Nursing

Point-of-Care Testing for the Emergency Department Patient

Quantity and Quality of the Available Evidence

David N. Alter, MD

� Context.—Point-of-care test (POCT) instruments pro- duce lab results with rapid turnaround times. Based on that fact, emergency department (ED) POCT requests are predicated on the belief that rapid test turnaround times lead to improved care, typically a decreased ED length of stay (LOS).

Objective.—To compile the available peer-reviewed data regarding use of POCT in the ED with an emphasis on ED-LOS.

Data Sources.—An English-language PubMed search using the following free text terms: (‘‘EMERGENCY’’ AND ‘‘POINT OF CARE’’) NOT ULTRASOUND as well as ‘‘RAPID INFECTIOUS DISEASE TESTING.’’ In addition, the PubMed ‘‘similar articles’’ functionality was used to identify related articles that were not identified on the initial search.

Conclusions.—Seventy-four references were identified

that studied POCT ED use to determine if they resulted in significant changes in ED processes, especially ED-LOS. They were divided into 3 groups: viral-influenza (n ¼ 24), viral-respiratory not otherwise specified (n ¼ 8), and nonviral (n ¼ 42). The nonviral group was further divided into the following groups: chemistry, cardiac, bacterial/ strep, C-reactive protein, D-dimer, drugs of abuse, lactate, and pregnancy. Across all groups there was a trend toward a significantly decreased ED-LOS; however, a number of studies showed no change, and a third group was not assessed for ED-LOS. For POCT to improve ED-LOS it has to be integrated into existing ED processes such that a rapid test result will allow the patient to have a shorter LOS, whether it is to discharge or admission.

(Arch Pathol Lab Med. 2021;145:308–319; doi: 10.5858/ arpa.2020-0495-RA)

Point-of-care test (POCT) instrument requests are typi- cally predicated on the premise that faster results will a

priori lead to better inpatient care secondary to quicker and targeted treatment. Rapid test result turnaround time, that is, POCT, can and does improve care when a result is required for a time-sensitive clinical action, for example, blood glucose immediately prior to meals for appropriate timing and administration of insulin dose. However, whether or not POCT actually improves overall inpatient care has not yet been conclusively proven in the literature. Emergency department (ED) POCT requests hypothesize that a rapid test result will not only speed up diagnosis, treatment, and management but will also necessarily and importantly lead to overall decreased ED length of stay (ED- LOS).1,2 Decreased ED-LOS per patient translates into faster patient throughput, less ED crowding, improved patient treatment, and overall better use of ED services.1, As

with the inpatient experience, it is not clear if faster POCT results improve ED patient care management, leading to shortened ED-LOS, nor is it obvious how much data exist to support that claim and for what tests and/or disease conditions. The purpose of this review was 3-fold; (1) to compile the existing peer-reviewed ED POCT implementa- tion literature; (2) to describe how often POCT use resulted in significant changes to the management of the ED patient, especially ED-LOS; and (3) to provide readers with a handy tool tracking what tests/conditions have been studied in the ED using POCT and how successful it was or not.

MATERIALS AND METHODS

An English-language PubMed search was performed using the following free text terms: (‘‘EMERGENCY’’ AND ‘‘POINT OF CARE’’) NOT ULTRASOUND (there was a large number of studies regarding the use of ED point-of-care ultrasound). In addition, a vein of studies associated with POCT (but not described as ‘‘point of care’’) was identified in the area of rapid infectious disease (predominantly influenza) testing. After the initial free text search, the PubMed ‘‘similar articles’’ function was used to identify related studies that avoided the searched free text terms. References were then reviewed to select out those that studied changes in ED processes secondary to introduction of POCT. For a reference to be included it had to be designed such that parameters were compared between POCT and non-POCT tested ED populations. Inclusion of ED-LOS as a studied metric was not a requirement. Excluded references consisted of those that compared ED-POCT to central

Accepted for publication October 8, 2020. From the Department of Pathology and Laboratory Medicine,

Emory University School of Medicine, Atlanta, Georgia. The author has no relevant financial interest in the products or

companies described in this article. Corresponding author: David N. Alter, MD, Department of

Pathology and Laboratory Medicine, Emory University School of Medicine, 1364 Clifton Rd, Atlanta, GA 30317 (email: Dnalter@ emory.edu).

308 Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter

laboratory test characteristics or demonstrated new methodologies with hypothesized ED uses.

Selected references were then sorted by test/condition, with further distinction into studies that reported significant changes or not with special attention given to ED-LOS. Additional reported parameters (regardless of significance) included but were not limited to inpatient LOS, change in testing practice, change in treatment plan, disposition, or use of additional diagnostic services. Identified relevant systematic reviews of existing studies were also included in the literature review and were used as benchmarks against the findings in related individual studies.

RESULTS

A total of 1764 references were initially identified. After reference review (abstract and entire study), 74 studies were selected for further review. All demonstrated that POCT results were resulted and reported faster than similar results generated in the central laboratory. The references were then sorted by test/condition into 3 categories; viral- influenza (n ¼ 21,3–23 with 3 systematic reviews24–26; Table 1), viral-respiratory not otherwise specified (n ¼ 4,27–29,34

with 4 systematic reviews30–33; Table 2) and nonviral (n ¼ 41)35–72,74–76 tests/conditions, including a systematic review related to lactate use73 (Table 3).

