand thepercentageof theseadmissions thatareemergencies rather thansimpler, short stay

admissions.Forthelatter,aconservativeestimatehasbeenusedfortherolloutscenario,sotheresultsmaywell

under-estimatethenetbenefitofrollingtheprogrammeout.

ThecostsofSPPtimehavenotbeenincludedinthecalculations.Thisisbecausetheevaluationisbasedonacost-

consequences analysis, comparing the pilot to ‘standard care’. It is assumed, therefore, that the SPPswould be

employedbySCASinanycase,withthesameemploymentcosts.

The iSTATdevice isthebiggestsinglecost itembyfar. Intheanalysespresentedhere,purchasingmoreunitswill

result inbig stepchanges in total costs if the scaleof thepilot is increased. If there isanyway inwhicha single

devicecouldbeusedbymoreSPPs,oriftherewereapossibilityofagreeingdiscountsformultiplepurchaseswith

theprovider,thenabettercostprofilecouldbeachievedforanexpandedprogramme.

Theincreaseinre-contactsinthepilotisofsomeconcern.Itisnotentirelyclearfromthedataifsomeofthesehave

been double-counted in the analysis. By the same token, some of the reported re-contactsmay have been for

unrelatedepisodesandthereforedonotreflectunsafedischarge.

Conclusion

Patients>65presentingwithacutefrailtysyndromes(confusion,immobilityandfalls)canbeaclinicallychallenging

cohortofpatientsandassuchmightbetransportedtohospitalforfurtherassessmentandmonitoring.TheBritish

GeriatricSocietynotesthatfrailtysyndromescanmaskseriousunderlyingillnessandassuchthesepatientsrequire

comprehensive investigation. The investigation of patients with frailty in the emergency department typically

involvesbloodtesting,thuscreatinganinequalityofcarebetweeninhospitalandprehospitalpatients.

In conclusion, this quality improvement project showed POCT to have a positive impact on appropriate patient

disposition, clinician confidence and earlier diseasemanagement. The projects results, whilst taken from a small

samplesizeandshowpromisefortheongoingimplementationofPOCTinboththepre-hospitalenvironmentandin

thefieldoffrailty.DisseminationoftheselearningsaimstoleadtoongoingandimproveduseofPOCTwithinother

pre-hospital services ultimately leading to better patient care andoutcomes, improved referrals and greater cost

benefittotheservicesusingthem.

• 78patientsaged65yearsto97years(Average85yearsold)

• Genderwas51.3%(n=40)femaleand48.7%(n=38)male

• 79.5%(n=62)ofpresentingcomplaintsbeingattributedtofalls

• Cliniciansreporteduncertaintyindisposition85.6%(n=67)ofthetimepriortoPOCT

• With decision-making being improved in 84.6% (n=66) of cases and improved confidence in disposition

reportedin75.6%(n.59)ofcases

• Results outside of reference rangeswere found in 55.1% (n=43) of the caseswith 53.5% (n=23) of these

requiringclinicalreferraloraction

• 60%(n=14) requiredtransportationto theemergencydepartmentwith theremainder receivingaprimary

careoroutpatientfrailtyspecificreferral

• Frails&FragilityResponseScheme(Sept16–Feb17)

o Dischargeonscene=49.7%and14.67%re-contactwithin7days

• POCTQIP(Sept17–Feb18)

o Dischargeonscene=82.1%and11.5%re-contactwithin7days

• Theoverall result of the roll out scenario is anet savingof £50,159. With696patients treatedover this

period,thisgivesanetsavingperpatientof£72andgivesaROIforthisscenarioof:4.6.

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