Canusingpointofcarebloodtestshelpinformdecisionmakinginpatientsover65presentingwithacutefrailtysyndrome?
We aim to improve the decisionmaking for common frailty conditions by introducingpointofcare(POCT)bloodtestsintotheemergencyservices.Weaimtoimprovepatientdischargeonsceneandre-contactratesaswellasincreaseclinicianconfidence.
PROJECTLEAD:Dolly(Melinda)McPherson–SpecialistParamedicPractitioner
ClinicalSupervisor–DrDavidClarke,RoyalBerkshireHospital
WokinghamCCGUrgentCareBoard–CarolynLawson
ACPFellowshipTeam–RobWay,JulietThorogood
SouthCentralAmbulanceService–KirstinWillis,PennyMeadley
OxfordAcademicHealthScienceNetwork–JulieHart
YorkHealthEconomicsConsortium–NickHex
©OxfordAcademicHealthScienceNetworkwww.healthandwealthoxford.org
Summary
Thenational‘see,treatanddischarge’ratesforparamedicshasincreasedhowever,despitethisincreaseddemand
onparamedicdecisionmakingtherehavebeenlimitedimprovementstopre-hospitaldiagnostics.Patientsoverthe
age of 65 years presenting with acute frailty syndromes are a notably complex clinical patient group for which
informedriskstratificationinclinicalreasoningisparamount.
ThiswasasinglesitequalityimprovementprojectusingPointofCarebloodtestingtohelpinformdecisionmaking
forpatients>65presentingwithacutefrailtysyndromes.
Results fromthisquality improvementproject intotheuseofPointofCaretesting (POCT)showedaself-reported
improvedconfidenceincliniciandecision-makingandpatientdisposition.Thisconfidencewasvalidatedbyimproved
dischargeonsceneandre-contactrates.Anunintendedoutcomeoftheprojectwastheaccumulationofpractical
knowledgeontheuseofPOCTinthepre-hospitalarena.TheseresultsshowpromisefortheongoinguseofPOCTin
the pre-hospital environment, however are not without limitations. Pre hospital services wishing to implement
POCTshouldfocusoncorrectdemographicidentificationandtrainingandinterpretationofresults.
- Point of care testing is an emergent theme for emergency services but todate there is limitedpublished
evidenceonitsusewithinthisenvironment.
- Patientspresentingwithacutefrailtysyndromescanpresentclinicallycomplexdecisionsregardingonward
careandreferral.
- ThisQuality improvementproject aimed to improve clinician confidenceanddecisionmaking forpatients
presentingwithacutefrailtysyndromes.
- During its implementation many lessons were learnt regarding the use of POCT in the pre hospital
emergencycareenvironmentthatmaybeusefulforotherservicesconsideringPOCT.
- TheresultsoftheprojectshowedpromisefortheongoinguseofPOCTandthefieldoffrailty.
- Theoverall result of the roll out scenario is anet savingof £50,159. With696patients treatedover this
period,thisgivesanetsavingperpatientof£72andgivesaROIforthisscenarioof:4.6.
Introduction
Point of care blood testing (POCT) is an expanding worldwide market13 that has become an established part of
serviceimprovementproposalswithintheNHStoreduceEmergencyDepartment(ED)times,lengthofhospitalstay
andimproveillnesspreventionschemes14.IntheUnitedKingdom(UK),PointofcareInternationalNormalisedRatio
(INR)testinginprimarycarehasbeenatopicofresearchsincetheearly1990’s11andpointofcarelactatemonitors
are being trialled for early sepsis guided therapy15.UK ambulance services have been identified as a service that
wouldbenefit fromPOCTtoguidepatientmanagementandcarepathways 9.10,13however there is littlepublished
evidence on the uses, benefits and health economics of POCT in the pre-hospital environment. This paper will
discussaqualityimprovementprojectutilisingPOCTtoaiddecision-makinginpatientsovertheageof65presenting
toSouthCentralAmbulanceservicewithacutefrailtysyndromes.
Thenational‘see,treatanddischarge’ratesforparamedicshasincreasedsincethe‘Takinghealthcaretothepatient’
report in20058withdischargeonsceneratesrisingby4%overthe last6years18.However,despitethis increased
demand on paramedic decision-making there have been limited improvements to pre-hospital diagnostics. The
committeeondiagnosticerrorinhealthcare6identifydiagnostictestingasanintegralpartofthediagnosticpathway
andnotethataclinician’sabilitytoriskstratifycanbeaffectedbyaccesstoresults.