The ‘‘nonviral’’ group was further subdivided into the following test/condition groups: chemistry (n ¼ 21)45–65; cardiac (n¼ 10)36–44; C-reactive protein (n¼5)66–70; lactate (n ¼ 2)73–75; drugs of abuse (n¼ 1)72; renal (n¼ 1)76; pregnancy (n¼1)75; bacterial/strep (n¼1)35; and D-dimer (n¼1).71 The ‘‘chemistry’’ group took into account POCT instruments designed to test the following analytes in combination or individually: sodium, potassium, chloride, bicarbonate, glucose, creatinine, alkaline phosphatase, alanine amino- transferase, aspartate aminotransferase, bilirubin, amylase, albumin, total protein, human chorionic gonadotropin, pO2, pCO2, and pH. In some of these studies, cardiac markers (CK-MB, troponin I, and/or myoglobin) were part of the chemistry menu,45,46,53–55,57,60,62 but it was clear from the discussions that they were focused more on general POCT instead of a cardiac evaluation per se.

Tables 1 through 3 summarize each study with a brief description of design and findings, annotated, as necessary, with clarifying comments, such as major reported significant and relevant nonsignificant findings as well as comments regarding the author’s use of the term ‘‘significant’’ if the data did not appear to be statistically significant. These summaries are not granular in detail but are provided to give the reader a sense of each study. Readers are encouraged to review the articles themselves to determine if they answer a specific need.

In addition, these tables track in 2 separate columns the following: (1) ED-LOS finding (significant/nonsignificant) and if ED-LOS was not reported in the study (ie, unknown if studied or not); and (2) if no other parameters were studied (yes/no) or not, and if any of them were significant or not as well.

As noted in the viral-influenza group and seen in the systematic reviews, there was a trend toward decreased antibiotic use with an increased and earlier use of antivirals. With respect to ED-LOS, the systematic reviews noted no overall decrease in ED-LOS. However, in the viral influenza group, 7 studies3,4,11,14,19,20,22 showed a significant decrease in ED-LOS, with 4 showing no significant change in ED- LOS.6,12,18,21 The remaining 10 studies5,7–10,13,15–17,23 did not report any findings related to ED-LOS.

In terms of the viral-respiratory not otherwise specified studies, 1 study27 with ED-LOS findings had a significant change in ED-LOS but with increased ED-LOS, not decreased, and the other reference29 showed no significant change. Two28,34 additional studies did not report any ED- LOS–related findings. Their related systematic reviews30–33

did not show any improvement in ED-LOS with POCT. Lastly, 1 study34 combined the use of procalcitonin with viral POCT to show that when used in conjunction, antibiotic usage could be reduced.

In the nonvirus category (all groups), 14 studies* showed a significant decrease in ED-LOS, and 12 showed no change.† The remainder (n ¼ 15)‡ did not report any ED- LOS findings. When those with significant ED-LOS findings are broken down by test/condition category, we are left with the following: cardiac37,43,44 (n ¼ 3), chemis- try47–49,52,54,56,59,61 (n¼ 8), and 1 each in C-reactive protein,68

drugs of abuse,72 and lactate74 groups. The lactate systematic review73 reported improved hospital mortality and opposing findings related to hospital LOS but nothing about ED- LOS.

As indicated in Tables 1 through 3, a variety of additional significant findings were identified on a case-by-case basis, but it was not clear if they actually improved patient outcomes. Of note, several studies did show decreased admissions4,7,11,13–15,19 and decreased hospital stays,§ which could a priori reflect improved outcomes. However, inpatient LOS is not a typical reason for requesting ED- POCT.42 Notably, several studies45,59–62 reported process changes in ED patient care processes to take advantage of the POCT, with significantly decreased ED-LOS seen in 2 of them,59,61 2 reporting no significant change,45,60 and 1 not reporting findings related to ED-LOS.62 The latter study looked at 11 different combinations of the following ED diagnostic processes (i-STAT (I-STAT refers to the muti- analyte handheld POC analyzer available from Abbott: com- plete blood count, radiology and electrocardiogram (ECG); the study found that all significantly improved treatment time except the combination of radiology and electrocar- diogram. In this study, the author explicitly stated that ED- LOS was not evaluated because of the presence of confounding variables that could add time to a patient discharge. Of note, 17 studies reported either no significant findings for any parameter or had findings reported without evidence of statistical significance, using terms such as ‘‘better,’’ ‘‘positive impact,’’ improved, etc.||

DISCUSSION

Emergency department POCT influenza testing consis- tently demonstrates evidence supporting that use of such reduces antibiotic use and prompts and earlier and wider use of antiviral medication. This was seen in both this review and associated systematic reviews on the use of POCT influenza testing. Clearly, it is a significant tool for improving care in those presenting with upper respiratory disease to the ED in terms of diagnosis and treatment; however, it has not been shown to consistently improve ED- LOS. These findings were not seen with viral-respiratory

* References 37, 43, 44, 47–49, 52, 54, 56, 59, 61, 68, 71, 72. † References 38–42, 46, 50, 55, 57, 63, 65, 75. ‡ References 35, 36, 45, 51, 53, 58, 60, 62, 64, 66, 67, 69, 70, 74, 76. § References 7–9, 12, 15, 16, 20, 27, 28, 34, 38. || References 39–42, 45, 55, 62–67, 69, 70, 74–76.

Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter 309

Table 1. References Associated With Emergency Department (ED) Patient Care for Viral-Influenza Point-of-Care Test (POCT)

Source, y Condition/Test

Type of Study as Described in Reference, Paraphrased as Needed

Conclusions, Abbreviated and/or Paraphrased as Needed; Mean Values Were Used Except When

Noteda

ED-LOS (Decreased

Unless Stated Otherwise) Other

Abanses et al,3

2006 Viral-influenza RCT (tested) versus

nonintervention (not tested) group

Based on patients who tested positive for influenza Decreased ED-LOS (156 6 57 versus 195 6 67 min;

95% CI, 19–60) Increased laboratory testing in non-POCT group CBC (22 [29%] versus 2 [2.5%]; RR, 12; 95% CI, 2.9–

49) Blood cultures (23 [31%] versus 2 [2.5%]; RR, 12;

95% CI, 3.0–51) RSV testing (34 [45%] versus 4 [4.9%]; RR, 9.2; 95%

CI, 3.4–25) Urinalysis (21 [28%] versus 4 [4.9%]; RR, 5.7; 95%

CI, 2.0–16) Chest radiographs 18 [24%] versus 9 [11%]; RR, 2.2;

95% CI, 1.04–4.5) For all conclusions stated as ‘‘significant without using

P value’’

SIG SIG

Benito- Fernández et al,4 2006

Viral-influenza Prospective rapid flu test– positive versus rapid flu test–negative patients

Decreased ED LOS (213.5 versus 470.4 min, P , .01) Decreased number of blood tests (33.3% versus 100%,

P , .01) Decreased number of urinalysis (80.9% versus 100%,

P , .01) Decreased number of chest radiographs (14.2% versus

32%, P , .01) Decreased CSF analysis (1.33% versus 21.3%, P , .01) Decreased admissions (2.3% versus 16.4%, P , .01) Decreased antibiotic use (0% versus 38.5%, P , .01)

SIG SIG

Lankelma et al,11

2019 Viral-influenza Retrospective observational

study (15-wk period in 2017 versus same period of time in 2018)

Introduction of rapid flu test

Decreased influenza admissions (91% versus 73%, P , .001)

Decreased ED-LOS (influenza-positive patients) (3.63; IQR, 3.15–4.57 versus 3.83; IQR, 2.9–4.55 h; P , .03)

Decreased hospital LOS (4.61 versus 5.86 d, P , .001)

SIG SIG

Martinot et al,14

2019 Viral-influenza Retrospective descriptive

observational study comparing 2 diagnostic strategies

Increased speed of antiviral treatment (9 versus 23 h, P ,.001)

Decreased ED LOS (10 h 17 min versus 12 h 52 min, P ¼ .005)

Decreased hospitalization rate (38.9% versus 61.3%, P ¼ .003)

Decreased antibiotic treatment (38.9% versus 55.7%, P ¼ .03)

SIG SIG

Youngs et al,20

2019 Viral-influenza Retrospective ‘‘before-after’’

introduction of a rapid influenza test

Decreased hospital LOS (5.5 versus 7.5 d, P ¼ .005) Increased antiviral prescription (80% versus 64.1%, P

, .001) Decreased cases of hospital-acquired influenza per day

(0.66 versus 0.95, P , .001)

SIG SIG

Trabattoni et al,19 2018

Viral-influenza Prospective, descriptive, observational study pre- POCT versus POCT

Decreased ED LOS (4.15 versus 6.06 h, P ¼ .03) Decreased hospitalization (9.7% versus 44.4%, P ¼ .02)

Fewer referred tests (62.1% versus 78.1%, P ¼ .003) and (80.5% versus 63.6%, P ¼ .01)

No difference in prescription use for antibiotic and antiviral use

SIG SIG

Jeong et al,22

2014 Viral-influenza Retrospective before and

after study comparing whether or not influenza rapid antigen tests changed antibiotic prescription and ED LOS

Decreased antibiotic use (25.0% versus 43.9%, P , .01)

Decreased discharge antibiotic use (9.6% versus 34.1%, P , .01)

Increased ED-LOS when using POCT 257 min versus 213 min, P , .01)

SIG SIG

310 Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter

Table 1. Continued

Source, y Condition/Test

Type of Study as Described in Reference, Paraphrased as Needed

Conclusions, Abbreviated and/or Paraphrased as Needed; Mean Values Were Used Except When

Noteda

ED-LOS (Decreased

Unless Stated Otherwise) Other

Bonner et al,6

2003 Viral-influenza RCT. Physician aware

versus unaware (during visit) of positive rapid flu test result

For positive test result patients, there was a significant reduction in aware versus unaware groups of the following: Numbers of complete blood counts (0 versus 13,

P , .001) Blood cultures (0 versus 11, P , .001) Urinalyses (2 versus 12, P ¼ .01) Chest radiographs (7 versus 26, P ¼ .001) Prescribed antibiotics (7 versus 26, P � .001) Prescribed antivirals (18 versus 7, P ¼ .02) ED-LOS (25 versus 49, P � .001)

