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SHORT COMMUNICATION
Point-of-care tests for infectious diseases: barriers to implementation across
three London teaching hospitals
Amaya L. Bustinduy (Amaya.Bustinduy@lshtm.ac.uk)
1,2
, Dakshika Jeyaratnam
3
, Sam Douthwaite
4
, Sarah Tonkin-Crine
5
, Rebecca Shaw
1
,
Laura Hyrapetian
6
, Nick Sevdalis
7
, Simon Goldenberg
8,9
, Elisabeth J. Adams
10
, Mike Sharland
1
, CLAHRC South London; Paediatric Infection Network
1.Paediatric Infectious Diseases Research Group, Infection and Immunity Institute, St George’s University of London, London, UK
2.Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
3.Department of Microbiology, King’s College Hospital NHS Foundation Trust, London, UK
4.Virology Department, Guy’s and St Thomas’ NHS trust, London, UK
5.Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
6.St George’s NHS trust, London, UK
7.Health Service & Population Research Department, King’s College London, London, UK
8.Centre for Clinical Infection and Diagnostics Research, King’s College, London, UK
9.Guy’s & St Thomas’ NHS Foundation Trust, London, UK
10.Aquarius Population Health, London, UK
Correspondence
Amaya Bustinduy, Clinical Research Department,
London School of Hygiene & Tropical Medicine,
Keppel Street, WC1 London, UK.
Tel: +44(0)79272642 |
Email: Amaya.Bustinduy@lshtm.ac.uk
Received
12 October 2016; revised 3 February 2017;
accepted 30 March 2017.
DOI:10.1111/apa.13867
Existing point-of-care tests (POCT) to help identify infec-
tion-related causes of illness can complement diagnostic
and disposition decisions in children attending emergency
departments (1). Evidence-based clinical algorithms can
integrate such POCT to aid in the admission and discharge
decision process. Paediatric studies validating these tools
are scarce, with very few studies conducted in UK centres
(2–5). POCT can be based on host infection markers (e.g.
finger prick tests for C-reactive protein (CRP) to help decide
whether the patient has a bacterial or viral infection) or
pathogen detection tests (e.g. throat/nose swabs to rapidly
diagnose viral infections such as RSV or influenza). The use
of POCT may reduce time in the emergency department (6),
help rationalise antibiotic prescribing (4) and reduce
investigations in these children (1,5). On admission to the
ward, POCT can also help with infection control proce-
dures to reduce the risk of transmission of hospital-related
infections. These benefits, however, have been mostly
documented in adults (7).
We present the experience across three paediatric tertiary
centres in South London with different POCT implemen-
tation strategies, research driven, during one respiratory
disease season (winter 2014–spring 2015) with the aim of
improving paediatric clinical process outcomes and poten-
tially reducing antibiotic use, and primarily focusing on the
barriers encountered for implementation.
At St George’s NHS trust, a service evaluation of febrile
children presenting to emergency department (ED) was
undertaken from October 2014 to March 2015. The aim of
the study was to collect clinical information on febrile
children and to develop an evidence-based tool to reduce
avoidable admissions in those with low-risk infections.
Results from the main study are reported elsewhere (8).
Outcome data included disposition of the patient, antibiotic
use and re-attendance to the ED within 28 days. As a
secondary outcome, ED staff were trained on the use of
three POCT that were introduced by company-provided
training: Alere-Afinion
TM
CRP test (four minutes), Alere i
influenza A/B
TM
(10 minutes) and Alere BinaxNOW
â
RSV
card (15 minutes). ED nurses and doctors were interviewed
about their experience of managing febrile children, fol-
lowing national guidelines (9), and their perceptions on
using POCT. Semistructured interviews were carried out
following an interview guide, and interviews were audio-
recorded and transcribed verbatim. At King’s College
Hospital (KCH), an observational study of children
Abbreviations
AMR, Antimicrobial resistance; CRP, C-reactive protein; ED,
Emergency department; GSTT, Guy’s and St Thomas’ Hospital;
KCH, King’s College Hospital; NHS, National Health Service;
PCR, Polymerase chain reaction; POCT, Point-of-care tests; RSV,
Respiratory syncytial virus; SGH, St George’s Hospital.
