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POC tests cut screening time down to 20 minutes
Effectively offset rapidly increasing census
How would you like to cut your blood chemistry and cardiac screening times from 90 minutes down to 20? Well, that’s exactly what the ED at Saint Joseph Hospital in Lexington, KY, did by introducing point-of-care (POC) testing.
As 2003 began, Marilyn Swinford, RN, BSN, CEN, director of emergency services at the Level 2 ED, was feeling the pressure of a rapidly increasing census. "We have 27 treatment areas with 50,000 annual visits," she notes. "We had been besieged for years, with annual increases of 9% and then 11%."
At the same time, Saint Joseph’s, which is involved with the Institute for Healthcare Improvement (IHI) in Boston, had been searching for process improvement and better flow through the hospital.
"The ED was just a ready-made opportunity to look at anything we could do to improve flow," she says.
At about the same time, a new emergency physician with previous POC testing experience joined the staff.
"Our lab director made a site visit to that hospital and was absolutely impressed by the model," Swinford recalls. "And the move was supported by [the IHI] as well."
Two key decisions remained: What kind of POC testing would be most valuable, and which device(s) should be chosen? "The emergency room physicians looked at some of the very common diagnostic tests that would make the biggest difference," Swinford relates. "Also, since we are a very predominant cardiac hospital, we had to have that capability."
The Saint Joseph lab conducted an extensive analysis of the tests that were commonly ordered, what percentage of the total they constituted, and what turnaround time was for each. "Then, we looked at the literature on the products we were considering," she says.
Ultimately, two different devices were chosen. One, the Portable Clinical Analyzer from i-STAT Corp. in East Windsor, NJ, consists of a hand-held device with a series of panel cartridges from which to choose. "We chose a common chemistry panel, called Six-plus — sodium, potassium, chloride, urea nitrogen, glucose, hematocrit, and it also calculates a hemoglobin," adds Swinford. "Then, we run another cartridge for creatinine." The second device, from San Diego-based Biosite, includes a triage cardiac panel and B-type natriuretic peptide (BNP) test to aid in diagnosis of congestive heart failure. Both devices ultimately were chosen on the basis of specificity and reliability, Swinford says.
The training for the i-stat device was easy, she says. One of our luxuries is that the line-level staff are trained to do the test, Swinford notes.
Initially, the product vendor came in for a series of 30-minute sessions. Now, the clinical educator performs the training. "It’s extraordinarily user-friendly," she adds. "And it’s only about a two-minute test."
ED techs were trained, as well as the RNs, which Swinford strongly recommends. She points out that if one person is designated to perform the test and he or she goes on vacation, the patient would not be best served. Her ED also has three devices in the department, "so everyone can multitask," Swinford says.
In addition, for a portion of the day, the ED has a medical lab technician. When she is present, the technician performs the cardiac markers and the i-stat tests. "This takes about 15 minutes," Swinford adds. "You charge the cartridge, put the blood in, and 15 minutes later, you get the result."
The advantage of having the medical technician do the test is the ability to correlate findings with the clinical picture of the patient. "If something is out of range, they can communicate with the ER physician right away," she explains. "That professional dialogue is huge [in significance]."
The ability to quickly rule out serious conditions results in a shorter length of stay for many patients, which contributes to improved satisfaction, Swinford notes. "We can do a very fast differential diagnosis," she explains. "If it does not come in clear cut clinically, we have the labs back quickly and can call in a specialist. We try to share this as a piece of our PR."
These benefits do not come without a cost, however. "There’s definitely a cost outlay; the meters, for example, are several thousand dollars, depending on the brand, and then there’s an ongoing expense for the cartridges," says Swinford. The cost is about $4.25 per test, according to i-stat. Swinford indicates that her POC testing is close to double the cost of traditional lab analysis, without adding an extra full-time equivalent for the medical technician, who she shares with the lab.
"But the return on investment for the hospital can be seen as we get more patients through the door and decrease turnaround time," she stresses. "Increasing volume and decreasing times is quantifiable, and when you go to meet with the CFO, you really need to justify this expense in terms of what you can do for turnaround."
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