NS SIG

Sharma et al,18

2002 Viral-influenza Retrospective review (early/

before ED D/C) diagnosis versus late diagnosis (after ED D/C)

Decreased antibiotic use (2% versus 24%, P ¼ .006) Decreased urinalyses (2% versus 24%, P ¼ .006) Decreased complete blood cell counts performed

(17% versus 44%, P ¼ .02)

NS SIG

Li-Kim-Moy et al,12 2016

Viral-influenza Retrospective ‘‘before-after’’ introduction of a rapid influenza test; positive POCT result versus standard test with positive result

Decreased hospital LOS by 1 d if admitted (P ¼ .006) Increased antiviral use (46.2% versus 21.5%, P , .001) Decreased time to influenza diagnosis (2.4 versus 24.4

h, P , .001) No decrease in overall ED-LOS

NS SIG

Iyer et al,21 2006 Viral-influenza Prospective, quasi- randomized, controlled trial POCT versus central laboratory

The adjusted odds ratios for urine culture in influenza test result–positive to influenza test result–negative patients were 0.46 and 0.67 in the POCT and standard care groups, respectively (P ¼ .005)

No significant differences were demonstrated with respect to laboratory tests ordered, chest radiographs obtained, antibiotic administration, inpatient admission, return visits to the pediatric ED, lengths of stay, or visit-associated costs positive POCT

NS SIG

Blaschke et al,5

2014 Viral-influenza Retrospective.

Rapid flu test result– positive versus rapid flu test result–negative patients

Fewer ancillary tests ordered (45% versus 60%, P ¼ .04)

Less antibiotic ordered (11% versus 47%, P , .001) Higher antiviral use (56% versus 2%, P , .001)

NR SIG

Cantais et al,8

2019 Viral-influenza Prospective using

questionnaire (before rapid test performed) to determine tests that would have been ordered without a rapid test result

Blood sampling (37.4% versus 6.6%, P , .001) Chest X-rays (33.3% versus 10.3%, P , .001) Lumbar punctures (7.0% versus 1.6%, P , .001) Urine culture (23.3% versus 4.9%, P , .001) Antibiotic treatments (16.9% versus 5.1%, P , .001) Hospital LOS (27.2% versus 20.4%, P , .013) The following decreases were noted (% of patients) of

tests that would have been ordered without a rapid test result

NR SIG

Garvey et al,9

2019 Viral-influenza Preintervention/

postintervention. Addition of a PCR POCT device

Decreased hospital LOS (2.4 versus 7.9 d, P , .001) Faster antiviral treatment (0.59 versus 1.1 d, P , .001)

NR SIG

Hansen et al,10

2018 Viral-influenza Prospective study using a

questionnaire to assess physician decision- making with/without a rapid test result for flu

Changed overall patient management in 61% (P ¼ .001)

‘‘Patient management’’ consisted of the following subsets: antibiotic prescription, antiviral prescription, procedures/imaging, laboratory studies, and admission versus discharge

NR SIG

Linehan et al,13

2018 Viral-influenza Pre versus post

intervention—addition of POCT PCR test

Significant reduction antimicrobial agents (33% versus 76%, P , .001)

Increased antiviral use (72% versus 95%, P ,.01) Decreased rate of admission (45% versus 88%, P

, .001)

NR SIG

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not otherwise specified groups in both the papers studied and associated systematic reviews.

Non–viral-related POCT had similar findings; namely, significant changes on a study-by-study basis across a range of ED processes regardless of test/condition, but inconsis- tent significant improvement for the most important common denominator of ED patient care, LOS. In fact,

the absence of ED-LOS findings in a number of ED-POCT studies raises the possibility that studies may have omitted ED-LOS findings if nonsignificant in favor of presenting only significant findings for other processes.

What is unclear from this review is why some studies showed significant ED-LOS decreases and why others did not. There was not a single study where laboratory test

Table 1. Continued

Source, y Condition/Test

Type of Study as Described in Reference, Paraphrased as Needed

Conclusions, Abbreviated and/or Paraphrased as Needed; Mean Values Were Used Except When

Noteda

ED-LOS (Decreased

Unless Stated Otherwise) Other

Nesher et al,15

2019 Viral-influenza Preintervention versus

postintervention (introduction of rapid flu test) comparing 2 different flu seasons

Decreased admission to test report (35.5 versus 8.4, P , .001)

Increased 36-h discharge rate, from 21.5% to 41.6% (P , .001)

Increased 48-h discharge rate, from 37.2% to 54.5% (P , .001)

Increased 72-h discharge rate, from 66% to 73.2% (P , .001

Decreased hospital ED-LOS (3.8 versus 4.4 d, P , .001)

NR SIG

Noyola and Demmler,16

2000

Viral-influenza Case (rapid test positive) versus control-1 (negative rapid test and culture) versus control-2 (positive culture, positive influenza—unknown at evaluation)

ED discharge with positive POCT result less likely to receive antibiotics (20% versus 53%, P ¼ .04)

Admitted with positive POCT test result had shorter antibiotic treatment (3.5 versus 5.4 d, P ¼ .03)