Patientsovertheageof65yearslivingwithfrailtyareanotablycomplexclinicalpatientgroup3forwhichinformed
riskstratification inclinical reasoning isparamount.Thispatientgroupcanpresent to theambulanceservicewith
acute frailtysyndromesthat requirecarefulassessmentandmanagement toavoid lossof independence, function
andmedical deterioration16. The combination of reduced diagnostic aids and clinical complexities in this patient
grouphaspotentialtoincreasetheriskofpoordecision-makingandnegativepatientoutcomes6.Intheambulance
service thismay translate into unnecessary admissions to the Emergency department (ED) or deterioration after
dischargeonscene.Pointofcarebloodtestingisanaturaladditiontothediagnosticrepertoireofaparamedicdue
toitscommonusewithinstandardreferralsitessuchasemergencydepartmentsandprimarycareservices.
Acutefrailtysyndromesaredefinedasseeminglybenignsymptomsthatcanmaskseriousunderlyingillness.These
areidentifiedasfalls,immobility,confusion/delirium,incontinenceandsusceptibilitytosideeffectsofmedications3.
Fallsarethemostcommonlyencounteredacutefrailtysymptomwithintheambulanceservice7.Intheolderperson,
falls are typically multifactorial and consideration should be given to environmental causes, underlying illness,
polypharmacy, neurological impairments, gait and balance decline and visual impairments16. Whilst the
comprehensive geriatric assessment and falls risks assessments can be carried out in the absence of laboratory
results4, it is important to identify health problems that may increase the risk of falling16. Altered or deranged
laboratoryresultsmayindicatemedicationssideeffectsorunderlyingillness2.
Observation from practice identifies that patients with frailty in the emergency department are commonly
investigatedwithbasicbloodtests,ECGs,observationsandphysicalexamination.Intheabsenceofbloodtestsinthe
prehospitalenvironmentstaffmaybesusceptible tooversensitivetriageof thispatientgroup,which in turncan
contributetoinappropriateadmission21.Admissiontohospitalresultsinpoorfunctionaloutcomesforpatientsliving
with frailty4 thus increasing the need to avoid unnecessary admission from the pre-hospital environment. This
knowledgeprovidedthebasisforformulationofthisqualityimprovementproject.
HorizonScanning
Resultsofapreliminaryliteraturesearchrevealedthatthereisapaucityofevidencedocumentingtheuseofpoint
ofcarebloodtestingdevicesintheoutofhospitalenvironment9,10,13.Themostnotableuseofpre-hospitalpointof
care testing is the Labkit® Near Patient Diagnostics service testedwith Surrey pathology services and South East
Coast ambulance service. This project involved a three-phase trial that researched effective functionality, pre-
hospital suitabilityand impactonpatientmanagement20, theoutcomesofwhichareunclear.Todate, therehave
beennopeer-reviewedpublicationsofthisprojecttoguidetheuseofPOCbTinfutureprojects.
Diserioetal9,10conductedtwoseparatetrialsintotheuseofPOCbTinprehospitalservicesinGermany.Thefirst
using i-STAT troponin I to facilitate the early identification of Non ST Segment Elevation Myocardial Infarction
(NSTEMI) and the second tomonitor critical care patients during Helicopter EmergencyMedical Services (HEMS)
transfertohospital.ThetroponinstudyfoundthePOCTresultstobeaccuratebutnotdiagnosticduetothecommon
requirementforserialtroponinmonitoringinhospital9.ThesecondstudyintouseofPOCTonHEMSinterhospital
transfers identified a need for transfer of real time results to achieve patient benefit10. Both studies lack
transferabilitytotheUKpre-hospitalseeandtreatmodelduetotheirfocusoncriticallyillpatientswhosetrajectory
ofcareispre-determinedbytheirpotentialorrealisedillness.
CurrentprojectsusingPOCTincludetheOxfordAcademicHealthScienceNetwork(AHSN)collaborationwithOxford
Health NHS Foundation Trust using POCT in the out of hours primary care environment, ambulatory units and
emergency medical units14. And numerous other pre hospital services who anecdotally report using POCT
throughouttheUKbuthavenotpublishedevidenceontheirexperiencesorfindingsforwiderlearning.
Evaluationofi-STATAlinitydevice
Oxford AHSN provided the devices and cartridgesfortheevaluation.Weassessedtheimpactonsaferdischarges, earlier disease management andincreasedclinicianconfidence.
Only trained operators used the Abbott iStat forpatientsover65presentingwithacomplaintoffallsor immobility or confusion and had an uncertaindispositionpoststandardexamination.
