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Youssef E, Benabbas R, Choe B, Doukas D, Taitt HA, Verma R, Zehtabchi S. Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis. Acad Emerg Med 2024. [PMID: 38826092 DOI: 10.1111/acem.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/19/2024] [Accepted: 05/10/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators. METHODS This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality). CONCLUSIONS Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.
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Affiliation(s)
- Elias Youssef
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Roshanak Benabbas
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Brittany Choe
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Donald Doukas
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Hope A Taitt
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Rajesh Verma
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
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de Koning L, Seiden-Long I, Anker K, Myers K, Stang A. Whole Blood Cardiac Troponin "Triaging" to Improve Early Detection of Myocardial Injury at a Pediatric Hospital. J Appl Lab Med 2024; 9:540-548. [PMID: 38300632 DOI: 10.1093/jalm/jfad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/30/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND The importance of offering on-site cardiac troponin (cTn) testing at pediatric hospitals may be underappreciated. We developed a rapid rule-in process for myocardial injury at a pediatric hospital experiencing delays in off-site high-sensitivity cardiac troponin T (hs-cTnT) testing. METHODS Collect-to-verify turnaround times (TATs) for off-site testing were reviewed. Pre-analytic changes to improve TATs were devised, implemented and evaluated, after which a new analyzer was selected and evaluated for on-site cTn testing. Performance of the new analyzer's assay was compared to the off-site hs-cTnT assay, and post go-live TATs for on-site testing were assessed. RESULTS Median collect-to-verify TAT for short turnaround-time (STAT) priority off-site plasma hs-cTnT testing was 104 min, with 35% of orders having a TAT >120 min. Eliminating serum separator tubes and requiring a separate plasma separator tube did not significantly reduce TATs. A QuidelOrtho Triage® MeterPro whole blood cardiac troponin I (cTnI) assay was implemented to "triage" time-critical and STAT priority specimens collected for off-site hs-cTnT testing. Elevated cTnI (≥0.02 µg/L) had a sensitivity of 91% for clear elevations in hs-cTnT (≥53 ng/L) but a 0% sensitivity for modest elevations (5 to 13 ng/L, 14 to 52 ng/L). An interpretive comment was auto-appended to cTnI results indicating that clinicians should wait for the hs-cTnT result if cTnI was normal. Median collect-to-verify TAT for on-site cTnI testing was <50% the TAT for off-site hs-cTnT testing. CONCLUSIONS On-site point-of-care whole blood cTn testing can rapidly confirm significant or late-presenting myocardial injury. Combined with simultaneous off-site high-sensitivity cardiac troponin (hs-cTn) testing, this workflow is a viable interim solution for pediatric hospitals without on-site hs-cTn testing.
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Affiliation(s)
- Lawrence de Koning
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
- Alberta Precision Laboratories, Diagnostic and Scientific Research Centre, Calgary, AB, Canada
| | - Isolde Seiden-Long
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
- Alberta Precision Laboratories, Diagnostic and Scientific Research Centre, Calgary, AB, Canada
| | - Katherine Anker
- Department of Pediatrics, Section of Emergency Medicine, Cumming School of Medicine, University of Calgary, Alberta Children's Hospital, 28 Oki Drive NW, Calgary, AB, Canada
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
| | - Kimberley Myers
- Department of Pediatrics, Section of Cardiology, Cumming School of Medicine, University of Calgary, Alberta Children's Hospital, 28 Oki Drive NW, Calgary, AB, Canada
| | - Antonia Stang
- Department of Pediatrics, Section of Emergency Medicine, Cumming School of Medicine, University of Calgary, Alberta Children's Hospital, 28 Oki Drive NW, Calgary, AB, Canada
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada
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Martín-Rodríguez F, Sanz-García A, Martínez Fernández FT, Otero de la Torre S, Delgado Benito JF, Del Pozo Vegas C, Pérez García R, Ingelmo Astorga EA, Sanchez Coalla A, López-Izquierdo R. Association between prehospital lactate categories with short- and long-term mortality: a prospective, observational multicenter study. QJM 2023; 116:835-844. [PMID: 37449904 DOI: 10.1093/qjmed/hcad167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/26/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Lactate is an already recognized biomarker for short-term mortality in emergency medical services (EMS). However, how different levels of lactate are associated with short-, mid- and long-term outcomes should be unveiled. AIM To determine how different categories of hyperlactatemia are associated with mortality. We also aim to clinically characterize hyperlactatemia groups. DESIGN A multicenter, prospective, observational study performed between January 2019 and February 2022, considering 48 basic life support units and 5 advanced life support units referring to 4 tertiary care hospitals (Spain). Patients were recruited from phone requests for emergency assistance in adults, evacuated to emergency departments. The primary outcome was in-hospital mortality from any cause within the first to the 365-day period following EMS attendance. The main measures were demographical and biochemical variables, prehospital advanced life support techniques used and patient condition categorized in 24 diseases. METHODS Univariate and Cox regression analysis. RESULTS A total of 5072 participants fulfilled inclusion criteria. Group #1 (non-hyperlactatemia) was composed of 2389 subjects (47.1%), Group #2 (mild hyperlactatemia) of 1834 (36.1%), Group #3 (hyperlactatemia) of 333 (6.6%) and, finally, Group #4 (severe hyperlactatemia) of 516 (10.2%). The 1-day mortality was 0.2%, 1.1%, 9% and 22.3% in the four lactate groups, respectively. Long-term mortality (365 days) was 10.2%, 22.7%, 38.7% and 46.7% in the four lactate groups, respectively. Differences between patients' conditions of lactatemia groups were also found. CONCLUSIONS Our results demonstrated that prehospital lactate categories were associated with short- and long-term outcomes in a different manner. These results will allow EMS to establish different risk states according to the prehospital lactate categories.
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Affiliation(s)
- F Martín-Rodríguez
- Medicine, Dermatology and Toxicology Department,, Faculty of Medicine, University of Valladolid, Valladolid, Spain
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
| | - A Sanz-García
- Nursing, Physiotherapy and Occupational Therapy Department, Faculty of Health Sciences, University of Castilla la Mancha, Talavera de la Reina, Spain
| | | | - S Otero de la Torre
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
| | - J F Delgado Benito
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
| | - C Del Pozo Vegas
- Medicine, Dermatology and Toxicology Department,, Faculty of Medicine, University of Valladolid, Valladolid, Spain
- Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | - R Pérez García
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - A Sanchez Coalla
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - R López-Izquierdo
- Medicine, Dermatology and Toxicology Department,, Faculty of Medicine, University of Valladolid, Valladolid, Spain
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
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Li Q, Zhao L, Chan CL, Zhang Y, Tong SW, Zhang X, Ho JWK, Jiao Y, Rainer TH. Multi-Level Biomarkers for Early Diagnosis of Ischaemic Stroke: A Systematic Review and Meta-Analysis. Int J Mol Sci 2023; 24:13821. [PMID: 37762122 PMCID: PMC10530879 DOI: 10.3390/ijms241813821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/25/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Blood biomarkers hold potential for the early diagnosis of ischaemic stroke (IS). We aimed to evaluate the current weight of evidence and identify potential biomarkers and biological pathways for further investigation. We searched PubMed, EMBASE, the Cochrane Library and Web of Science, used R package meta4diag for diagnostic meta-analysis and applied Gene Ontology (GO) analysis to identify vital biological processes (BPs). Among 8544 studies, we included 182 articles with a total of 30,446 participants: 15675 IS, 2317 haemorrhagic stroke (HS), 1798 stroke mimics, 846 transient ischaemic attack and 9810 control subjects. There were 518 pooled biomarkers including 203 proteins, 114 genes, 108 metabolites and 88 transcripts. Our study generated two shortlists of biomarkers for future research: one with optimal diagnostic performance and another with low selection bias. Glial fibrillary acidic protein was eligible for diagnostic meta-analysis, with summary sensitivities and specificities for differentiating HS from IS between 3 h and 24 h after stroke onset ranging from 73% to 80% and 77% to 97%, respectively. GO analysis revealed the top five BPs associated with IS. This study provides a holistic view of early diagnostic biomarkers in IS. Two shortlists of biomarkers and five BPs warrant future investigation.