Decreased hospital LOS (control group 1) (4.3 versus 7.4 d, P ¼ .02)

Nonsignificant hospital LOS (control group 2) (4.3 versus 7.5 d, P ¼ .30)

When comparing case versus control 2, no differences were observed for any parameter

NR SIG

Poehling et al,17

2006 Viral-influenza RCT, groups randomized to

performance of test versus no performance of test

In ED, fewer children had additional diagnostic tests (39% versus 51%, P ¼ .03)

Otherwise there was no difference in chest radiograph performance, blood culture, urinalysis/urine culture, or antibiotic or antiviral prescription

NR SIG

Brooke-Pearce and Demertzi,7

2019

Viral-influenza Retrospective cohort comparing laboratory versus ED POCT during 2 different time periods

Increased discharge from ED (3 [8.6%] versus 58 [40%])

Decreased admissions (91.7% versus 60%) Decreased hospital LOS (13.1 versus 9.7 days) Increased use of antiviral medication (62.5% versus

87.3%) When the positive results are compared against the

negative before and after, improvement using POCT is also seen

No statistical data were reported None of the findings were categorized as ‘‘significant’’

but were summed up as ‘‘positive impact’’

NR NS

Schechter- Perkins et al,23

2019

Viral-influenza Prospective randomized to POCT versus CL

‘‘No significant difference in either our primary outcome of time to disposition, nor in our secondary outcome, of antibiotic administration/prescription, regardless of whether participants had their influenza testing done by the POC test or the core lab test’’

NR NS

Egilmezer et al,24

2018 Viral-influenza Systematic review Nondefinitive effect on ED LOS

Most papers showed a significant increased use of antivirals and decreased antibiotic use

Lee et al,25 2019 Viral-influenza Systematic review No decrease in ED LOS Increased antiviral prescription Decreased additional lab testing except US

Petrozzino et al,26 2010

Viral-influenza Systematic review Reduced diagnostic testing Reduced antibiotic use and increased antiviral prescription Improves seasonal influenza diagnostic specificity

Abbreviations: CBC, complete blood count; CI, confidence interval; CL, central laboratory; CSF, cerebrospinal fluid; D/C, discharge; ER, emergency room; IQR, interquartile range; LOS, length of stay; NOS, not otherwise specified; NR, not reported; NS, nonsignificant; PCR, polymerase chain reaction; RCT, randomized control trial; RR, relative risk; RSV, respiratory syncytial virus; SIG, significant. a The % indicates the percentage of patients in each group tested.

312 Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter

turnaround time did not improve, as expected, but it was unclear as to why some studies showed a decrease when others did not when looking at similar test/conditions (focusing on the ‘‘chemistry group’’). Most likely these differences go back to the fact that processes differ across institutions and that patient care (ED or otherwise) is a multifactorial process,42,51,55,65 whereas improvement of one factor does not translate into an overall decreased patient LOS.42,52 Several studies did note in their discussions and findings that significant changes may have been associated with overall quality improvements48,49,55,56 that had occurred prior to or as part of the study. In addition, several studies could not rule out the Hawthorne effect (observer bias) as the reason for their data.42,60,64

CONCLUSIONS

Emergency department POCT can have both significant and nonsignificant impacts on patient care depending on the parameter studied, especially ED-LOS, and depending on the study evaluated. In theory, a rapid laboratory test result would decrease ED-LOS, but this finding is not consistently seen across a wide range of tests and conditions. It stands to reason that to make that rapid test result decrease LOS, it should be coupled to a change in other ED-related patient care processes so that patients can be rapidly discharged to either home or admission.

For unclear reasons, the number of identified studies appeared to be disproportionately low relative to the ubiquity of ED POCT in use (demonstrated by where the

Table 2. References Associated With Emergency Department (ED) Patient Care for Viral-Respiratory Not Otherwise Specified (NOS) Point-of-Care Test (POCT)

Study Condition/

Test

Type of Study as Described in Reference

(Paraphrased as Needed)

Conclusions (Abbreviated and/or Paraphrased as Needed), Mean Values Were Used for All Times

Except When Noteda

ED-LOS (Decreased

Unless Stated Otherwise)

SIG Change Other or Not

Rogers et al,27 2015

Viral- respiratory NOS

‘‘Before and after’’ introduction of POCT

Regardless of POCT result: Decreased duration of antibiotic use (2.8 versus 3.2

d, P ¼ .003) Increased ED-LOS (282 versus 256 min, P ¼ .002)

Positive viral POCT result: Decreased duration of antibiotic use (2.7 versus 3.2

d P � .001) Decreased inpatient LOS (3.2 versus 3.5 d, P ¼ .03) Decreased time in isolation (74 versus 82 d, P ¼ .03)

SIG (increased)

SIG

Andrews, et al,29 2017

Viral- respiratory NOS

A quasi-randomized trial design with control (central laboratory) and intervention (POCT FilmArray) arms

No decrease in ED-LOS or hospital LOS Decreased result to admission time (39.5 h to 19.0 h,

P , .001) Decreased admission to antiviral time (24; IQR, 22.7–

85.2 versus 60.4; IQR, 11.6–33.0 h)