Theprojectaimedtoimprovepre-hospitaldiagnosticsforpatientspresentingtotheambulanceservicewithacute
frailtysyndromes. Itwashypothesizedthataccesstocertainbloodresultswould increasetheabilitytomakesafe
andconfidentdischargeswhilealsoensuringthatalteredbiochemistrycouldbeinvestigatedappropriatelyeitherby
primarycareprovidersoremergencyphysicians.
Themainobjectiveswere:
• Saferdischarges(measuredbyre-contactratesandresultsaffectingdecision-making)
• Earlierdiseasemanagement(measuredbyonwardreferralsandhospitallengthofstay)
• Increasedclinicianconfidence(measuredbyselfreportinresponsetoqualitativequestions)
ThiswasasinglesitequalityimprovementprojectimplementedfromSeptember2017toMarch2018withinanNHS
ambulance service. Four specialistparamedicsand four frailtyparamedicswere trained in theuseof theAbbot i-
STAT Alinitywith CRG4+ and CHEM8 cartridges providing Venous blood gas (VBG), Urea and Electrolytes (U&Es),
lactate,HaemoglobinandHaematocrit.
Patientswereeligibleforinclusioniftheywere>65yearsoldwithapresentingcomplaintofFallsORimmobilityOR
confusionandhadanuncertaindispositionpoststandardexamination.Patientswereexcluded fromPOCT if their
carepathwaywasclearfromstandardexaminationorincaseswherePOCTwouldnotmakeadifferencetoonward
careordecision-making.
Trained staff could use POCT during their normal duties for any patient that met the inclusion criteria or could
receivereferrals. InadditiontouseondaytodaySProtasthe i-STATAlinitywasusedweeklyonafallsandfrailty
responseserviceduetoitsabilitytoattracttherequireddemographicandincreasetheimpactoftheQIP.
Staffweretrainedintheuseandinterpretationofresultsfromthedevice.Referencerangescompatiblewithlocal
pathology services were programmed to the i-STAT Alinity with abnormal and critical results differentiated.
Abnormal ranges automatically highlighted amber whilst critical results were highlighted red. In recognition of
normallyabnormalbiochemistryandhaematology inthispatientgroup,accesstotheBerkshire IntegratedClinical
Environment(ICE)portalwasobtainedtocomparepre-existingresults.AccesstoGPadviceprovidedasafetynetto
the learning process of results interpretation and staff were encouraged to use this. Results were recorded on
ambulanceserviceelectronicpatientsrecords(EPR)withverbalhandovertohospitalorprimarycareclinicians.
StaffcompletedanonlinesurveyaftereachuseofPOCTansweringthefollowingquestions:1-Patentgender,2-
Presenting complaint, 3 -Was there uncertainty about patient disposition prior to POCT? if notwhywere bloods
done?4-DidPOCTassistdecision-making?IfNo,whynot?5-Whereanylaboratoriesabnormalitiesdiscovered?If
yes, did these require action? If yes, what action was taken? 6 - Patient disposition? Home/ED/GP referral and
home/GP referral and ED, 7 - Overall to you feel that access to POCT results improved your (or your colleagues)
confidenceindisposition?
Priortothepilot/evaluationstartdate,laboratorystaffattheJohnRadcliffeHospitalvalidatedandsetupthedevice
carried out the installation with connectivity to LIMS & EPR; full documentation was written including standard
operatingprocedures,andtrainingandestablishmentofstaffcompetency.
Results
Thequalityimprovementprojectrecruited78patientsaged65yearsto97years(Average85yearsold).Genderwas
female51.3% (n=40)andmale48.7% (n=38)with79.5% (n=62)ofpresentingcomplaintsbeingattributed to falls.
Clinicians reported uncertainty in disposition 85.6% (n=67) of the time prior to POCTwith decision-making being
improvedin84.6%(n=66)ofcasesandimprovedconfidenceindispositionreportedin75.6%(n.59)ofcases.
Resultsoutsideofreferencerangeswerefound in55.1%(n=43)of thecaseswith53.5%(n=23)of theserequiring
clinical referral or action, of which 60% (n=14) required transportation to the emergency department with the
remainderreceivingaprimarycareoroutpatient frailtyspecificreferral.Outpatient frailtyreferralsweretoa falls
clinic,Parkinson’sspecialistteamorarapidaccessclinicfortheolderperson.PatientsadmittedtotheEDwereall
subsequentlyadmittedunderspecialtyintohospitalwithameanlengthofstayof4.4days(range1-29days)whilst
thosedischargedonscenehada5.1%(n.4)rec-ontactratewithin48hours,a11.5%re-contactratewithin7days.
