Point-of-care testing reduces length of stay in emergency department chest pain patients
ABSTRACT We determine the effect of cardiac troponin I point-of-care testing on emergency department (ED) length of stay in chest pain patients.
This was a before-and-after trial in a university-based ED with 75,000 annual visits. Participants were consecutive patients with a chief complaint of chest pain who were admitted to the hospital. During the first 2-week period (before), only central laboratory testing of troponin was performed. During the second 2-week period (after), treating nurses performed bedside point-of-care testing for troponin I, as well as central laboratory testing. Test turnaround times, time from triage until calling in admissions, and time from triage until patients left the ED to be transferred to a floor (ED length of stay) were determined and compared between the 2 study periods. Comparisons between study periods are expressed as mean differences with 95% confidence intervals (CIs). A sample of 100 patients in each group had 90% power to detect a 1-hour difference in length of stay (2-tailed alpha=0.05).
There were 232 patients before and 134 after introduction of point-of-care testing. Mean age (SD) was 63 years (16 years), and 44% were female patients. Baseline characteristics were similar in both groups. The rate of positive troponins was also similar (9.5% versus 6.1%). ED length of stay was significantly reduced after introduction of point-of-care testing (5.2 hours [95% CI 4.6 to 5.8 hours] versus 7.1 hours [95% CI 6.6 to 7.7 hours]; mean difference 1.9 hours [95% CI 1.1 to 2.7 hours]). The time until the admission was called in to bed control was also significantly reduced by introducing point-of-care testing (2.7 hours [95% CI 2.4 to 3.1 hours] versus 4.7 hours [95% CI 4.3 to 5.0 hours]; mean difference 1.9 hours [95% CI 1.4 to 2.5 hours]). Point-of-care testing turnaround (14.8 minutes [95% CI 14.1 to 15.5 minutes]) was significantly shorter than for central laboratory testing (83 minutes [95% CI 77 to 89 minutes]; mean difference 68 minutes [95% CI 62 minutes to 74 minutes]). With central testing as the criterion standard, point-of-care testing had a sensitivity of 100% (95% CI 63% to 100%) and a specificity of 96% (95% CI 92% to 99%).
Bedside performance of troponin I point-of-care testing by treating nurses significantly reduces ED length of stay.
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ABSTRACT: This article is a systematic review of the effectiveness of four practices (assay selection, decision point cardiac troponin (cTn) threshold selection, serial testing, and point of care testing) for improving the diagnostic accuracy Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) in the Emergency Department. The CDC-funded Laboratory Medicine Best Practices (LMBP) Initiative systematic review method for quality improvement practices was used. The current ACC/AHA guidelines recommend using cardiac troponin assays with a 99th percentile upper reference limit (URL) diagnostic threshold to diagnose NSTEMI. The evidence in this systematic review indicates that contemporary sensitive cTn assays meet the assay profile requirements (sensitivity, specificity, PPV, and NPV) to more accurately diagnose NSTEMI than alternate tests. Additional biomarkers did not increase diagnostic effectiveness of cTn assays. Sensitivity, specificity, and NPV were consistently high and low PPV improved with serial sampling. Evidence for use of point of care cTn testing was insufficient to make recommendation, though some evidence suggests that use may result in reduction to patient length of stay and costs. Based on the review of and the LMBP recommendation criteria, we recommend the use of cardiac troponin assays without additional biomarkers using the 99th percentile URL as the clinical diagnostic threshold for the diagnosis of NSTEMI. We recommend serial sampling with one sample at presentation and at least one additional second sample taken at least 6h later to identify a rise or fall in the troponin level. No recommendation is made either for or against the use of point of care tests. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry (CDC/ATSDR). Copyright © 2015. Published by Elsevier Inc.Clinical Biochemistry 02/2015; 48(4-5). DOI:10.1016/j.clinbiochem.2015.01.014 · 2.23 Impact Factor
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ABSTRACT: Intra-laboratory turnaround time (TAT) is a key indicator of laboratory performance. Improving TAT is a complex task requiring staff education, equipment acquisition, and adequate TAT monitoring. The aim of the present study was to evaluate the intra-laboratory TAT after laboratory automation implementation (June 2013-June 2014) and to compare it to that in the preautomation period (July 2012-May 2013). Intra-laboratory TAT was evaluated both as the mean TAT registered and the percentage of outlier (OP) exams. The mean TAT was 36, 38, and 34 min during the study periods, respectively. These values respected the goal TAT established at 45 min. The OP, calculated at 45 min as well as at 60 min, decreased from 26 to 21 and from 11 to 5, respectively. From a focused analysis on blood count cell, troponin I, and prothrombin (PT) test, TAT improvement was more evident for tests requiring longer preanalytical process. The follow-up of TAT from June 2013 to June 2014 revealed the reduction of the mean TAT as well as of the OP exams after automation implementation and that automation more strongly affects the test in the preanalytical phase including centrifugation of the sample, such as troponin I and PT. © 2015 Society for Laboratory Automation and Screening.Journal of the Association for Laboratory Automation 01/2015; DOI:10.1177/2211068214566458 · 1.50 Impact Factor
American Journal of Emergency Medicine 12/2014; DOI:10.1016/j.ajem.2014.12.018 · 1.15 Impact Factor