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Affiliation(s)
- Qianyun Li
- Department of Emergency Medicine, University of Hong Kong, Hong Kong, China; (Q.L.)
| | - Lingyun Zhao
- Department of Emergency Medicine, University of Hong Kong, Hong Kong, China; (Q.L.)
| | - Ching Long Chan
- Department of Emergency Medicine, University of Hong Kong, Hong Kong, China; (Q.L.)
| | - Yilin Zhang
- Department of Emergency Medicine, University of Hong Kong, Hong Kong, China; (Q.L.)
| | - See Wai Tong
- Department of Emergency Medicine, University of Hong Kong, Hong Kong, China; (Q.L.)
| | - Xiaodan Zhang
- Department of Emergency Medicine, University of Hong Kong, Hong Kong, China; (Q.L.)
| | - Joshua Wing Kei Ho
- School of Biomedical Sciences, University of Hong Kong, Hong Kong, China
| | - Yaqing Jiao
- Department of Emergency Medicine, University of Hong Kong, Hong Kong, China; (Q.L.)
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Montero-San-Martín B, Oliver P, Fernandez-Calle P, Sánchez-Pascuala Callau JJ, Díaz Almirón M, Alcaide Martín MJ, Fernández-Puntero B, Duque Alcorta M, Valero Recio JM, Martín Quirós A, de Ceano-Vivas la Calle M, Martín Sánchez J, Rivas Becerra B, Vega Cabrera C, Melgosa Hijosa M, Buno Soto A. Laboratory interpretative comments and guidance: clinical and operative outcomes on moderate to severe hyponatraemia patient management. J Clin Pathol 2023; 76:116-120. [PMID: 34518360 DOI: 10.1136/jclinpath-2021-207611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/29/2021] [Indexed: 01/26/2023]
Abstract
AIMS Hyponatraemia is the most common body fluid disorders but often goes unnoticed. Our laboratory incorporated a standardised procedure to help clinicians detect moderate/severe hyponatraemia. The study aims were to evaluate the outcomes on patient care and clinicians' satisfaction. METHODS The study, observational and retrospective, included 1839 cases, adult and paediatric patients, with sodium concentration <130 mmol/L. The procedure consisted of interpretative comments in the emergency and core laboratories report and the point-of-care testing blood gas network report. We evaluated hyponatraemia length in two equal periods: before and after the implementation. We conducted a survey addressed to the staff of the clinical settings involved to know their satisfaction. RESULTS The median hyponatraemia length decreased significantly from 4.95 hours (2.08-16.57) in the first period to 2.17 hours (1.06-5.39) in the second period. The lack of hyponatraemia patients follow-up was significantly less after the procedure implementation. The survey was answered by 92 (60 senior specialists and 32 residents) out of 110 clinicians surveyed. Ninety of them (98%) answered positively. CONCLUSIONS We have demonstrated the reduction in the time for diagnosing and management by physicians, the higher uniformity in the time required to solve hyponatraemia episodes following our laboratory procedure and the clinicians' satisfaction.
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Affiliation(s)
| | - Paloma Oliver
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | | | - Marta Duque Alcorta
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | | | | | | | - Antonio Buno Soto
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain
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Yan N, Wei L, Li Z, Song Y. Establishment of a nomogram model for acute chest pain triage in the chest pain center. Front Cardiovasc Med 2023; 10:930839. [PMID: 37025691 PMCID: PMC10070711 DOI: 10.3389/fcvm.2023.930839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 03/02/2023] [Indexed: 04/08/2023] Open
Abstract
Background Acute myocardial infarction (AMI) is the leading life-threatening disease in the emergency department (ED), so rapid chest pain triage is important. This study aimed to establish a clinical prediction model for the risk stratification of acute chest pain patients based on the Point-of-care (POC) cardiac troponin (cTn) level and other clinical variables. Methods We conducted a post-hoc analysis of the database from 6,019 consecutive patients (excluding prehospital-diagnosed non-cardiac chest pain patients) attending a local chest pain center (CPC) in China between October 2016 and January 2019. The plasma concentration of cardiac troponin I (cTnI) was measured using a POC cTnI (Cardio Triage, Alere) assay. All the eligible patients were randomly divided into training and validation cohorts by a 7:3 ratio. We performed multivariable logistic regression to select variables and build a nomogram based on the significant predictive factors. We evaluated the model's generalization ability of diagnostic accuracy in the validation cohort. Results We analyzed data from 5,397 patients that were included in this research. The median turnaround time (TAT) of POC cTnI was 16 min. The model was constructed with 6 variables: ECG ischemia, POC cTnI level, hypotension, chest pain symptom, Killip class, and sex. The area under the ROC curve (AUC) in the training and validation cohorts was 0.924 and 0.894, respectively. The diagnostic performance was superior to the GRACE score (AUC: 0.737). Conclusion A practical predictive model was created and could be used for rapid and effective triage of acute chest pain patients in the CPC.
