Feature Story

Moving the sicker quicker with ER point-of-care

March 2004
Anne Paxton

Stressed by staff shortages and deluged with ever-sicker patients, many of the nation’s 4,000 emergency departments have reached a crisis point. If ever-quicker laboratory testing at the point of care can’t rescue the ED, can it at least make life there easier?

It’s a question more and more hospital labs and EDs are asking as they contemplate the wider test menus, snap-in cartridges, and automated features of new point-of-care testing instruments on the market.

As Christopher Fetters, president of the consulting firm Nextivity, York, Pa., sees it, "POC tests should have an impact on the quick treatment of acute patients and/or affect the flow of patients in the ED-the front door to your hospital." But, he adds, they won’t work unless the tests benefit patients, are easy to use, and make financial sense.

"We’re seeing increased interest in our type of testing so emergency departments can move patients faster through that decision point of treat or discharge," says Ron Newby, director of marketing for Nova Biomedical, maker of the Stat Profile Critical Care Xpress.

This kind of "process reengineering" can pay dividends, research has shown. One study of efforts to reduce crowding and ED patient length of stay, at Massachusetts General Hospital, found dramatic improvements after a point-of-care testing satellite laboratory was added to the ED.

Though the differences in length of stay were not significant for individual tests, the combined effect of providing glucose, pregnancy, urine dipstick, CK-MB, and troponin tests in the satellite POC lab (which reduced test turnaround time by 87 percent) was a shorter length of stay-by 41.3 minutes.

Emergency departments often see patients who waited too long to see the doctor-and the ED’s first question is which of them can wait a little longer. But triage has become more complicated in recent years. Despite lingering perceptions that the growing ranks of the uninsured use the emergency room for routine primary care, the state of California found the number of critically ill visits at EDs increased by 59 percent between 1990 and 1999, and urgent visits went up 36 percent. In 2001, only 9.1 percent of emergency visits were classified as nonurgent.

Under the Emergency Medical Treatment and Labor Act, emergency departments are the only guaranteed means in the U.S. for the uninsured to receive medical care-a circumstance emergency physicians blame for the spike in ED closures over the last decade.

Those that remain are under greater pressure to triage patients quickly yet use staff efficiently. To help ease the process, many are opting for a POC service that is midway between the bedside and the central laboratory.

"What we do is probably more ’point of service’ as opposed to POC," Newby says. "But ’bedside’ is not really the point. The point is the right tests measured in the right time frame."

Though people tend to think of point of care as "next to the patient," it’s really more temporal than spatial, agrees Janice Zimmerman, MD, director of medicine emergency services at Ben Taub General Hospital, Houston.

An urban level-one trauma center with 580 beds that serves a primarily indigent population, Ben Taub gets approximately 100,000 ER visits a year, Dr. Zimmerman says. The ER has its own stat laboratory, in which a Nova analyzer is used for venous and arterial blood gases, eleclytes, renal function, and glucose testing. In addition to the Nova analyzer, another analyzer is used for CBCs along with urine dipsticks and a kit for pregnancy tests.

"Our nurses are already stretched too thin, and I don’t want the nurses distracted by a device at the bedside. So the decision was made here that any satellite or stat laboratory would come under the main lab," she says.

But it wasn’t a formal analysis of the tradeoffs involved in adding POC testing to the ER that moved hospital administrators to buy into the concept. That didn’t happen until one summer a few years ago when the hospital’s computer system crashed.

"When the system went down, the lab would have to generate handwritten reports or we would call the laboratory for every result, and with such high volume here, it was just not feasible," Dr. Zimmerman says.

"Although the staff had been asking for a stat lab for some time, that’s how we got started. They put in a machine for us to do electrolytes and renal function, then we lobbied to expand it to a stat lab."

ED physicians at Ben Taub try to be practical about what they request. "I’m willing to wait a little longer to know their bilirubin," Dr. Zimmerman says. "If it’s high, there’s no emergency action. But a high potassium-yes, there is emergency action. Whether we’d add cardiac enzymes at this point, I don’t think it will help, because when we looked at the volume and our processes, that information would not justify the additional expense unless other system changes were made."

Manijeh Danaye-Elmi, MS, MT (ASCP), is chemistry manager for Community Medical Center, a three-hospital system in Fresno, Calif. The three separate ERs, along with the intensive care and cardiovascular units, use Nova analyzers handled through the same point-of-service system, with the laboratory in charge of not only instrument quality, maintenance, and QC, but also immediate real-time monitoring through Nova’s Patient Data Management, or PDM. The ER’s specimens are analyzed in the laboratory through the Nova analyzer using whole blood; they’re not analyzed at the point of service.

"The result comes directly to the laboratory before it gets posted to the HIS," Danaye-Elmi says. "The nurses are trained in how to collect samples, order tests, and introduce samples to the analyzer for analysis, but they do not see the result until the laboratory posts it first."