©2017 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 1
Acta Pædiatrica ISSN 0803-5253
presenting with symptoms or signs of upper respiratory tract
infection was undertaken from January to July 2015. A
ward-based diagnostic platform called BioFire Filmarray
(bioM
erieux, Marcy-l’
Etoile, France) was used with com-
pany-provided training. Ward staff were trained to perform
the respiratory pathogen assay which detects 17 respiratory
viruses and three bacteria by polymerase chain reaction
(PCR) in 70 minutes. A staff satisfaction questionnaire was
used with a graded response of 1–5 on ease of use and
utility. Questionnaires were distributed trust-wide. At Guy’s
and St Thomas’ NHS trust –Evelina Children’s Hospital
(GSTT),a ward-based service evaluation was conducted
from October 2014 to March 2015, using the Enigma
â
MiniLab
TM
FluAB-RSV PCR assay (Enigma Diagnostics Ltd,
Salisbury, UK), a fully automated molecular platform able
to detect influenza A and B and RSV in 90 minutes (9–11).
The platform was introduced by company-provided training
of staff with a competency assessment and then by the
research nurse at which point staff got a barcode for the
machine. Relevant staff were identified by ward matron and
interested clinical teams. Ward staff were trained to perform
the test on any child with signs or symptoms of upper or
lower respiratory tract infection. Duplicate samples were
obtained in viral transport medium and tested in parallel
with the standard laboratory-based assay (RVP Fast v2,
Luminex, Austin, TX, USA). Diagnostic accuracy, error
rate, turnaround time and use of hospital resources were
measured and compared with the previous influenza season
in which only the RVP was used. A staff satisfaction
questionnaire was offered to all ward staff (trained or
untrained in the use of the test) contacted through an
electronic trust-wide email distribution list, and they were
asked to provide quantitative and qualitative feedbacks
about their experience of using the Enigma test.
A total of 942 paediatric patients had a POCT performed
across the three centres during October 2014 to July 2015.
(Table 1) At St. George’s ED, POCT uptake was 30% less
than the laboratory counterpart test for CRP and viral
respiratory panel, with 102 POCT compared to 341 labo-
ratory-based tests. This was mainly for serum CRP samples,
whereby 225 were sent to the laboratory compared to 41
tested by POCT. Fifteen medical ED staff including three
consultants, five junior doctors, four senior registrars and
clinical fellows and three nurses were interviewed to
explore individual perceptions on the use of these tests.
Overall, the concerns about using the CRP POCT were
being unsure about performance of the test, missing the
‘odd sick child’ and using the test in isolation. The
advantages mentioned were the immediateness of the result
available in four minutes, the ease of use and being a blood-
sparing procedure. For the respiratory viruses POCT, they
were highly appreciated for the possibility of quickly
cohorting patients, decreasing antibiotic use and being able
to reassure parents. Downfalls mentioned included ques-
tions about performance of the test, error messages and
sample duplication.
At KCH, 460 tests were performed on the ward. The
BioFire platform was well received. Any concerns from staff
members were shared with the PI. Thirty-four respondents,
a mixture of nursing staff and paediatric consultants,
completed the survey. Highlighted advantages included fast
results in one hour, good tests for infection control, early
treatment and reduction in length of stay. Concerns
included a limitation on space to house the equipment,
needed for additional trained staff and high cost of the test.
In the GSTT paediatric ward, the ENIGMA platform
POCT used had a good uptake among staff. More POCT
were conducted compared to routine laboratory testing
(462 patients tested by POCT vs 370 patients tested by
routine laboratory). Results from the free-text portion of the
questionnaire from 34 staff who completed it were analysed
for themes. Advantages included parental anxiety reduc-
tion, better bed allocation, fast cohorting or isolation,
increased safety and reduction in antibiotic use. Concerns
raised by staff members included difficulty handling dis-
crepant results (POCT laboratory), more people needed to
be trained and no changes to patient care observed.
We have described three hospitals across South London
with different settings (ED and ward-based) and testing/
clinical protocols but that all implemented a POCT to
improve process outcomes and complement antibiotic
stewardship programmes. In the two ward-based centres,
Table 1 Number of patients tested within the study period by POCT and in the
reference laboratory
POCT Main laboratory
St George’s NHS trust (Children’s ED) 102 341
King’s College Hospital (Paediatric ward) 460 520
Guy’s and St Thomas’ trust (Paediatric ward) 462 370
Figure 1 Proposed stepwise process for the full integration of POCT into
paediatric clinical practice. Randomised control trials (RCT) with integrated cost-
effectiveness analysis. Training of medical staff to increase uptake leading to
practice change.