NS SIG

Brendish et al,28 2017

Viral- respiratory NOS

Parallel-group, open-label, single-center, randomized controlled superiority trial with control (central laboratory) and intervention (POCT FilmArray) arms

Decreased hospital LOS (5.7 versus 6.8 d, P ¼ .04) More patients were given single versus multiple

antibiotic dose (31 versus 10, P ¼ .001) More patients had shorter duration (,48 h) of

antibiotics (50 versus 26, P ¼ .0047) No difference in antibiotic use

NR SIG

Lee et al,34

2020 Viral-

respiratory NOS

Prospective twin-center cohort—studied the use of procalcitonin in conjunction with POCT viral tested

Decreased hospital LOS (14 versus 16.1 P ¼ .03) Increased ED discontinuation of antibiotic use (26.0%

versus 16.1%, P ¼ .007) Shorter duration of intravenous antibiotics (10.0 versus

14.5 days, P , .001)

NR SIG

Doan et al,30

2012 Viral-

respiratory NOS

Systematic review Insufficient to support routine rapid viral testing as a means to reduce antibiotic use in pediatric EDs

Results suggest that rapid viral testing may be beneficial in terms of reducing rates of antibiotic use, urine investigations, and blood investigations, but are not statistically significant because of a lack of power. Rapid viral testing does reduce the rate of chest X-rays in the ED

Doan et al,31

2014 Viral-

respiratory NOS

Systematic review Insufficient evidence to support routine rapid viral testing to reduce antibiotic use in pediatric EDs

Rapid viral testing may or may not reduce rates of antibiotic use, and other investigations (urine and blood testing)

Moore et al,32 2013

Viral- respiratory NOS

Systematic review Lack of good, consistent clinical data surrounding their use outside of the laboratory is a limiting factor in their implementation

Nicholson et al,33 2014

Viral- respiratory NOS

Systematic review There was no evidence of association between diagnostic group and prescribing or clinical outcomes

Abbreviations: IQR, interquartile range; LOS, length of stay; NR, not reported; NS, nonsignificant; SIG, significant. a The % indicates the percentage of patients in each group tested.

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Table 3. References Associated With Emergency Department (ED) Patient Care for Nonviral Point-of-Care Test (POCT)

Source, y Condition/

Test

Type of Study as Described in Reference

(Paraphrased as Needed) Conclusions (Abbreviated and/or Paraphrased as

Needed); NS Changes Included

ED-LOS (Decreased

Unless Stated Otherwise)

Other Parameter

SIG/NS/NXP

Ayanruoh et al,35

2009 Bacterial,

strep Retrospective comparing

rapid strep test use with prior time period

Reduced antibiotic prescription rate (41.38% versus 22.45%, P , .001)

NR SIG

Singer et al,43

2005 Cardiac Patients with possible

acute coronary syndromes before and after comparing CL to POCT cardiac markers

Decreased ED LOS (5.2 [CI, 4.6–5.8] versus 7.1 [95% CI, 6.6–7.7] h)

Decreased bed control notification time (2.7 [95% CI, 2.4–3.1] versus 4.7 [95% CI, 4.3–5.0] h)

SIG SIG

Meek et al,44

2012 Cardiac Patients presenting to the

ED with chest pain. Traditional (CL testing) and accelerated pathways (POCT)

Decreased ED-LOS discharged (297 versus 545 min, P � .001)

Decreased ED-LOS admitted (609.5 versus 733.5 min, P ¼ .007)

SIG SIG

Giannitsis et al,37

2019 Cardiac Prospective multicenter

comparing CL and POCT cardiac marker testing in conjunction with copeptin

Dual-marker strategy using a unique marker— copeptin

Decreased ED-LOS (3.8 versus 4.8 hours P , .001) using POCT troponin and copeptin

SIG NXP

Goodacre et al,38

2011 Cardiac Multicenter RCT

randomized to diagnostic assessment using POCT or not in patients presenting with chest pain suspicious for myocardial infarction. The RATPAC Trial

No significant change in ED-LOS Increased proportion of ED safe discharges to home

(32% versus 13%, P , .001) Decreased hospital LOS (8.8 versus 14.2, P , .001)

NS SIG

Loten et al,40

2010 Cardiac Patients presenting with

chest pain suspicious for myocardial infarction were randomized to POCT or not across 2 hospitals (for the patients in the POCT arm, physicians could still use CL)

No significant change in ED-LOS NS NXP

Koehler et al,39

2013 Cardiac Before and after

introduction of POCT No significant change in ED-LOS Increased patient care team satisfaction and

perception of increased communication

NS NS

Renaud et al,41

2008 Cardiac Patients presenting with

chest pain suspicious for acute coronary syndrome randomized to either POCT or CL troponin testing

No significant change in ED LOS Faster decision-making for anti-ischemia treatment

(151 versus 198 min). No P value given, ‘‘Therefore, the diagnosis of myocardial infarction could be made slightly earlier in the subset of patients with vague symptoms’’

NS NS

Ryan et al,42

2009 Cardiac Patients with possible

acute coronary syndromes randomized to POCT with CL (acting only POCT results) or CL only across 4 EDs

No significant change in ED-LOS No change in floor transfer time (5.4 versus 5.5 h) No change in disposition times for POCT versus CL

for admitted or discharged patients ‘‘This (POCT) did not translate to a time savings in discharging patients across all study sites (at one site POCT increased time to departure.)’’