Discharge on scene and re-contact rates from the 2016 falls and frailty response project without POCTwere on
average49.7%fordischargeonscenewitha7dayre-contactrateof14.7%5.
CASE1
An84-year-oldfemalewithlearningdifficulties,HTNandosteoporosispresentingwithanexplainedfallintheearlyhours
of themorning. On initial assessment the patientwas uninjured, fullymobile, alert and orientatedwith a slightly raised
respiratoryrateandSP02OF88%.Initialthoughtwasgiventoprovidingoralantibioticsanddischargingonscenehowever
POCTresultswhencomparedwithresultstaken10daysearlier(viatheICEportal)revealedaNaloweredto122from136,a
Hb lowered from 128 to 82 and respiratoryacidosiswithmetabolic compromise.With thesenew findings itwas deemed
necessarytoadmitthepatienttotheemergencydepartmenttoinvestigatetheunderlyingcauseoftheseacutefindings.The
patientwassubsequentlyadmittedtothemedicalteamfromEDwhoprovidedpositivefeedbackregardinguseofPOCTon
thisjob.
CASE2A92-year-oldfemalepresentedtotheambulanceserviceafteranon-injuryfall.Shewasseenbyanambulancecrewwho
referredtothefallscarasthepatientwasaregularfalleranddidnotappeartohavehadanyinputfromthefallsteamand
didnothaveanypackageofcare.ThecrewhaddiscoveredaBPof218/98howeverthepatienthadrefusedadmission.On
examinationherBPremainedelevated,butthepatientwasasymptomaticandPOCTdiscoveredaHbof84.Thepatientwas
reportingsomefatiguebutnoheart failuresymptomsandhadnothadafullbloodcountsince2015.Areferralwasmade
backtoherGPwhoadvisedanincreaseinBPmedicationandbookedareviewofHb.Wesawthisladyagainafewmonths
laterduetoanotherfall,herBPwasnowmanagedwithinnormallimitsandherHbhadimproved.
Outcomes
Results from this quality improvement project showed a self-reported improved confidence in clinician decision-
makingandpatientdisposition.Thisconfidencewasvalidatedbyimproveddischargeonsceneandre-contactrates,
andbypatientonwardmanagementpostreferral.TheseresultsshowpromisefortheongoinguseofPOCTinthe
pre-hospitalenvironmenthoweverarenotwithoutlimitationsandshouldnotbeinterpretedatfacevalue.
Theresultsyieldedahighpercentageofreported increasedconfidenceand improveddecision-makingthroughout
theproject.Theyes/noformattomeasurementofconfidencemayoverstatetheoverallimprovementhoweveronly
limited cases reported no increase in confidence. Resultsmay also have been affected by trained staff becoming
acclimatisedtotheusePOCTandthereforebecomereliantonresultstomaintainthesamethresholdofconfidence
indischarge.
A significant number of tests returned results outside of reference ranges but not all required clinical action or
referral.Thosethatdidnotrequireactionwereresultsthatcouldbeconfirmedasnormallyabnormalorcouldbe
explainedbypreviousmedicalhistoryandcomorbidities.Interpretationofresultsrequiredcomplexclinicaldecision-
makingandshouldbethefocusofanyfurtherprojectsutilisingpointofcarebloodsinthepre-hospitalenvironment.
Forexample,identificationofarespiratoryacidosismaybeattributedtoachronicconditionsuchasCOPDormaybe
attributabletoaseverepneumonia10eachrequiringadifferentpathwayofcare.
CASE3An 87-year-old female presentingwith her second fall within a week.Her observations and physical examinationwere
within normal limits however family were concerned about her recent increase in falls. Point of care bloods revealed a
metabolicalkalosiswithmildhyponatraemiasecondarytoindapamideuseforhypertension.ThispatientsGPwascontacted
andthepatientsindapamidestoppedforashortperiodoftimewithrepeatbloodsinthecommunityscheduled.Inaddition,
thepatients’bloodpressurewouldbereviewedwhilststoppingtheindapamide.Thispatientdidnotcontacttheambulance
servicewithinthenextmonth.
CASE4Crewreferralforpointofcarebloodtestsand‘fallsandfrailtycar’.This94year-oldfemalepatientwithdementiahadan
unknownlengthoftimeonthefloorafterbeingfoundbycarersonthefloorinthemorning.Duetoknownvasculardementia
thepatienthadno recollectionof the fall butwasuninjured,mobilisingasnormalandhadno clinicalsigns, symptomsor
history making her high risk for collapse of unknown cause. Carers stated that patient has previously not had good
experienceswithadmission.Undernormalconditionsintheabsenceofpointofcarebloodtestingthispatientwouldneed
conveyingforCK levels toexcludeacutekidney injurysecondary to rhabdomyolysis from the long lie.Pointof carebloods
enabledus to compareCreatinine levelswitha recent result (1weekearlier)andapply theRIFLE criteria foracutekidney
injury.AstherewasnoacuteriseincreatinineaGPreferralwasmadetodoarepeatsetofrenalfunctionbloodstoensure
nochangestothis.
