Do the cost-benefit equations include the cost of ED staff time in doing
the tests?
I have always been suspicious of any change in working practice that
dumps more jobs on clinical staff that can, and should be done by non-
clinical staff.
Time-critical stuff (gases, BM, ?troponins, K+), fine. But not the rest.
I had some experience as an SHO in an ED with a gadget which did
amylase, U+E, Hb, CK etc. The labs closed their weekend service and
PRHOs / staff nurses spent their life doing tests that were perhaps not
urgent, but couldn't wait until Monday. Waiting times went through the
roof and the labs quickly re-openend their OOH service.
Modern thin film technology for NPT is quicker and more reliable, but I
still reckon the lab staff should be doing the tests (if needs be in the
ED), rather than put another time demand on front-line clinical staff.

Goat


In article <[log in to unmask]>, Jason Kendall
<[log in to unmask]> writes
>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.

Dr G Ray
A&E
Sussex
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