NS NS

Body et al,36

2017 Cardiac RCT across 2 different EDs Increased ‘‘safe’’ discharge of patients within 4 h

with acute coronary syndrome symptoms (8% versus 26%, P ¼ .004)

Safe ¼ the patient did not have a missed AMI or develop a MACE (death) AMI or coronary revascularization) within 30 d

NR SIG

Singer et al,56

2015 Chemistry Before and after

implementation of POCT Decreased time to completion of IV contrast (81

versus 177 min, P ¼ .03) Decreased ED-LOS in patients who received an IV

contrast (260 versus 347 min, P ¼ .03)

SIG if IV contrast used

SIG

Hsiao et al,47

2007 Chemistry Patients (pediatric not

critical) who appeared to need POCT available blood work randomized to POCT or CL

Decreased ED-LOS (204.0 versus 165.5 min, P , .001)

SIG SIG

314 Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter

Table 3. Continued

Source, y Condition/

Test

Type of Study as Described in Reference

(Paraphrased as Needed) Conclusions (Abbreviated and/or Paraphrased as

Needed); NS Changes Included

ED-LOS (Decreased

Unless Stated Otherwise)

Other Parameter

SIG/NS/NXP

Kankaanpää et al,61 2016

Chemistry Before and after implementation of POCT following by use of EAT

Decreased ED-LOS (3 h 22 min versus 3 h 51 min, P , .001)

Decreased ED-LOS using EAT with POCT (3 h 6 min versus 3 h 22 min, P ¼ .03)

Process change

SIG SIG

Baumer- Mouradian et al,59 2019

Chemistry Four key interventions were tested by using plan-do-study-act cycles

Decreased DKA diagnostic time (26 versus 86 min, P , .001)

Decreased IV placement in patients without DKA (36% versus 85%, P , .001)

Decreased ED-LOS (186 versus 206 min, P ¼ .009) in patients discharged from the hospital after DKA evaluation

Process change

SIG SIG

Kankaanpää et al,49 2018

Chemistry Nonambulatory ED patients tested by either POCT or CL (nonrandomized)

Decreased ED-LOS (4 h 57 min versus 5 h 52 min P ¼ .01) when imaging was not required

Decreased ED-LOS (5 h 48 min versus 7 h 10 min versus P ¼ .01) when imaging was required

SIG NXP

Jang et al,48

2013 Chemistry Noncritical but requiring

laboratory testing randomized to POCT or CL

Decreased ED-LOS (350 [IQR, 206–1002) versus 372 [IQR, 217–1150] min); median difference 22 min (95% CI, 4–40 min)

Decreased ED-LOS in patients discharged to home (256 [IQR, 180–421] versus 268 [186–435] min); median difference 12 min (95% CI, 2–22 min)

Reported as significant without P value

SIG NS

Murray et al,54

1999 Chemistry Patient blood work

randomized to POCT or CL blinded from evaluating physicians

Decreased ED-LOS (3 h 28 min versus 4 h 22 min, P ¼ .02)

SIG NS

Lee- Lewandrowski et al,52 2003

Chemistry Before and after implementation of an ED POCT satellite lab

Decreased ED-LOS when POCT tests were combined. (347 versus 389, P ¼ .006)

NS decreases in ED-LOS for pregnancy, urine dipstick, and cardiac marker tests when used separately

SIG NS

Kendall et al,50

1998 Chemistry Patient blood samples

randomized to POCT or CL; no exclusion criteria

No significant change in ED-LOS Decision made earlier for POCT:

Hematologic testing (80 versus 154 min, P ¼ .001)

Biochemical testing (80 versus 165 min, P , .001)

Arterial blood gases (62 versus 82 min, P ¼ .09)

NS SIG

Asha et al,46

2014 Chemistry Two patient groups (acute

coronary syndrome and general) were randomized to POCT (troponin or general chemistry, respectively) or CL

No significant change in ED-LOS Decreased disposition decision (both groups) (3.24

versus 3.50 h, P ¼ .04)

NS SIG

Singer et al,57

2018 Chemistry Prospective observational

case controlled No significant change in ED-LOS Decreased ED care time (7.6 versus 8.5 h, P ¼ .02) ED care time ¼ arrival to disposition determination

NS SIG

Li et al,63 2018 Chemistry Before and after implementation of POCT across 26 EDs

No significant change in ED-LOS NS NXP

Parvin et al,65

1996 Chemistry Before and after

implementation of a POCT chemistry analyzer

No significant change in ED-LOS NS NS

Pines et al,55

2018 Chemistry Before and after

implementation of POCT

No significant change in ED-LOS Perceptual feeling among staff that quality of care

was improved

NS NS

Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter 315

Table 3. Continued

Source, y Condition/

Test

Type of Study as Described in Reference

(Paraphrased as Needed) Conclusions (Abbreviated and/or Paraphrased as

Needed); NS Changes Included

ED-LOS (Decreased

Unless Stated Otherwise)

Other Parameter

SIG/NS/NXP

Lee et al,51 2011 Chemistry Patients age .15 y clinically required to have laboratory tests randomized to POCT or CL

