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Gatefold

Point-of-care testing

Research by Dagmara Scalise

The United States is the world’s biggest market for diagnostic testing, and one of the most active segments within that is point-of-care testing, or POCT. As test devices become more compact and easier to use, as well as more accurate, tests can be more frequently performed at the point of care, whether that is the emergency department, intensive care unit or a patient’s home. Among the most common tests are those for blood glucose, blood gases, cardiac markers and sepsis, as well as pregnancy and ovulation.

The biggest advantage of POCT is speed. Although home-based point-of-care testing is common, 70 percent of POCT takes place in hospitals, doctor’s offices and other provider locations, and experts predict this segment will grow an average of 15.5 percent each year, significantly outpacing home-based testing.

This gatefold gives an overview of POCT, discusses the challenges, benefits for hospitals, and provides a glimpse of what experts believe point-of-care testing will look like in the future.

Who’s Who in  a POCT program

Laboratory POCT coordinator

  • Keeps database of testing personnel
  • Coordinates training of new personnel
  • Chooses testing methods
  • Monitors quality control and proficiency programs

Nurse manager

  • Enforces policies
  • Schedules new employee training and annual certification of testing personnel
  • Schedules annual point-of-care competency evaluation of staffa POCT program

Education department

  • Trains new employees
  • Certifies testing personnel

Laboratory staff

  • Trains new employees
  • Reviews quality control data
  • Verifies equipment function and maintenance

9 Tips for Developing a Successful POCT Program

The No. 1 reason hospital-based POCT programs fail is poor quality control. Point-of-care testing tends to expand rapidly and gets out of control unless guidelines are in place. Here are some things to ensure your program succeeds:

  1. Have a written point-of-care testing program policy.
  2. Define who is responsible for each part of the program (e.g., laboratory point-of-care coordinator, nurse manager).
  3. Decide where testing will be performed and who will perform it.
  4. Define the purpose and methodologies of each type of test.
  5. Spell out reporting procedures.
  6. Establish an operating budget.
  7. Assess the cost of POCT versus laboratory tests, including cost of training personnel; labor associated with processing and analyzing the specimen; annual reagent, control maintenance and depreciation costs; cost of proficiency programs for staff; and potential impact on length of stay, net savings and improved outcomes.
  8. Monitor the program periodically.
  9. Evaluate the program on an ongoing basis.

Sources: Sg2, 2006; Washington State Clinical Labor-atory Advisory Council, 2005; H&HN research, 2006

Types of Tests and Where They Are Administered

Just as there are different types of diagnostic tests, there are multiple places where testing takes place: in the home, hospital laboratories, private laboratories or at the point of care. 

Location  Types of tests performed
Hospital Laboratory Markers for heart attack, including CK, myoglobin, troponin
Home Pregnancy, ovulation predictors, blood glucose monitors, fecal occult blood tests to monitor colorectal cancer
Reference Labs High-volume specialty tests
Direct Access Laboratory Tests (also known as patient-authorized testing, in which patients order their lab tests directly without going to a physician) Complete blood counts, cholesterol levels, throat and urine cultures, blood glucose, thyroid and HIV antibody tests
Point-of-Care Tests Glucose, blood gases, cardiac markers, blood clotting and heart failure blood tests

Source: H&HN research, 2006

Where Hospital POCT is Performed

A 1999 survey of hospitals, clinics and independent laboratories in the Pacific Northwest revealed that even then, point-of-care testing was widespread. The 58 hospitals in the survey indicated that point-of-care tests are performed in multiple areas of the hospital:

Nurses’ station
87%
ED
86%
Patient bedside
84%
Intensive care/critical care unit
70%
Patient exam room
43%
Surgical area
43%
Health fair
24%
Specimen collection station
9%
Other*
9%

*Hospital locations include the pulmonary laboratory, hospital clinic, blood donor site, nursery,
OB department, vascular/cardiac catheterization/angioplasty laboratory, and IV/transfusion department.
Source: Pacific Northwest Laboratory Medicine Sentinel Monitoring Network, 1999

Hospital-Based Lab Tests vs. Point-of-Care Tests

Point-of-care tests offer hospitals several advantages: Results are available more quickly, which can lead to faster care and improved patient outcomes; costs are lower; and physician satisfaction is often higher because they don’t have to wait around for laboratory results. But because point-of-care testing is less precise than tests performed in the lab, results must sometimes be verified in the lab, resulting in extra costs. Here’s a side-by-side look at the two types of tests:

Laboratory tests Point-of-care tests
• Are the “gold standard” and offer more accurate results • Are less accurate
• Are managed by pathologists and lab directors  • Are managed by doctors and clinical directors
• Are performed by lab technicians • Are usually performed by nurses
• Use expensive, advanced devices • Are inexpensive, simplified devices
• Focus on accuracy, quality and turnaround time • Focus on workflow, error reduction and throughput