Whilst there is a perceived improvement on discharge on scene and re-contact rates when POCTwas utilised it
wouldbedifficulttodeterminecausationduetocofoundingvariablessuchastargetedpatientselection,partnership
with the falls and frailty response scheme and advanced assessment and clinical reasoning of the specialist
paramedicrole.
Anecdotally, cases that showed the most benefit from the use of POCT were those that involved patients with
significant cognitive impairment or those that were uncooperative to thorough physical exam or history taking.
Cliniciansreportedthatthecombinationofbiochemicalandhaematologicalmarkerswithhistory,observations,ECG
and physical exam more accurately identified patient acuity thus assisting decision-making. Cases that did not
benefitfromuseofPOCTwerethosethatrequiredassessmentofinfectionandtheidentificationofsepsis.Dueto
thelackofinflammatorymarkers(WhiteCellCount(WCC)andC-ReactiveProtein(CRP))inthei-STATAlinityassays
thesecasesoftenreturnednormalresultsyethadahighre-contactrate.Lactateintheseinstanceswasnotuseful
duetoitsindicationofhypoperfusioninsteadofinflammationandassuchwasonlyraisedinsepticshock1.Dueto
thisrecurrentthemestaffwereadvisednottoutilisePOCTtoassistdecision-makinginthesecases.
Considerations
AnunintendedoutcomeoftheprojectwastheaccumulationofpracticalknowledgeontheuseofPOCTinthepre-
hospitalenvironmentfordisseminationtootherserviceswishingto implementsimilarprojects.Specificareasthat
should be considered by these services are the initial set up, maintenance of the device and cartridges, correct
demographicidentificationandtrainingandinterpretationofresults.
Initialsetupshouldensurethatactionrangesareconsistentwithlocalhospitalsandpathologylaboratoriestoavoid
inappropriate referrals. Highlighted action ranges are recommended as they assist in quick interpretation and
reductionofhumanfactorserrors.Forthebenefitofdatagatheringandavoidanceofduplicationofinvestigations
the i-STAT Alinity should have access to a networkwhen docked for chargingwith results transmitted to a local
pathology.
Duringprojectdevelopment,thetargetdemographicshouldbecarefullyconsideredtomaximisehealtheconomics.
Thisprojectaimedto facilitatedischargeonsceneand/orearlierdiseaserecognitiontoreducetheoverallcostof
care.Withtheinitialfinancialoutlayofdevicecostandtheongoingcostsofcartridgesitisunlikelythattheaddition
ofanyPOCTdevicetoallambulancevehicleswithouttargeteddemographicswillbearealisticfutureaim.Theuse
of specialist services suchas specialistparamedics, team leaders, clinicalmentorsor critical careparamedicsmay
targetitsusesufficientlywithoutdefiningthepatientdemographictooclosely.
Maintenance of the device, cartridges and project pose logistical challenges for pre-hospital services. The i-STAT
Alinity requires a device temperature of >15 degrees Celsius to operate which can cause some delays on scene
duringthewintermonths.Inaddition,cartridgesmustbekeptstrictlybetween2-8degreesCelsiusforstorageand,
oncewarmedtoroomtemperaturepriortouse,haveareducedexpirytime(CRG4=2months,CHEM8+=14days)
and cannot be returned to cold storage. This could pose problems for ambulance stations whomay not have a
securetemperaturemonitoredfridgethatcouldbeused.
Finally, appropriate training and interpretation of results significantly affects the outcomes of patients and the
project.Accesstopre-existingresults is invaluabletotheadequate interpretationofpatientsresultsandclinicians
shouldhaveaccesstoseniormedicaladviceduringtheuseofPOCT.
Economicanalysis
YorkHealthEconomicsConsortium(YHEC)carriedoutaneconomicanalysisofthispilot.Theaimofthisevaluation
is to informabusinesscase todemonstrate thevalueofPOCTto the localClinicalCommissioningGroups (CCGs).
The evaluation is a cost-consequences analysis with results expressed as cost savings per patient. A return on
investmentwasalsocalculated,basedupontheincrementalcostsoftheintervention.
