Hi,
Would you be prepared to send me a copy of your chest pain protocol? I'm
looking for something similar for my service.
Bruce Finlayson
Norfolk & Norwich University Hospital
Colney Lane
Colney
Norwich
NR4 7UY
[log in to unmask]
Thanks
----- Original Message -----
From: "Rocky" <[log in to unmask]>
To: "Bruce Finlayson" <[log in to unmask]>
Sent: Tuesday, March 11, 2003 11:31 PM
Subject: Re: near patient testing
Paul,
Isn't 0.01 reckoned to be a bit low nowadays. The cut-off on this system is
0.02, which I think is good enough. Also, when you also look at the risk
stratification, you're not sending any of the high risk patients home
anyway. I'd be happy to send you a copy of our protocol, if you want.
There's always an over-riding clinical decision at the end. You should
contact the distributors and talk to them.
We use the protocol on all patients - in practice, it's usually an hour or
so (or sometims a lot more) before they get to us. In Craigavon, they keep
the patients for longer than us but I don't see the need if you believe the
myoglobin is very sensitive and very early. All I can say si that we've
been very happy with this system and it has certainly reduced our admissions
significantly. In addition, it's given our SHOs something to use and be
confident in, so they are not sending home high risk patients with atypical
symptoms ( I think).
Cheers,
Rocky.
----- Original Message -----
From: "Paul and Julie Atkinson" <[log in to unmask]>
To: "Laurence Rocke" <[log in to unmask]>
Sent: Tuesday, March 11, 2003 9:15 PM
Subject: Re: near patient testing
Rocky
What is the cut-off level for a positive TropI on your NPT kit?
We ran a study (presented at Edinburgh 02) using the Cardiac Status kit from
Spectral and compared it to lab testing at 7 hours after onset of pain in
ECG-Normal patients - the NPT kit was only 60% sensitive for ACS compared
with 100% for a lab troponin I of >0.01ug/l - not surprising as the NPT
cut-off was 1.5ug/L - diagnostic of AMI but not sensitive for ACS.
Also, do you have a minimum post-pain delay before testing?
Regards
Paul Atkinson
Addenbrooke's
----- Original Message -----
From: "Rocky" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, March 11, 2003 7:05 PM
Subject: Re: near patient testing
We use near patient testing for specific things in our dept. In patients
with cardiac-sounding chest pain, we use a protocol that combines clinical
risk stratification with two serial ECGs and two triple marker panels
(myoglobin, CK-MB, and Troponin I - the Cardiac Triage System from Biosyn
Diagnostics) over two hours. With this we are sending about 60% of these
patients home. We've done well over 200 patients so far, without any
problem, as far as we know. Are just about to do a telephone follow-up but
I suspect we'd have heard about any disasters. If the episode of pain is
more than 12 hours, one test should be enough - gold standard for the wards,
after all.
For patients query PE, we use a clinical risk scoring system and Simplify
D-dimers (ten minutes, £1). We can send home about 25% of these patients
without further testing.
For query DVTs, we use D-dimers along with Wells criteria and compression
USS by Radiology. We use Clexane to keep the patients ambulant until the
USS is done - one to three days. I think a lot of people are doing this, or
similar.
We're hoping to start a project soon looking at the use of B-type
Natriuretic Peptide as a marker (qualitative and quantitative) for heart
failure.
So you do have to choose the types of patients but I think NPT is here to
stay and will become more and more the norm, as tools for us to decide on
admission, placement and discharge of our patients.. I do agree that it's
useless as a blunderbuss (and too expensive to use in that manner).
Cheers,
Rocky
----- Original Message -----
From: "Jason Kendall" <[log in to unmask]>
To: "Laurence Rocke" <[log in to unmask]>
Sent: Tuesday, March 11, 2003 9:35 AM
Subject: Re: near patient testing
> Near Patient Testing is NOT the complete solution to faster treatment /
> disposition decisions / transit times / improved outcome, etc. It may,
however,
> have a definite role in certain situations.
>
> If NPT of a "critical care profile" (biochem, haematology and ABGs) is
applied
> to an unselected population of emergency department patients (i.e. all
those
> that require an urgent blood test), it will not make a significant
difference in
> terms of transit time or clinical outcome (mortality or length of hospital
stay)
> to the group as a whole in a typical UK ED. This is because there are
generally
> many other important factors that need to also be addressed (absence of
> in-patient beds, access to radiology, etc). It does not even appear to
expedite
> discharge, where factors such as organising transport, social
arrangements...
> seem to outweigh any benefits of NPT.
>
> NPT does improve processes of care by significantly improving turnaround
time
> and expediting therapeutic decision making. This benefit seems to get
lost,
> however, when trying to translate this into measurable improvements in
outcome
> in the population as a whole. There may be benefit in certain selected
> sub-groups of patients (we all appreciate the benefit of NPT for glucose,
for
> example, although this is clearly already well established). The problem
is that
> this technology is expensive (see below) and is most likely to be used
fairly
> indiscriminately whenever results are required "urgently".
>
> It is definitely NOT cost-effective if implemented piecemeal within a
trust
> (i.e. just in the ED, for example). There will be no savings in fixed
costs
> within the central laboratory, and the overall effect is to make testing
> everywhere else in the hospital more expensive. If there is the motivation
and
> political will (amongst the pathologists!) to completely change testing
within
> the hospital more widely, implementing NPT in the ED, MAU, CCU, ITU,
theatres...
> then there is a definite economic argument for this, since fixed costs in
the
> central lab can be reduced (i.e. sacking technicians).
>
> The above arguments are very generic, and local factors are very
important. If
> your central lab service is very poor, you don't have resident MLSO's,
need to
> stick samples in taxis... then any of these factors will increase the case
for
> NPT, because they will influence the clinical or economic issues.
>
> Specific conditions, such as NPT for chest pain will depend critically on
the
> service that you get from your lab. We get access to 24 hour urgent
troponins
> from our lab, and it is likely that the time saved in turnaround with NPT
(of
> the order of 60 mins) would not outweigh the economics of NPT,
particularly
> since the decisions made based upon troponins are not immediately "time
> critical" - i.e. discharge decisions for rule-out, and commencement of Gp
> IIB/IIIA for rule-in. If your lab offers a poor service by batching
troponins,
> however, then there is a powerful argument for NPT, because the potential
for
> time savings and admission prevention is huge.
>
> Jason Kendall.
>
> "Dunn Matthew Dr. (RJC) ACCIDENT & EMERGENCY - SwarkHosp-TR" wrote:
>
> > Jason Kendall has done a huge amount of work on near patient testing in
A
> > and E. My understanding from one of his presentations was that it wasn't
as
> > cost effective as one would hope (or in my case expect). Anyone from
Bristol
> > able to update us on what the line is?
> >
> > Matt Dunn
> > Warwick
> >
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> > The opinions expressed in this email represent the views of the sender,
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