Emergency Center Profile
- 6th busiest Emergency Center in Massachusetts, including Boston
- More than 63,000 visits per year
- 32 Emergency Center physicians
As part of their preparations for a move into a new, state-of-the-art facility, the Emergency Center (EC) at Lawrence General Hospital began to re-think their processes. The new location would have more space—and this meant there could be room to introduce point-of-care (POC) testing for patients experiencing chest pain.
While the idea seemed promising in theory, their clinicians and laboratorians alike questioned whether POC testing would actually improve patient care. For Laboratory Administrative Director Teri Scuderi, it was a unique opportunity to demonstrate the value the laboratory provides, particularly with important cardiac tests like troponin I, where accuracy is just as important as rapid turnaround time.
Lawrence General is a 216-bed hospital situated in the northeast corner of Massachusetts. The institution is known for its innovative, rapid response in triaging and assessing potential heart attack patients. With access to the latest diagnostic tools and clot-busting medication, Lawrence General staff can administer lifesaving treatment shortly after the patient arrives in the EC.
Though the service was excellent, the EC facility itself was not ideal. Cramped quarters meant that patients had to wait in hallways. Private exam rooms were hard to come by and it was even difficult to park. The new, $20 million location would triple the size of the EC, offering 41 private exam rooms. With all of the changes underway, EC physicians began to consider POC testing.
Lab Director Teri Scuderi quickly took note. “There is a lot to consider with point-of-care testing,” she says. “But ultimately, our lab is in the best position to provide the turnaround time and quality that the EC needs.”
Having weighed the pros and cons of POC versus core lab testing, Scuderi followed a two-pronged strategy: (1) highlight the performance of critical cardiac troponin I tests and (2) explain the challenges associated with point-of-care testing.
Delivering Gold Standard Performance, Fast
For many labs, one of the driving reasons behind implementing POC testing is the belief that it will improve turnaround time. In the EC, clinicians want the fastest turnaround possible so they can make treatment decisions more quickly and decrease patients’ wait time. But fast turnaround time isn’t only achievable via POC.
“I wanted to make sure the EC physicians knew we were already fast and consistent,” says Scuderi. “Over the past seven years our lab has never received a complaint about turnaround time for cardiac tests.” She notes that the lab uses two Access Immunoassay Systems to run Beckman Coulter’s AccuTnI® troponin I assay for the delivery of fast, accurate and reliable results. The test generates results in about 13 minutes, allowing the lab to deliver them within 30 minutes from the time of sample draw. This is well within the range of the “hour or less” threshold recommended by the National Association of Clinical Biochemistry—and it meets the expectations of the hospital’s EC physicians.
But speed isn’t the only benefit. The AccuTnI assay is also known for its gold standard clinical performance—quality that would be difficult to duplicate with a POC device, says Scuderi. Among other benefits, AccuTnI uses antibodies that bind to the most stable region of the cTnI molecule. This can dramatically improve the quality and reliability of patient test results, aiding in risk stratification as well as the diagnosis of myocardial infarction. In contrast, many POC devices lack the cleared claim for use in risk stratification.
Further, clinicians receive specific, precise results, reducing the need to clarify data with the laboratory. Once they receive the results, they can take action.
Beyond the AccuTnI assay, the lab’s general workflow helps improve turnaround on many tests. Using Beckman Coulter’s DL2000 Data Manager, the laboratory autovalidates results, so immunoassay results that fall within expected ranges are sent automatically to physicians—with no manual intervention required. This not only speeds information flow from the lab, but also further improves test result accuracy.
Scuderi communicated these advantages to physicians, which helped build the case for the laboratory. But there were other considerations as well—such as the work involved in establishing and managing POC testing.
POC Testing Challenges
Several factors make effective POC testing complicated and difficult to manage operationally, points out Scuderi.
“It’s not as easy as just buying a strip, putting drops of blood on it and waiting 15 minutes,” says Scuderi. “POC testing requires a certain infrastructure.”
For example, POC testing in the EC requires significant quality control reporting mechanisms and also must meet specific requirements from the Joint Commission on Accreditation of Health Care Organizations (JCAHO).
At Lawrence General, clinicians wondered if these quality control challenges and regulatory hurdles would require extra administrative work and detract from the EC’s focus on patients.
Then there was the matter of the finger stick. In many cases, the lab phlebotomist or dedicated EC resource would likely need to perform a finger stick collection for the POC device and then draw additional venous blood for other tests conducted in the lab. With POC testing, extra steps would be tacked on to a process that is supposed to be fast and additional training would likely be required—hardly a best practice in patient care.
“In addition,” says Scuderi, “whoever is administering the test would also need to enter the result and make sure everything is properly accounted for in the system. All that still has to be coordinated with any other tests—such as routine CBCs—that are performed in the core lab.”
“Our lab has more stringent procedures, a trained staff and automation to decrease the risk of error,” says Scuderi. “In our situation, we simply saw no reason to perform POC testing,” says Scuderi. “It would have been more labor-intensive and we can do it just as fast—and less expensively—in the laboratory.”
A Validated Decision
“It’s clear that physicians understand the importance of troponin I testing and see the value we provide in delivering fast, accurate and reliable results that aid in the management of their patients,” Scuderi says. “The bottom line is that we’ve sold doctors on the quality of testing in our lab and POC cardiac testing is no longer a consideration.”
Investigating the POC option required time and energy, but in the end it was a healthy exercise because it reinforced the value the laboratory is providing.
“My personal feeling is that you can’t compete with state-of-the-art instruments and assays in the lab,” says Scuderi. “We do the lion’s share of work here, we’re accredited and we’re supervised. This means we can help deliver the best patient care. You simply won’t find that same level of rigor outside the lab.” |
