In ED/urgent cares, the lab tests and the POC team

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Charna Albert

December 2023—A point-of-care testing team from TriCore was part of standing up three dual emergency department/urgent care centers in as many years, with a fourth set to open in March 2024.

“They are super busy, as was expected. There’s a great need for this type of site,” says Kathleen David, MT(ASCP), TriCore’s associate director for near patient testing services, which oversees all of TriCore’s point-of-care testing, including that of a large health care system in New Mexico.

The sites differ from other freestanding emergency departments in that they follow a hybrid health care model, developed by a consultant company, that combines emergency medicine and urgent care services under one roof. About 6,000 point-of-care tests are performed monthly at each site—more tests than are performed in some of the health care system’s smaller hospital laboratories.

David and her point-of-care team led POC test implementation for each of the ED/UC sites, which are located in Albuquerque and the surrounding metro area and see 120 to 160 patients a day. The consultant company manages the sites. The physicians, nurses, and other clinical staff are health care system employees, as are the lab staff, who are largely emergency medical technicians and clinical laboratory assistants who complete training on the POC instruments. TriCore point of care oversees the technical and regulatory aspects of the onsite point-of-care testing.

For patients, the hybrid ED/UC model eliminates the need to choose the level of care. Upon arrival, they’re treated by default as urgent care patients, transitioning to acute care if necessary, and they’re billed only for the level of care they receive. “The patient gets an ED acknowledgment so they know they’re being treated at the ED level and not at the urgent care level,” David says. In 2019 and 2020, with two sites open, 70 percent of patients at both sites were treated and billed at urgent care level rates. The current ratio is 40 percent ED and 60 percent urgent care patients.

Typical urgent care centers tend to steer clear of nonwaived devices, David says. But because the ED/UC offers high-acuity testing, they had to build a moderately complex laboratory and obtain a CLIA certificate and have testing personnel with the required qualifications, as well as engage a CLIA medical director for each site and a technical consultant. TriCore’s point-of-care team fills the consultant role.

The test menu, which is standardized across the sites, came together in discussions between the ED and point-of-care teams. Emergency department physicians and others made known what types of patients they expect to see and what they want to be able to treat, and the POC team told them what’s available. “They would love lipase,” but there is no point-of-care device for it, David says. “And there were a couple other tests like that; either it would be prohibitively expensive or there isn’t a point-of-care option.” Those are now stat send-outs.

David

The POC tests provided today are as follows: CBC/diff, mono, glucose, pH, fecal occult blood, breath alcohol, prothrombin time/INR, D-dimer, basic metabolic panel, venous blood gas, lactate, hepatic panel, amylase, troponin, B-type natriuretic peptide, β-hydroxybutyrate, urine drug screen, urine dipstick, urine pregnancy, group A strep, flu A/B, SARS-CoV-2, and RSV.

Stat send-outs, in addition to lipase, include ammonia, salicylate, acetaminophen, CBC review, body fluid testing, magnesium, phosphorus, ethanol, creatine kinase, heparin anti-factor Xa, and partial thromboplastin time. Lower-priority tests, such as cultures, are sent to TriCore.

The lists of tests change periodically. Initially a β-hCG assay was on the point-of-care test menu but it was removed because it could detect β-hCG levels only up to 2,000 IU/L. “After 2,000 you have to send it out, so we stopped doing it,” David says. Later, new providers said the POC test was useful even with its limitation. “So we brought it back.” Heparin anti-factor Xa was a recent addition to the stat send-out list, and soon carboxyhemoglobin may be added. The ED team reviews order sets regularly, too, removing tests that can’t be run stat or that no longer meet its needs.

In selecting devices for the lab, David and her colleagues first looked at what was already in use in the system’s six hospitals. If no POC device was in use already, the POC team made the decision with input from the ED/UC staff. “We did look at two options for molecular [respiratory] infectious disease, and then we had the lab staff come in and look at both of them and decide which one was easier to use.” The 10 different machines that were chosen can run multiple analytes. Each site has six of the molecular respiratory devices, and multiples of some of the other POC devices.

The devices are interfaced to TriCore’s middleware solution. “The requirement was that they would be able to be interfaced and that there was a bidirectional connection,” David says, so the point-of-care team could monitor the devices, add and give staff access remotely, and ensure testing is successful. The test panels had to be built in the middleware and in the LIS and EHR; once built, the health care system’s revenue cycle team verified billing was correct. And the CLIA medical director signed off on the interface validation.

The point-of-care team is on call 24/7. If the physician decides a result doesn’t fit with the overall clinical picture, they can redraw or send a specimen out for stat testing. And some specimens must be sent out. “For instance, a urine specimen that’s cloudy or bloody would get sent out because we don’t have microscopes or confirmatory testing. We have job aids to help in those situations.”