Methods
The Specialist Paramedic Practitioner (SPPs) participating in the POCT pilot filled in a data capture form for each
patient. This formwas designedby SCAS to providedata for the evaluationof thepilot, including the economic
evaluation.
ThekeymeasuresthatindicateabenefitfromtheuseofPOCTweredefinedas:
• Hospital avoidance – measured as the number of times POCT confirmed discharge when clinicians were
unsureinpriorassessment;
• Saferdischarge–measuredasreductioninre-contactrates(48hoursand30days)andreductioninhospital
stays;
• Earlier disease management – measured as the number of detected abnormalities requiring correction
(presumedtobemissedintheabsenceofPOCT);
• Clinicianconfidence–measuredasimprovedreportedconfidencelevelswhenusingtheiSTATdevice.
Oncompletionof thepilot, the full datawereprovided toYHECwhohaveundertakenananalysis to identify the
impacton these indicatorsand toassignappropriateeconomicvalues to them. Theeconomicvalueswere taken
fromrecognisedsources,suchasthenationalPaymentbyResultstariffsforEDattendancesandhospitaladmissions
andstaffcostsreportedbythePSSRUUnitCostsofHealthandSocialCare.
In the case of hospital avoidance, it is assumed that this includes avoidance of ED attendance and avoidance of
hospitaladmissionsthatmayresultfromEDattendance. Inthecaseofsaferdischarge,re-contactswererecorded
duringthepilotasoccurringwithin48hoursand1week,asopposedto48hoursand30days,asspecified inthe
original statementof indicators, citedabove.Forcomparisonwith standardpractice,datawereprovidedbySCAS
from the Reading, Newbury & Bracknell area, on patients who presented with falls, from December 2016 and
February 2018. These data include categorisation of the number of patients treated on scene and the number
conveyed. Forthesameperiod,thenumberofpatientswhore-contactedtheservicearealso included. Toavoid
thepotentialbiasfromincludingtwowinterperiods,oneyearofdatawasusedintheanalyses(February2017to
February2018).DatawasalsoprovidedbySCASonaFallsandFrailtyResponsepilot,which involvedSPPsandan
OccupationalTherapistandwhichtargetedpatientsover65whohadhadfalls.Thedataonthispilotwerereported
inAugust2016.Dataon thecostsof running thepilot, including thecostsof thePOCTdeviceand thecartridges,
wereobtainedfromSCAS.
Costs
AtotalofeightSPPsweretrainedintheuseoftheiSTATdevice.Formaltrainingisestimatedtotakeabouthalfa
day. SCASprovidedacostof£18perhour forSPPs. However,as staffonBand6of theAgenda forChangepay
scales,thefullcost,includingsalaryoncostsandoverheads,isgivenelsewhereas£43perhour.Othercostsforthe
pilotare:theiSTATdevice;thetwotypesofcartridge;andafridge.Thecartridgesarepurchasedinbatchesof25,
butthecostpercartridgedoesnotchangewiththenumberofbatchespurchased.Thesecostsareincorporatedin
thetable1,showingthefullestimatedcostsofthepilot.
Table1. CostsofthePOCTpilot
Unitcost(£) No.ofunits Total(£)
iSTATdevice 6,500.00 1 6,500.00
Fridge 100.00 1 100.00
Chem8Cartridges 5.48 77 421.96
CRG4+Cartridges 3.32 77 255.64
Sub-totaldevicecosts 7,277.60
Training8SPPsa 1,204.00
Totalcostofpilot 8,481.60
Thisgivesacostpereligiblepatientseeninthepilotof£110.15.Itisassumedthatallofthesepatientsweretested
usingPOCT,despitesevencaseswhereitisstatedthattherewasnouncertaintyaboutpatientdispositionpriorto
testing.
Outcomes
EconomiccostsandbenefitsforincreasingnumbersofSPPs:
ThispilotwascarriedoutbythreeSPPs,whereaseighthadbeentrained,indicatingthatalargerscalerolloutofthe
programmewouldbesoughtinfuture.Usingthecostsandbenefitsidentifiedinthispilot,itispossibletocalculate
whattheresultswouldbeofapilotwithlargernumbersofSPPs,butwithallotherelementsthesame.