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Affiliation(s)
- Na Yan
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
| | - Ling Wei
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
- Department of Emergency, TEDA Hospital, Tianjin, China
| | - Zhiwei Li
- Department of Pathophysiology, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Yu Song
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
- Department of Emergency, TEDA Hospital, Tianjin, China
- Correspondence: Yu Song
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Optimization of Patient Management in the Gynecology Emergency Department Using Point-of-Care Beta hCG. Diagnostics (Basel) 2022; 12:diagnostics12071670. [PMID: 35885574 PMCID: PMC9318004 DOI: 10.3390/diagnostics12071670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Point-of-care testing (POCT) provides shorter turn-around times and, in many cases, potentially improves medical decision making. The AQT90 FLEX® benchtop immunoanalyzer (Radiometer Medical ApS, Copenhagen, Denmark) allows for the determination of beta-human chorionic gonadotropin (βhCG) in 18 min. The main aim of this study was to evaluate the impact of measuring βhCG using the AQT90 analyzer in the gynecology emergency department (ED) compared to the standard practice of using central laboratory blood testing on the patient length of stay (LOS). Methods: The evaluation consisted of two parts. The first one, conducted in the central laboratory, focused on the analytical performances of the AQT βhCG assay. The second one, conducted in the ED, aimed at determining the impact of POCT βhCG implementation on the timeframe in which ED patients require βhCG assessment. Results: The within-lab imprecisions at the mean values of 17 and 287 IU/L were 2.7% and 3.7%, respectively. Using Deming regression (n = 60), the following equation was obtained in the central lab: AQT90 βhCG = 1.1 Roche βhCG—12.9 (r = 0.997). The implementation of POCT βhCG in the ED significantly reduced patient LOS (145 (90−212) min vs. 205 (155−265) with and without AQT90, respectively, p < 0.001). At the 2 IU/L decision level, a 99.7% agreement with the Roche assay was reported (kappa statistics, 0.99). Conclusions: We confirm that the analytical qualities of the AQT 90 were in line with those obtained in the central lab. The implementation of the POCT βhCG is associated with a shorter LOS in the ED due to the faster availability of the results and the faster decision-making possibilities.
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Martín-Rodríguez F, López-Izquierdo R, Sanz-García A, Del Pozo Vegas C, Ángel Castro Villamor M, Mayo-Iscar A, Martín-Conty JL, Ortega GJ. Novel Prehospital Phenotypes and Outcomes in Adult-Patients with Acute Disease. J Med Syst 2022; 46:45. [PMID: 35596887 PMCID: PMC9123608 DOI: 10.1007/s10916-022-01825-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/29/2022] [Indexed: 12/05/2022]
Abstract
An early identification of prehospital phenotypes may allow health care workers to speed up and improve patients’ treatment. To determine emergency phenotypes by exclusively using prehospital clinical data, a multicenter, prospective, and observational ambulance-based study was conducted with a cohort of 3,853 adult patients treated consecutively and transferred with high priority from the scene to the hospital emergency department. Cluster analysis determined three clusters with highly different outcome scores and pathological characteristics. The first cluster presented a 30-day mortality after the index event of 45.9%. The second cluster presented a mortality of 26.3%, while mortality of the third cluster was 5.1%. This study supports the detection of three phenotypes with different risk stages and with different clinical, therapeutic, and prognostic considerations. This evidence could allow adapting treatment to each phenotype thereby helping in the decision-making process.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center. Faculty of Medicine, Valladolid University, Valladolid, Spain.