"When an audio signal goes off at a station in the laboratory, that means somebody has put something through the instrument. So you look at the patient’s history, check for instrument error or problems with the analytes or critical values, then you say, ’I’m going to release the result." After that it goes through the LIS and HIS, then to the user." On average, turnaround time is less than seven minutes, depending on the results-critical, delta-check failure-or instrument error flag, if any.

"We call it remote review," Newby says. ėThe results are measured at the point of service by the POC operator or respiratory therapist and transmitted to the laboratory for someone to review, then released back to the instrument. It only adds a few seconds to the TAT, but it gives the laboratory a sense of control because they’re trained to pick up things that might be wrong."

Ten years ago, capturing data at the point of care was "not something we did," Danaye-Elmi says. "But the blood gases and some of the metabolic tests are too important to just leave out there without knowing what they’re doing. Our medical director was constantly pursuing the idea of getting a data manager to capture dataóideally in real time, not a month later."

The Nova analyzer does metabolic tests including sodium, potassium chloride, glucose, BUN, creatinine, lactate, ionized magnesium, and ionized calcium as well as blood gases. Danaye-Elmi is now evaluating Nova’s new analyzer with more automated QC and a test for creatinine, which would complete the menu.

Where the Nova instruments are placed depends on each hospital’s layout. "At the Fresno hospital," Danaye-Elmi says, ėwe have instruments in the NICU for babies, the ICU and CVU, short-stay surgery, and recovery pediatric acute care unit, and we have one in the laboratory which is also a whole blood analyzer for the ER, because the distance between the ER and laboratory is very short, while the ICU and CVU are on the 10^th floor." The university hospital, on the other hand, has two instruments in the ICU, one in the OR, and one in the main laboratory which serves the ER through a tube, only one floor away. In the Clovis, Calif., hospital, the Nova analyzers are in the lab only.

Nova’s instruments offer automated QC. "Whenever you’re at the point of service, automated QC is very important. But we’re really seeing it in the respiratory therapist and laboratory market, because there are fewer people available to do that type of work," Newby says.

But Tim Lynch, product manager for Instrumentation Laboratory’s Gem Premier 3000, says it is rare for a laboratory to review results before releasing them to the operator of the POC analyzer. In his view, there are real drawbacks.

"The primary issue with suppressing results so they can be reviewed by the laboratory is that a technologist must be available at all times to review the results quickly,î he says. ėOtherwise the purpose of having the testing performed at the point of care is lost."

Given the shortage of technologists, he notes, those on staff have limited time to dedicate to real-time review of results from other areas.

He defines "point of care" based on where the testing is performed, not by the technology that’s used. "We have a number of customers who test at the point of care where an analyzer resides in a fixed area near a patient," Lynch says.

Companies with handheld devices tend to view point-of-care as bedside testing, he says. "But we have found that rarely happens, since in many cases a handheld device must be brought to a fixed area to download or print patient results." Testing isn’t complete, in his view, until the results are in the patient chart, mainly through hospital or lab information systems.

"The difference in turnaround time is really due to the process that’s followed," Lynch says. "We have Gem Premier 3000s in both POC settings and in laboratories. The benefit of point-of-care testing is reducing the time between when a sample is drawn and when it’s analyzed and acted upon."

South Shore Hospital, Weymouth, Mass., has had Gem Premier 3000 analyzers for about two and a half years. "The units we have are not what I consider POC testing," says Charles Arienti Jr., MSM, RRT, director of respiratory care at South Shore. "The Gem 3000 analyzers are centrally located so they’re always within 100 feet of where you are. We station one in the ER, one in the operating room, one in the CCU, and one in our Level-three NICU."

With the second busiest ER in the state, Arienti says, South Shore’s ER does about 6,000 blood gas tests a year, and sending them to a central laboratory would be impractical. "Not to have a blood gas lab in the ER would be awful," he says.

Most blood gas results are produced in less than two minutes. "They’re all interfaced with the hospital information system,î he says, ėso the data transfers immediately from the analyzer into the HIS and will print out automatically at that unit where the patient is."

Arienti is a fan of the Gem Premier 3000’s onboard quality management system, Intelligent Quality Management, or iQM, which is designed to deliver automated, real-time QC.

South Shore reconfigured its Gem Premier 3000 analyzers to the automated iQM system last July. "Basically, blood gas machines can be relatively complex," Arienti says. "With iQM, the analyzer does its own QC. So the system runs numerous controls all day, depending on the level of use, from 9 QCs to 27 QCs in the course of the day.

"That’s so much more than any hospital would run if they were doing it manually. If at any time the analyzer fails QC or it detects a problem it cannot resolve itself, it shuts itself down. So it’s a dramatic timesaver for the staff because they don’t have to do manual QC and manual repair."

