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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