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain.
| | - Raúl López-Izquierdo
- Advanced Clinical Simulation Center. Faculty of Medicine, Valladolid University, Valladolid, Spain
- Emergency Department. Hospital, Universitario Rio Hortega, Valladolid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de La Princesa, Madrid (IIS-IP), Spain.
| | - Carlos Del Pozo Vegas
- Advanced Clinical Simulation Center. Faculty of Medicine, Valladolid University, Valladolid, Spain
- Emergency Department. Hospital, Clínico Universitario, Valladolid, Spain
| | | | - Agustín Mayo-Iscar
- Department of Statistics and Operative Research. Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | - José L Martín-Conty
- Facultad de Ciencias de La Salud, Universidad de Castilla La Mancha, Talavera de La Reina, Spain
| | - Guillermo José Ortega
- Data Analysis Unit, Health Research Institute, Hospital de La Princesa, Madrid (IIS-IP), Spain
- Consejo Nacional de Investigaciones Científicas Y Técnicas (CONICET), Buenos Aires, Argentina
- Science and Technology Department, Universidad Nacional de Quilmes, Bernal, Buenos Aires, Argentina
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Amissah M, Lahiri S. Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department. Healthcare (Basel) 2022; 10:healthcare10050942. [PMID: 35628079 PMCID: PMC9140672 DOI: 10.3390/healthcare10050942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023] Open
Abstract
Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitation, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.
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Roadmap for large-scale implementation of point-of-care testing in primary care in Central and Eastern European countries: the Hungarian experience. Prim Health Care Res Dev 2022; 23:e26. [PMID: 35445652 PMCID: PMC9112671 DOI: 10.1017/s1463423622000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: The aim of this study is to give a broad overview of the international best practices regarding the implementation of point-of-care testing (POCT) in primary care (PC) setting and to highlight the facilitators and barriers for widespread national uptake. The study focuses on the managerial and organizational side of POCT, offering a roadmap for implementation as well as highlighting the most important requirements needed to unlock the clinical and economical potential of POCT in the Hungarian healthcare system. Methods: We conducted an English language scoping literature review between January 2012 and June 2021 to assess the recent trends of POCT implementation in developed countries. Our research focuses on the recent publications of several European and Anglo-Saxon countries where POCT utilization is common. In parallel, we reviewed the Hungarian regulatory framework, ongoing governmental legislation, and strategies influencing the POCT dissemination in the Hungarian PC sector. Results: Among the possible POCT usage in PC, we identified several clinically relevant devices and tests (C-reactive protein, urine, blood glucose, D-dimer, prothrombin time) important in screening and early detection of morbidities representing high disease burden. Based on international literature, general practitioners (GPs) are interested in the shortened diagnostic times, portable devices, and better doctor–patient relations made possible by POCT. There are several concerns, however, regarding initial and operational costs and reimbursement, limited scientific evidence about quality and safety, unclear regulations on quality validation of tests, as well as managerial aspects like PC staff training and IT integration at the GP level. Conclusion: As our review highlights, there is considerable interest among GPs to implement POCT as it has the potential to improve quality of care; however, there are many obstacles to overcome before widespread uptake. Further investigation is recommended to elaborate management and quality insurance background and to develop appropriate regulatory framework and financial scheme for GP practices. Preferably this work should involve the local practicing GPs to better tailor the implementation roadmap to country-specific details.