"If you inject in the NICU, breakdowns always happen because you get Wharton’s jelly [the mucoid connective tissue of the umbilical cord] in the machine, and it plays havoc with the electrodes. With the older type of analyzer, it would literally take three hours to take the machine apart, clear the lines, change the membranes, and put it back together. Here, if we manage to do that, it takes a matter of a few minutes to put a new cartridge in."

"This weekend I was told we got a call from a hospital 10 miles away that runs an older analyzer asking if we have any calibration solution, and the therapist laughed and said we don’t do that anymore."

Analyzers of the greatest use in the ER do more than blood gas testing. "ICUs are entirely different because lots of patients are on ventilators anyway. If you look at the patient population presenting to the ER, it is a minority of patients that require blood gas first. The primary concern is more likely to be electrolyte balance or glucose or lactate levels, so the more of these tests you add, the more applicable the analyzer is to the ER."

Kevin Hopkins, RRT, director of respiratory care for Hutcheson Medical Center, Fort Ogelthorpe, Ga., says problems with test interference led his hospital to consider changing the cartridge-based system it uses for testing blood gases.

"We use a lot of sedatives to ventilate, and that interfered with the handheld test results, so we still had to send the tests to the benchtop. We wanted a product we could place in strategic positions throughout the hospital, including the ER, so we’d always be a matter of seconds from a blood gas machine, and not revert back to a benchtop that might be several minutes away," Hopkins says.

"Before bedside testing was in vogue, we had these long walks. The laboratories were never located in close proximity to the ICU or ER. Now we have a machine right in the next room, we can get the blood gas going, and we’re in the line of sight of the patient and back with numbers ready to make treatment changes in less than three minutes."

Fetters says some of the POC products on the market are impractical for the ER and even confusing to laboratorians. But others are well suited to the task and more than cost-effective. For example, he said in a February online discussion sponsored by the American Association for Clinical Chemistry, "a $26 set of cardiac markers that allows you to risk-stratify a patient having crushing chest pain and send them to the right place in your hospital the first time is a no-brainer. It’s good for the patient, it’s good for the flow of the ER, it’s good for the CCU which doesn’t have to monitor a patient without an MI, and it’s a test that’s easy for the staff to perform."

Instrumentation Laboratory’s iQM is another example. One reason it has been so well received by point-of-care coordinators, Lynch says, is that CLIA regulations place responsibility for patient testing on the person who maintains the CLIA license, most often the pathologist or laboratory director, and "iQM gives laboratories more confidence in the reported results."

Since iQM was launched in February 2003, every customer but one has purchased the Gem Premier 3000 with this feature, and 80 percent of customers who purchased before the launch have converted to iQM, Lynch reports.

At Memorial Hermann Hospital, Houston, for example, 500 to 600 nurses are using 15 Gem Premier 3000s. "The POC coordinator is very happy with them because they are easy to use," Lynch says, "and iQM gives the users peace of mind. If there’s any problem with the instrument-for instance, there is insufficient heparin in the syringes or a clot develops because it’s not mixed properly-iQM automatically recognizes it, takes automatic corrective action, checks to ensure it worked, and disables testing if it hasn’t. That all happens without the laboratory getting involved."

Laszlo Sarkozi, PhD, director of the chemistry department and professor of pathology at Mt. Sinai Medical Center, New York, says two Gem Premier 3000s have been placed in the ED in the last six months, in part because of laboratory budget cuts. "The laboratories had to reduce personnel. And we wanted to see if some of these tests could be performed in the ED, which would improve patient care and save technician time."

He contrasts emergency department testing with POC testing in the operating room. "In the OR, we have people such as respiratory therapists who are really trained and familiar with instrumentation. And in the emergency department they are often inexperienced or newcomers and they rotate in and out. It’s the nature of the unit."

"For a while, the nursing and medical staff flooded us with phone calls in spite of the training they received," Dr. Sarkozi says. "They didn’t have experience with the instrumentation and requested a lot more training and support."

"But pretty soon," he adds, ėthey realized that packing the specimen and sending it to us is more time-consuming than getting a syringe and injecting it into the instrument. So even if the work is different, it takes less time and effort on their part than sending it to the laboratory."

The ED is happy about the instant availability of results and the avoidance of problems such as pneumatic tube breakdowns. "The chairman of the emergency department bumped into me a couple of weeks ago and said it’s a real lifesaver," Dr. Sarkozi reports.

"We don’t have the dollars-and-cents evaluation," he adds, "but we noticed that in the last six months our laboratory workload from the ED was reduced by at least 30 percent-and it’s a great help to us because we’re able to reassign our staff who used to do this work."

Anne Paxton is a writer in Seattle.