Sources: Sg2, 2006; H&HN research, 2006

The No. 1 reason hospital POCT programs fail is inadequate QUALITY CONTROL

The Impact of Faster Results

POCT reduces test turnaround time, improves physician satisfaction and increases hospital revenue. Research shows that moving select tests, such as rapid glucose testing, from the central lab to the point of care, like the ED or the ICU can:

Reduce

  • ED length of stay by 41 minutes per patient
  • Test turnaround time by 87 percent
  • ED divert hours by 27 percent, when combined with other multidepartment efforts
  • ICU length of stay by 23 percent
  • The number of patients requiring dialysis

Increase

  • ED physician satisfaction by 50 percent
  • Direct hospital revenue from decreased ED diversions
  • Net savings per patient (by nearly $3,200 from rapid glucose testing, for example)

Sources: Sg2, 2006;  Lee-Lewandrowski, et al., Archives of Pathology and Laboratory Medicine, 2003;
Van den Berghe, et al., Critical Care Medicine, 2006; H&HN research, 2006

Where POCT Can Make a Difference

There are multiple hospital environments that can benefit from point-of-care testing.

Cardiac Biomarkers Where: Emergency Departments
The issue: Overcrowding and long turnaround times for cardiac markers can limit throughput
The benefit: POCT should be evaluated to determine impact on throughput
Sepsis Testing Where: ICU
The issue: Early recognition of sepsis is critical for prevention and treatment
The benefit: Rapid identification of bacterial source reduces expense of wasted medication; continued testing guides intensity of treatment
Testing
blood clotting abilities
(PT/INR Testing)		 Where: Ambulatory Anticoagulation Clinics
The issue: Used to monitor the effectiveness of blood thinning drugs such as warfarin
The benefit: Clinics improve outcomes and decrease hospitalization; POCT can directly generate revenue and drive patient compliance at home

Sources: Sg2, 2006; H&HN research, 2006

POCT Cardiac Markers: A Closer Look

Hospital adoption of point-of-care cardiac marker tests grew from 4 percent in 2001 to 12 percent in 2004. Yet this type of test is highly controversial, in part because clinicians and laboratory directors have differing expectations for test turnaround time. Doctors expect test results in about 37 minutes, while labs expect them to be ready in about 60 minutes. In reality, test turnaround time actually takes about 90 minutes. Vendors, hoping to make the tests more common, are targeting their marketing efforts to physician offices rather than labs. While testing cardiac markers can be beneficial, it can also unnecessarily drain hospital resources since the point-of-care tests are less precise and may result in the need for further testing. Poor quality control, such as improperly trained workers, can mean even less accurate tests.

Sources: Sg2, 2006; H&HN research, 2006

Top POC Tests for Hospitals

The biggest value of POC tests is that they allow for rapid treatment decisions, such as in trauma or high throughput units. Here are some POC tests with the most value for hospitals:

Tight glycemic control: In surgical and intensive care areas, tight glycemic control is financially profitable and has dramatic outcome improvements. In the surgical ICU, it reduces in-hospital mortality by 34 percent, bloodstream infections by 46 percent and renal failure by 41 percent. It also saves between $1,580 and $3,191 per patient hospitalization.

B-Type natriuretic peptide (BNP) testing: BNP testing for heart failure improves patient triage in the ED. Patients coming into the ED with shortness of breath are typically first treated for infection. BNP testing lets physicians quickly identify those patients who have heart failure.

Molecular diagnostics: These cutting-edge tests are getting smaller and simpler, and in the future will allow POC screening for infectious disease.

Sources: Sg2, 2006; H&HN research, 2006

POCT in the Future

POCT is getting more sophisticated. Molecular diagnostics, a process that determines how genes and proteins interact in a cell, have improved test accuracy, giving rise to new types of tests for diseases such as cancer and viruses like hepatitis B and C. But sophistication brings its own set of challenges with staffing, operations and quality control.

3 Challenges hospitals will face in the future

1 Staffing complexity will likely require laboratory technicians to perform the tests
2 Operations require an available pathologist for rapid results analysis and consultation
3 High cost of errors requires quality assurance

Sources: Sg2, 2006; H&HN research, 2006

Resources

How We Did It

This gatefold was produced by interviewing point-of-care testing and diagnostic testing experts, as well as using published research and publicly available white papers.

Research: Dagmara Scalise (dscalise@healthforum.com)
Design: Chuck Lazar (clazar@healthforum.com)

This article 1st appeared in the September 2006 issue of HHN Magazine.


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