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Effectiveness of a Mobile App in Reducing Therapeutic Turnaround Time and Facilitating Communication between Caregivers in a Pediatric Emergency Department: A Randomized Controlled Pilot Trial. J Pers Med 2022; 12:jpm12030428. [PMID: 35330427 PMCID: PMC8948631 DOI: 10.3390/jpm12030428] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 01/27/2023] Open
Abstract
For maintaining collaboration and coordination among emergency department (ED) caregivers, it is essential to effectively share patient-centered information. Indirect activities on patients, such as searching for laboratory results and sharing information with scattered colleagues, waste resources to the detriment of patients and staff. Therefore, we conducted a pilot study to evaluate the initial efficacy of a mobile app to facilitate rapid mobile access to central laboratory results and remote interprofessional communication. A total of 10 ED residents and registered nurses were randomized regarding the use of the app versus conventional methods during semi-simulated scenarios in a pediatric ED (PED). The primary outcome was the elapsed time in minutes in each group from the availability of laboratory results to their consideration by participants. The secondary outcome was the elapsed time to find a colleague upon request. Time to consider laboratory results was significantly reduced from 23 min (IQR 10.5–49.0) to 1 min (IQR 0–5.0) with the use of the app compared to conventional methods (92.2% reduction in mean times, p = 0.0079). Time to find a colleague was reduced from 24 min to 1 min (i.e., 93.0% reduction). Dedicated mobile apps have the potential to improve information sharing and remote communication in emergency care.
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Cullen L, Collinson PO, Giannitsis E. Point-of-care testing with high-sensitivity cardiac troponin assays: the challenges and opportunities. Emerg Med J 2022; 39:861-866. [PMID: 35017187 DOI: 10.1136/emermed-2021-211907] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022]
Abstract
Methods to improve the safety, accuracy and efficiency of assessment of patients with suspected acute coronary symptoms have occupied decades of study and have supported significant changes in clinical practice. Much of the progress is reliant on results of laboratory-based high-sensitivity cardiac troponin assays that can detect low concentrations with high precision. Until recently, point-of-care (POC) platforms were unable to perform with similar analytical precision as laboratory-based assays, and recommendations for their use in accelerated assessment strategies for patients with suspected acute coronary syndrome has been limited. As POC assays can provide troponin results within 20 min, and can be used proximate to patient care, improvements in the efficiency of assessment of patients with suspected acute coronary syndrome is possible, particularly with new high-sensitivity assays.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Paul O Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University of London, London, UK
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Bodington R, Kassianides X, Bhandari S. Point-of-care testing technologies for the home in chronic kidney disease: a narrative review. Clin Kidney J 2021; 14:2316-2331. [PMID: 34751234 PMCID: PMC8083235 DOI: 10.1093/ckj/sfab080] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Indexed: 01/09/2023] Open
Abstract
Point-of-care testing (POCT) performed by the patient at home, paired with eHealth technologies, offers a wealth of opportunities to develop individualized, empowering clinical pathways. The non-dialysis-dependent chronic kidney disease (CKD) patient who is at risk of or may already be suffering from a number of the associated complications of CKD represents an ideal patient group for the development of such initiatives. The current coronavirus disease 2019 pandemic and drive towards shielding vulnerable individuals have further highlighted the need for home testing pathways. In this narrative review we outline the evidence supporting remote patient management and the various technologies in use in the POCT setting. We then review the devices currently available for use in the home by patients in five key areas of renal medicine: anaemia, biochemical, blood pressure (BP), anticoagulation and diabetes monitoring. Currently there are few devices and little evidence to support the use of home POCT in CKD. While home testing in BP, anticoagulation and diabetes monitoring is relatively well developed, the fields of anaemia and biochemical POCT are still in their infancy. However, patients' attitudes towards eHealth and home POCT are consistently positive and physicians also find this care highly acceptable. The regulatory and translational challenges involved in the development of new home-based care pathways are significant. Pragmatic and adaptable trials of a hybrid effectiveness-implementation design, as well as continued technological POCT device advancement, are required to deliver these innovative new pathways that our patients desire and deserve.