2©2017 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd
Implementation barriers for POCT Bustinduy et al.
although staff overall welcomed the POCT, the main issue
was not having enough trained personnel in all shifts. As the
uptake of their test increased beyond the ward where the
machines were housed, excessive demands were placed on
the trained staff to run tests from patients outside their
ward, leading to a queue of tests to be run. The decision by
the KCH and GSTT trusts to implement such a POCT will
ultimately depend on impact on length of stay, antibiotic
use and cost-effectiveness analysis (analysis awaited). In the
ED-based study (St. George’s ED), implementation barriers
were centred around the clinician’s uncertainty about the
test and fear of underinvestigating a potentially sick child.
Other problems included running a new technology within
a busy service that was not yet integrated into the depart-
mental clinical care pathways. Particular reticence was
found with the implementation of CRP and the fear of a
poor negative predictive value as a rule-out test, despite the
growing evidence that this is not the case (12). Overall, the
ward-based implementation had a more positive feedback
from the staff; however, parallel sampling for laboratory
testing makes this platform difficult to justify its cost.
This report is set within context of the global threat of
antimicrobial resistance (AMR) and the growing recogni-
tion on the value of POCT as valuable rapid diagnostic tools
(13,14). Scaling up of these tests may help reduce unnec-
essary empiric antibiotic use and reduce invasive investiga-
tions often performed to overcome diagnostic uncertainty
(15). Implementing these tests, however, is challenging (2).
Behaviour changes are needed to modify long-established
ways of providing clinical care and empirically prescribing
antibiotics for febrile children (16). New technology needs
time to become established as part of routine care and to
build evidence on its potential benefits (17). The need to
shift practice and integrate POCT into paediatric care as in
adult settings is clear and will require a multistage
approach. Overcoming implementation barriers is para-
mount in order to succeed in this approach and to make
local and national recommendations (18).
We propose a stepwise framework to integrate POCT
into paediatric clinical practice based on the three major
areas identified from the different centres as summarised in
Figure 1. (i) POCT RCT paediatric studies: multicentred
studies with cost-effective analysis to demonstrate
improved outcomes; (ii) increasing staff knowledge and
confidence to decrease uncertainty on the tests: need for
more comprehensive teaching and training on the different
devices, with particular emphasis on their evidence-based
efficacy; (iii) integration: integrate POCT into existing care
pathways and guidelines.
Qualitative assessments on the impact of interventions
are helpful to understand implementation difficulties and
can help pave the way for future integration of novel
interventions such as POCT into paediatric practice.
ACKNOWLEDGEMENTS
We would like to thank the ED staff members at St George’s
Children’s ED that contributed to the work presented; To
Alere
TM
for the donation of the POCT and reagents for the
study; Enigma Diagnostics for funding the GSTT Project; A
Vecino and C Mak for help on the survey and data analysis
at GSTT; and Evelina London Mountain ward staff,
patients and parents for support and feedback. We thank
staff and patients of the paediatric (especially Toni and
Guy) wards and bioM
erieux for the diagnostic platforms
and tests. We thank Dr. Adam Irwin for his instightful
review of the manuscript.
COMPETING INTERESTS AND FUNDING
DJ Project received funding from bioM
erieux. SD and EA
received funding from Enigma Diagnostics. NS’ research is
funded by the NIHR via the ‘Collaboration for Leadership
in Applied Health Research and Care South London’ at
King’s College Hospital NHS Foundation Trust, London,
UK. The views expressed are those of the authors and not
necessarily those of the NHS, the NIHR or the Department
of Health. Sevdalis is also a member of King’s Improvement
Science, which is part of the NIHR CLAHRC South
London and comprises a specialist team of improvement
scientists and senior researchers based at King’s College
London. Its work is funded by King’s Health Partners
(Guy’s and St Thomas’ NHS Foundation Trust, King’s
College Hospital NHS Foundation Trust, King’s College
London and South London and Maudsley NHS Founda-
tion Trust), Guy’s and St Thomas’ Charity, the Maudsley
Charity and the Health Foundation. The views expressed in
this publication are those of the authors and not necessarily
those of the NHS, the National Institute for Health
Research or the UK Department of Health. NS is also the
Director of London Safety and Training Solutions Ltd,
which provides quality and safety training and advisory
services on a consultancy basis to healthcare organisations
globally.
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