Thebenefits fromgreater scale canbeexpected to increase in linear fashion,witha stablebenefitper SPP. The
costs,ontheotherhand,willnotallvaryinthesameway.Runningcosts(suchasChem8andCRG4+cartridges)will
increaseinalinearfashion,buttheset-upcosts(theiSTATdevice,thefridgeandthetraining)willnot.TheProject
LeadinSCAShasindicatedthatoneiSTATdevicecanbeusedby4-6SPPs.AssuminganaverageoffiveSPPscanuse
eachdevice,anewonewillhavetobepurchasedforeachsixthuser.TheiSTATdeviceisthehighestcostiteminthe
projectset-upresultinginamarkedsteppedcostprofileasthepilotincreasesinsize.AstheiSTATdeviceisshared
bymoreSPPs,thecostperusedecreasestothepointthatbreak-evenisjustaboutreached,beforeanewdevicehas
tobepurchasedtocontinueincreasingthesizeofthepilot.
Economiccostsandbenefitsforincreasingpilotlength:
Thepilotranfrom25/09/2017to06/03/2018,whichmeansthatthestart-upcostswereapportionedoveraperiod
ofjustundersixmonths.Ifthepilotwereextendedoveralongertimeperiod,theapportioningofthesecostswould
result in a lower cost per case. This indicates that, with the same resources used in the pilot, the result would
becomeanetsaving,onceithadbeenunderwayforaroundelevenmonths.Thisisdueentirelytoapportioningthe
start-upcostsoveralongerperiodand,consequently,agreaternumberofpatients.
Economiccostsandbenefitsforincreasingpatientcontacts:
TheaveragenumberofpatientsseenperSPPperweekinthispilotwas1.12.Thismaybelowerthanthenumberof
relevantpatientsthataSPPwouldtypicallyseeforanumberofreasons.Pilotsoftentaketimetobedinandworkat
theleveltheywouldwhenaprogrammeisfullyrolledoutandestablished.Thisindicatesthatthepilotwouldhave
producedanetsavingfromapatientcontactlevelof2.3patientsperSPPperweek,onaverage.Inotherwords,ifa
totalof159patientshadbeenseeninthepilot.
Impactofdifferentpercentagesofadmissionsthatareemergencyimpatientadmissions:
ThecostofadmissionsfromEDattendancesusedwas£617,basedon‘non-electiveshortstay’.Ingeneral,avoidable
admissionsarelikelytobeshortstay,butinthecaseofolderpeople,evenarelativelyminorcauseforadmissioncan
resultinalongerstayinhospital.Asaresult,aproportionoftheseadmissionsarelikelytohaveahighercost.To
test the impactof this,apercentageofadmissions fromEDareassumed tobe ‘emergency inpatientadmissions’,
whichhaveacostpercaseof£3,058.Thisfigureindicatesthatthepilotwouldproduceanetsavingifjustunder25%
of admissions from ED were emergency impatient admissions, with the remainder being non-elective short stay
admissions.
NetEconomicImpactofaRoll-outScenario:
To assess the combined impact of the parameters that have been tested above, a scenario has been created to
understandthecombinedimpactoncostsandbenefits. Thissimulateswhattherolloutoftheprogrammemight
look like,usingwhatwebelieve tobe realistic, but conservative, values for eachof these fourparameters,while
maintainingallothercharacteristics stable.Using thesevalues, the rolloutscenariowould result ina totalof696
relevantpatientsbeingseenovertheyear.
Parameter Valueusedinthescenario
Rationale
Sizeoftheprogramme 8SPPs Theoriginalintentionofthepilotwastouse8SPPs
Lengthoftheprogramme 1year Aconservativetimeperiodoverwhichbudgetsavingsmaybesought
PatientcontactsperSPPperweek 1.5patients Aconservativeincrementonthenumberinthepilot
PercentofadmissionsfromEDthatare‘emergency’
15% Aconservativeestimategiventhatpatientsareelderly
Thesamecostsandbenefitsanalysishasbeenundertakenon this scenarioaswasdone for thepilot.Theoverall
resultofthisscenarioisanetsavingof£50,159.With696patientstreatedoverthisperiod,thisgivesanetsaving
perpatientof£72.Usingthecostsandsavingsabove,thisgivesaROIforthisscenarioof:4.6.
SavingsfromavoidedEDattendances £77,265
Savingsfromsaferdischargea -£13,174
Totalsavings £64,091
Totalcostofthescenario £13,932
Netresult £50,159
TheresultsfromthepilotofthePOCTusedbySPPsshowamoderateimprovementintheavoidanceEDvisits.There
isamoderatedecreaseinsaferdischarge,althoughthereislesscertaintyabouttherobustnessofthis.Combining
thesewiththecostsofthepilotresultsinasmallnetcost,withaROIof0.54.