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Affiliation(s)
- Richard Bodington
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK
| | | | - Sunil Bhandari
- Department of Renal Research, Hull Royal Infirmary, Hull, UK
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14
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Trenti T. Synergy Between Point-of-Care Testing and Laboratory Consolidations. EJIFCC 2021; 32:328-336. [PMID: 34819822 PMCID: PMC8592627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Central or area laboratories will offer an improved number of diagnostic testing services, where drivers for change will involve chronic disease clinical care for an increasingly older population, new emerging diagnostic technologies and personalized medicine. Higher automation quality and ever more diagnostic field integration will lead to higher productivity by means of an improved throughput. At the same time Point of Care Testing (POCT) site of patient care allows for timely medical assessment, which can lead to improved patient outcomes, more effectiveness and patient satisfaction. POCT test introduction in clinical practice should be assessed by an outcome-based policy to avoid adverse events, failure to diagnose providing appropriate timed treatment. The use of POCT devices does not only require technological considerations for the production and management of acceptable tests possibly managed by central laboratory, but also implicates a shift in diagnostic practice across all health organizations. The interaction between laboratory professionals and clinicians will be enriched with new methods of evaluation of patient needs in the internet of things and mobile Health worlds, where boundaries between POCT and central laboratory or hospital and primary healthcare will no longer exist and where all data can be shared and disseminated among stakeholders in the healthcare system.
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Affiliation(s)
- Tommaso Trenti
- Corresponding author: Tommaso Trenti Laboratory Medicine & Pathology Department, Azienda Universitaria Ospedaliera e USL di Modena via Giardini 1355 Modena I-41126 Italy E-mail:
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Abstract
The diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has ramifications on both an individual level and a public health level. The use of appropriate testing mechanisms is paramount to preventing transmission, along with offering treatment to those who are infected and show appropriate symptomatology. The choice of employing a specific test often relies on laboratory capabilities, including the abilities of the medical technologists, the cost of testing platforms, and the individual quirks of each test. This chapter intends to discuss the relevant issues relating to diagnostic testing for SARS-CoV-2, including specimen types and collection methods, viral detection methods, and serological testing.
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Bargnoux AS, Kuster N, Sutra T, Laroche L, Rodriguez A, Morena M, Chenine L, Chalabi L, Dupuy AM, Badiou S, Cristol JP. Evaluation of a new point-of-care testing for creatinine and urea measurement. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:290-297. [PMID: 33908840 DOI: 10.1080/00365513.2021.1914344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Point of care testing makes it possible to obtain results in an extremely short time. Recently, radiometer has expanded the panel of tests available on its ABL90 FLEX PLUS blood gas analyzer (ABL90) by adding urea and creatinine. The aim of this study was to verify the performance of these new parameters. This included assessment of imprecision, linearity, accuracy by comparison with central laboratory standard assays and interferences. In addition, clinical utility in a dialysis center was evaluated. Within-lab coefficients of variation were close to 2%. The mean and limits of agreement (mean ± 1.96 SD) of the difference between ABL90 and Roche enzymatic assays on cobas 8000 were 0.5 (from -1.4 to 2.3) mmol/L and -0.9 (from -19.5 to 17.8) µmol/L for urea and creatinine, respectively. The ABL90 enzymatic urea and creatinine assays met the acceptance criteria based on biological variation for imprecision and showed good agreement with central laboratory. The two assays were unaffected by hematocrit variation between 20 and 70%, hemolysis and icterus interferences. It should be noted that the relationship between lab methods and ABL90 was conserved even for high pre-dialysis values allowing easy access to dialysis adequacy parameters (Kt/V) and muscle mass evaluation (creatinine index). Rapid measurement of creatinine and urea using whole blood specimens on ABL90 appears as a fast and convenient method. Analytical performances were in accordance with our expectations without any significant interferences by hemolysis or icterus.
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Affiliation(s)
- Anne-Sophie Bargnoux
- Département de Biochimie et Hormonologie, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Nils Kuster
- Département de Biochimie et Hormonologie, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Thibault Sutra
- Département de Biochimie et Hormonologie, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Laëtitia Laroche
- Département de Biochimie et Hormonologie, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Annie Rodriguez
- Département de Biochimie et Hormonologie, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Marion Morena
- Département de Biochimie et Hormonologie, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Leila Chenine
- Département de Néphrologie, Dialyse et Transplantation, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | | | - Anne-Marie Dupuy
- Département de Biochimie et Hormonologie, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Stéphanie Badiou
- Département de Biochimie et Hormonologie, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Jean-Paul Cristol
- Département de Biochimie et Hormonologie, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
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