POC in the ER? As point-of-care technology expands, more hospitals adopt rapid testing programs
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Taking their cue from physician practices, hospital-based physicians, lab directors and clinicians are increasingly recognizing the value of point-of-care testing in hospital settings. Although patient population and cost continue to influence which hospitals are likely to purchase which tests, overall acceptance appears to be on the upswing.
In the last three years, administrators have seen an increase in point-of-care testing at hospitals, according to Fred Halvach, senior vice president of pharmacy services at Broadlane (Dallas, Texas) and Martin McBride, senior director of pharmacy services. “However, the type of testing and location of performing the tests is highly variable due to the differences in patient conditions and disease states,” says Halvach. “Hospitals must evaluate the various point-of-care (POC) devices for their patient population. This requires a multidisciplinary approach with laboratory technologists, physicians, nurses and hospital administrators.” Particularly as organizations such as the Centers for Disease Control and Prevention and the National Institutes of Health work to increase public awareness of preventing the spread of infection, more hospitals “seek value in defining the severity of patient disease states,” he adds.
“Hospitals are trying to get a greater understanding of patients as they come in the door,” says Ed Gravell, vice president of marketing management at Cardinal Health (Dublin, Ohio). “They are looking to screen patients, and either isolate or treat them immediately, and this is driving point-of-care testing. [And while] it’s important to get testing closer to the patient, we must also consider the cost, relevancy, turnaround time and complexity of a test.”
The increasing accuracy of rapid tests has also helped to drive the hospital market, according to Barbara M. Maillet, senior director, laboratory services, Premier (Charlotte, N.C.). “I think point-of-care testing is certainly becoming more prevalent in hospital settings, because it correlates so well with lab testing and [because of] the increased specificity and sensitivity of test results as compared with lab results.”
The emergence of hospital rapid testing began with bedside glucose testing and pregnancy testing in the ER (to confirm that patients are not pregnant prior to being exposed to radiation), according to Gravell. Today, the list has expanded to include cardiac markers to evaluate heart function and, in some cases, testing for Methicillin Resistant Staphylococcus Aureus (MRSA). Examples of hospital-based rapid tests include:
- Blood Urea Nitrogen (BUN)
- Serum Creatinine (SCR)
- Electrolytes
- Hemoglobin and Hematocrit
- Cardiac markers (e.g., Creatine Kinase, Creatine Kinase-MB and troponin)
- B-type Natriuretic Peptide (BNP)
- Hemoglobin
- Albumin
- White blood count
- Prothrombin time.
Gastrointestinal rapid tests also are becoming more widely used in hospitals, according to Corey Case, senior product manager, Cardinal Health. “And, flu and strep testing are becoming more prevalent as well,” he says. “Rapid flu testing [accounts for] a huge volume for us from a distributor perspective.
“Of course, cost is always an issue [with regard to] point-of-care testing,” he continues. “But, so is ease-of-use.” So, tests such as flu and strep, which can be completed by a nurse or nurse aid are becoming increasingly prevalent in hospitals, he adds.
MRSA testing is becoming more prevalent, too, especially as concerns about it have grown among both clinicians and the public at large. Still, the most rapid test currently available is a two-hour molecular test or a manual microbiology test with 24-hour turnaround. “If there becomes a future test for MRSA with [more] rapid turnaround, there very well may be increased use among hospitals,” says Maillet. But, the cost of the test would be a big factor in how quickly it catches on, she adds. She also anticipates expanded use of cardiac markers in the hospital setting. “As more cardiac markers are identified, they probably will be used in hospitals,” she says. “Premier is looking to expand its current offering of test kits.”
One hospital joins bandwagon
At Doctor’s Medical Center (Modesto, Calif.), Terrell Chambers, MBA, CLS, MT (ASCP), director, lab services, and his supervisor, Nav Sharma, CLS, MT (ASCP), are exploring opportunities in point-of-care testing. However, they are selective in their choice of tests. “We have added more testing capability, [including] Rotavirus and coagulation,” says Chambers. “We have also expanded our waived metabolic panel and added it to our rapid response team.” In addition, the hospital has added a device, which enables open-heart surgeons to titrate heparin.
Chambers acknowledges his hospital’s need for more cardiac testing, but is hesitant to add this due to the lack of standardization between point-of-care and lab cardiac tests. “Particularly in the case of BNP and troponin [which are used to diagnose heart failure], the rapid tests run on different platforms from our lab tests,” he points out. Other rapid tests, such as glucose, don’t present this issue, he adds.
In other cases, Doctor’s Medical Center’s decision to add a test boils down to its cost-effectiveness. For instance, the state of California requires hospitals to screen certain populations for MRSA, Chambers explains. “We investigated the two-hour test, but it was too expensive and we opted to add the 24-hour test. If a more rapid test that is cost-effective becomes available in the future, we may explore it. But, we are pleased with our current system for testing MRSA.”
Lab accountability
While cost is an issue that sometimes prevents hospitals from adding new tests, it is not the only issue. Hospital labs are responsible for quality assurance and training of users of point-of-care devices. “Hospital lab directors are responsible for all lab results, including point-of-care testing [that is not CLIA-waived],” says Maillet. “So, if [complex] point-of-care testing is being done in the ER or intensive care unit, and no one in those units has their CLIA certificate, then that particular testing is completed under the lab’s CLIA certificate, [making] the lab director ultimately responsible for the end test result.”
When the lab director lacks oversight over the staff or clinicians who may be running a particular test, he or she is placed in a compromising position, Maillet continues. However, hospitals often have protocols in place for ensuring the competency of staff running complex point-of-care tests, she adds. “And, there are many hospitals capable of providing excellent care without implementing point-of-care testing,” she says. “[We are aware of] hospitals that have been recognized for their excellent care of cardiac patients without implementing point-of-care programs.”
The future of POC
While not all hospitals have bought into the benefits of point-of-care testing programs, they may feel some pressure to come on board in the future. “Hospitals are challenged with competitors marketing shorter emergency department wait times,” says Halvach. “The use of point-of-care devices could lead to decreases in the turn-around time of test results and [help ensure] prompt treatment of patients. As public awareness grows, it is likely our clients will request to have more of these products on contract.”
Advances in technology should lead to a broader menu of point-of-care tests in hospitals, note Gravell and Case. They point to advances in molecular technology and biomarkers, as well as research around blood thinners. “As the technology expands, it’s safe to say we should see more point-of-care testing in hospitals,” says Gravell.