Modifyingsomeoftheparametersinthepilot,toaconservativeestimationofwhatwouldhappeniftheprogramme
wasrolled-out,resultsinanetsavingandaROIof4.6.Theresultswouldmostlikelyshowaneteconomicbenefit
withreasonableincreasesonanyoneofthreeoutofthefourparameterstested:thedurationofthepilot;thelevel
ofpatientcontacts;andtheproportionofhospitaladmissionsthatwouldbeemergencies.Theimpactofchanging
thefourthparameter(thesizeofthepilot)variesaccordingtotheexactvalueoftheparameter,butdoesnotshow
anoverallimprovementorworseningoverthelongterm.
Ithasnotbeenpossibletocalculatetheeconomicbenefitsofearlierdiseasemanagement.Physicianconfidencehas
clearlyincreased,butthereisno,immediate,economicbenefittothis.
Thescenarioforrolloutwasdesignedtobeplausible. However,thehigh levelofattritionofSPPsmaymakethis
uncertain. At the least, there may be higher training costs than used here to account for attrition. These are
modest,however,andwouldnotchangetheoverallnetbenefitofthisscenario.
Thebiggestuncertainties,whichmayhavea significant impacton the result, are thepercentageof EDvisits that
result inadmissionsand thepercentageof theseadmissions thatareemergencies rather thansimpler, short stay
admissions.Forthelatter,aconservativeestimatehasbeenusedfortherolloutscenario,sotheresultsmaywell
under-estimatethenetbenefitofrollingtheprogrammeout.
ThecostsofSPPtimehavenotbeenincludedinthecalculations.Thisisbecausetheevaluationisbasedonacost-
consequences analysis, comparing the pilot to ‘standard care’. It is assumed, therefore, that the SPPswould be
employedbySCASinanycase,withthesameemploymentcosts.
The iSTATdevice isthebiggestsinglecost itembyfar. Intheanalysespresentedhere,purchasingmoreunitswill
result inbig stepchanges in total costs if the scaleof thepilot is increased. If there isanyway inwhicha single
devicecouldbeusedbymoreSPPs,oriftherewereapossibilityofagreeingdiscountsformultiplepurchaseswith
theprovider,thenabettercostprofilecouldbeachievedforanexpandedprogramme.
Theincreaseinre-contactsinthepilotisofsomeconcern.Itisnotentirelyclearfromthedataifsomeofthesehave
been double-counted in the analysis. By the same token, some of the reported re-contactsmay have been for
unrelatedepisodesandthereforedonotreflectunsafedischarge.
Conclusion
Patients>65presentingwithacutefrailtysyndromes(confusion,immobilityandfalls)canbeaclinicallychallenging
cohortofpatientsandassuchmightbetransportedtohospitalforfurtherassessmentandmonitoring.TheBritish
GeriatricSocietynotesthatfrailtysyndromescanmaskseriousunderlyingillnessandassuchthesepatientsrequire
comprehensive investigation. The investigation of patients with frailty in the emergency department typically
involvesbloodtesting,thuscreatinganinequalityofcarebetweeninhospitalandprehospitalpatients.
In conclusion, this quality improvement project showed POCT to have a positive impact on appropriate patient
disposition, clinician confidence and earlier diseasemanagement. The projects results, whilst taken from a small
samplesizeandshowpromisefortheongoingimplementationofPOCTinboththepre-hospitalenvironmentandin
thefieldoffrailty.DisseminationoftheselearningsaimstoleadtoongoingandimproveduseofPOCTwithinother
pre-hospital services ultimately leading to better patient care andoutcomes, improved referrals and greater cost
benefittotheservicesusingthem.
• 78patientsaged65yearsto97years(Average85yearsold)
• Genderwas51.3%(n=40)femaleand48.7%(n=38)male
• 79.5%(n=62)ofpresentingcomplaintsbeingattributedtofalls
• Cliniciansreporteduncertaintyindisposition85.6%(n=67)ofthetimepriortoPOCT
• With decision-making being improved in 84.6% (n=66) of cases and improved confidence in disposition
reportedin75.6%(n.59)ofcases
• Results outside of reference rangeswere found in 55.1% (n=43) of the caseswith 53.5% (n=23) of these
requiringclinicalreferraloraction
• 60%(n=14) requiredtransportationto theemergencydepartmentwith theremainder receivingaprimary
careoroutpatientfrailtyspecificreferral
• Frails&FragilityResponseScheme(Sept16–Feb17)
o Dischargeonscene=49.7%and14.67%re-contactwithin7days
• POCTQIP(Sept17–Feb18)
o Dischargeonscene=82.1%and11.5%re-contactwithin7days
• Theoverall result of the roll out scenario is anet savingof £50,159. With696patients treatedover this
period,thisgivesanetsavingperpatientof£72andgivesaROIforthisscenarioof:4.6.
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