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Thoughts From A Clinician

Do you iSTAT?

Editors note: The FlightBridgeED Blog team is now performing peer reviews of each article. We encourage you to get invloved as well. At the end of each post, you will find at least 2 peer review commentaries, sometimes in agreement with the article, sometimes not...We want to challenge each other (and you) to bring clincially relevant information to you. This is one more example of FlightBridgeED's committment to excellence. - Mike Verkest

 

In today’s critical care transport environment, there is a growing list of diagnostic and therapeutic procedures that were once available only in the inpatient environment.  This includes the use of point-of-care testing for blood analysis using machines like the iSTAT by Abbott (1).  As with any tool in the tool box, a thoughtful risk-benefit analysis should help guide the use of this technology.  Point-of-care laboratories have been utilized in health care facilities for quite some time, but their out-of-hospital role remains unclear.  Do they have a place in transport medicine?  Could their use potentially elevate the care rendered?  There has been some healthy discussion among air and ground critical care providers as to the value of iSTAT machines in the transport environment, and while many providers agree that their use could increase awareness of an individual patient’s condition, the cost-benefit ratio remains poorly defined. 

            Point-of-care laboratory testing may have particular utility in rural areas with long transport times.  However, the relatively lower call volume in these areas makes it difficult to justify the added expense of this technology.  Many rural hospitals and clinics may not have 24 hour labs and be able to include the iSTAT as an adjunct during off hours. However, point-of-care testing may be considered dispensable in the transport world.  Why would such a potentially useful piece of equipment be seen as unnecessary?  Cost!  Not just upfront cost, but the cost of continual inspection, operation, and maintenance of the device.  Cartridges must be refrigerated and have expiration dates once opened, and maintenance is outsourced to the clinical engineering department of an inpatient institution.  In addition, there are annual competencies for crew members operating the machines.  Thus, the question as to whether point-of-care testing in the transport environment is worth the cost remains unanswered.  Many of the answers depend on how we move forward with this technology.  Will protocols be developed that give providers the latitude to make treatment decisions based on point-of-care results?  How will treatment guidelines that incorporate point-of-care testing be developed?  Are treatment options available that would be influenced by these results? 

            Is your program or service currently utilizing point-of-care laboratory testing?  Why or why not?  Most programs look at low call volumes, short transport distances, and costs as deterrents to its use.  So why are we bringing it up here?  To get a pulse on what is going on in the transport world and to start some meaningful dialogue to help move our industry forward.  As with any other tool in our tool bag, point-of-care testing may have great utility, with the potential to help many patients.  On the other hand, the technology may not be helpful in our environment and may even lead to harm if results are misinterpreted or misapplied.  Clearly, provider education and training – not only on how to utilize the equipment but also in the correct interpretation and response – may be most important of all.  In order to make a true difference with this (or any other) piece of equipment, we will have to first educate ourselves and set clear and concise goals.  This will set us on the right path to gaining an understanding and knowledge for the future of patient care and critical care education. 

References:

  1. https://www.pointofcare.abbott/us/en/offerings/istat/istat-handheld

klint

Klint Kloepping is a US trained Critical Care Paramedic and Flight Paramedic. He is currently pursuing a Baccalaureate degree in EMS management.  Klint works full time as a Flight Paramedic in the Midwest, USA.  Klint is also an EMS Instructor. 

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Twitter @NoDesat

Peer Review:

Klint brings up many valid points and takes an objective look at one of the hot topics in the pre-hospital transport environment.  He brings up powerful arguments throughout this article, with many pros and cons.  One such point I’d like to expand on is the education aspect and overall critical thinking that needs to be in place prior to rolling out such a device.  I think having the ability to understand the patient from the perspective of labs, or ABGs, would give the provider a stronger ability to make correct differential diagnosis arguments, mechanical ventilation changes, and overall decisions in patient care. With that being said, those decisions will be solely based on each provider’s understanding of the labs and the critical thinking that needs to occur with proper application of the point-of-care testing results. There is no argument against having more information that strengthens our ability to make proper treatment decisions. The problem is based on each organization’s education, span of control, and transport times to name a few. If the organization has transport times of 10-20 minutes, it wouldn’t make sense to have point-of-care testing in that environment. The applicable changes to patient care may or may not be seen in that time frame and delaying transport for the purpose of making those changes would not be advantageous in my opinion.

As Klint illustrated, each company should do a needs analysis that includes education, both initial and ongoing, transport type, and transport time.  Competency validation would need to happen quarterly, with a focus on patient care case evaluation; case-based learning, and overall critical thinking. Without this, point-of-care testing and the valuable information one gleams from the test results will be useless.

Eric Bauer, MBA, FP-C, CCP-C, C-NPT

 

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To begin, there are several great points brought up by Klint.  The whole purpose of point-of-care testing (POCT) is to be able to test at the point where patient care is being rendered.  While I can see the additional benefit of POCT in the transport environment in certain patient conditions, it still poses several different problems or concerns that must be given thought. 

Any facility/program that conducts laboratory testing for health purposes is regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).  There are certain tests that are considered “waived” under CLIA and this would include some POCT.  Although these tests are generally considered simple and carry a low risk for erroneous results, they are not completely void of error.  The main tests that transport providers would consider helpful; such as ABGs, chemistry panel, and CBC, are not considered waived per CLIA.  Many of these are considered moderate to high complexity and must meet the standards of CLIA as well as federal and state regulations.  This alone can pose significant problems/constraints as well as a management headache for many programs.

It has been recognized and can be debated by many experienced clinicians, that patient improvement from the use of POCT has increased over the past 10-15 years.  However, most of this evidence continues to be circumstantial in comparison to evidence-based clinical studies.  These studies continue to be necessary for programs to truly say that POCT has a definitive role in improving the outcomes of their patient care.  Playing advocate, I will have to say that I do see where having ABGs and even certain chemistry values can be very beneficial and even improve patient care, especially in the setting of ventilator management.  Even small ventilator changes in response to changing ABG status can make a significant difference in the overall care of patients.  However, it can still be debated that only flights/transport times over a certain period of time would qualify for this.

In addition, the issue of cost and billing has to be considered.  In a perfect world, I would love to be able to only think about what is best for the patient and improving their care. However, as many of us have experienced in management positions, costs and reimbursement rates drive decisions within a company.  When it comes to pre-hospital ground or air transport, it is very difficult to determine the cost savings of POCT when compared to a normal cost analysis.  Often times, looking at the most downstream savings; such as improved patient outcomes; are much more difficult to measure as POCT is only a small segment of their overall care.  With the recent move to healthcare reimbursement focusing on value-based care, there may very well be changes in the way that budgets are looked at and allocation of money and resources in the future.  This is still unclear when it comes to the pre-hospital transport environment however.

There also remains the potential for serious impacts on patients’ health if POCT is performed incorrectly or results are not correctly interpreted.  This is where I feel education is imperative.  There really is no concern that I can see that healthcare providers would perform these tests incorrectly.  The process of test collection and quality control could be taught to any given lay person.  The concern I see is in regards to interpretation of results.  There must be clear guidelines and active involvement from medical directors when it comes to interpreting these tests and how to adjust patient care accordingly.  I do believe fully that if medical directors would take a more active role in the education process, as well as the clinical educators within the company, POCT use could be very beneficial to patient care and ultimately overall outcomes.

Ashley Bauer, MSN, MBA, APRN, FNP-C


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