Decreased door-to-clinical-decision time (46 versus 86 min, P , .001)

New decisions within 60 min (72.8% versus 12.5%, P , .001)

NR SIG

Mogensen et al,53 2011

Chemistry RCT across different condition groups; DVT; ACS; AA; acute infection

Acute infection group; faster decision time from 4 h 8 min versus 7 h 35 min (P ¼ .009)

No significant decision time change for DVT, ACS, or AA groups

NR SIG

Whitney et al,58

2016 Chemistry Cost-effective analysis

using data from a previously done study in children with acute gastroenteritis

Decreased cost of lab testing ($784.48 versus $1087.78)

‘‘Mean savings of $36.32 per patient in children with gastroenteritis-related moderate dehydration’’

Referred to as ‘‘significant’’ without P value

NR SIG

Goldstein et al,60

2018 Chemistry Patients were randomized

to receive CL or POCT enhanced workflow pathways

Eleven different combinations of i-STAT, CBC, ECG, and radiology

Enhanced ED workflow (involving POCT) was significantly faster than the nonenhanced workflow. Multiple workflows (P ¼ .001, P ¼ .02, P ¼ .0009, P ¼ .01 P ¼ .001, P ¼ .03).

Greater than 20% with a faster treatment time Process change LOS as a parameter was not used because of

confounding variables that could inadvertently increase LOS

Workflows are different combinations of lab tests with/without ECG and/or chest X-ray

NR SIG

Abualenain et al,45 2018

Chemistry Patients with 1 of 7 specified complaints (chest pain, abdominal pain [female], abdominal pain [older], syncope [older], missed dialysis, history of gastrointestinal bleeding, suspected sepsis) had POCT performed in triage area

Triage POCT was helpful and resulted in immediate care in 12% of cases

NR NXP

Asimos et al,64

2000 Chemistry Convenience sample of

blunt penetrating trauma patients with disposition/ management plans compared before and after review of POCT results

Sodium, potassium, chloride, and urea nitrogen measurements were not influential in the initial management of major trauma patients. Hemoglobin, glucose, blood gas, and lactate occasionally result in morbidity-reducing or resource-conserving management changes in severely blunt-injured patients

NR NS

Soremekun et al,62 2013

Chemistry Prospective observational of patients with triage such that they were expected to wait in the waiting room

Abnormal POCT results in triage were helpful in 6% of patients; changed the triage level in 15% of patients; and in 6% resulted in a rapid physician evaluation

Process change

NR NS

Nijman et al,68

2015 C-reactive

protein Febrile children (1 mo to

16 y) before and after (POCT) CRP testing

Decreased ED-LOS (148 versus 178 min, P � .001) SIG NXP

Butler et al,66

2019 C-reactive

protein Patients with COPD

presenting with acute exacerbation of COPD randomized to usual care or usual care guided by POCT CRP across several institutions

Decreased antibiotic use (57.0% versus 77.4%; adjusted odds ratio, 0.31; 95% CI, 0.20–0.47)

Fewer patients in the CRP-guided group reported antibiotic use than in the usual care group (150 of 263 patients [57.0%] versus 212 of 274 patients [77.4%]; adjusted odds ratio, 0.31; 95% CI, 0.20–0.47)

Not classified as significant

NR NS

Roulliaud et al,69

2018 C-reactive

Protein Febrile individuals before

and after (POCT) CRP testing

Decreased ED consultation time (60 versus 180 min)

NR NS

Gonzales et al,67

2011 C-reactive

protein Patients presenting with

acute-onset new cough randomized to CRP in CL versus POCT

No difference in antibiotic use between CRP-tested and control participants

NR NS

316 Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter

identified studies originated). Perhaps this study will trigger additional studies attempting to prove that ED-POCT is worthwhile and can shorten ED-LOS.

Regardless of findings identified (significant or otherwise), the data in this review should help EDs and laboratories assess their needs against what has and has not been studied. This review should also help hospitals consider the need to address process improvements to be integrated with the use of POCT to improve the ED patient care experience with a decreased LOS.

References

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Table 3. Continued

Source, y Condition/

Test

Type of Study as Described in Reference

(Paraphrased as Needed) Conclusions (Abbreviated and/or Paraphrased as

Needed); NS Changes Included

ED-LOS (Decreased

Unless Stated Otherwise)

Other Parameter

SIG/NS/NXP

Schot et al,70

2018 C-reactive

protein Febrile children (3 mo to

12 y) randomized to either use of POC CRP or no CRP

No difference in antibiotic prescription between groups

NR NS

Lee- Lewandrowski et al,71 2009

D-dimer Before and after implementation of POCT

Decreased ED-LOS (7.14 versus 8.46 h, P ¼ .02) SIG NS

Lewandrowski et al,72 2008

Drug abuse Before and after implementation of POCT

Decreased ED-LOS (8.1 versus 11.1 h, P � .001) SIG NXP

Wentling et al,74

2019 Lactate Prospective study with

physicians blinded to POCT lactate results

POCT lactate were not clinically useful in the ED to stratify or classify patient severity

NR NS

Morris et al,73

2017 Lactate

systematic review

Systematic review Improvements in care noted 5 studies trend in reduced mortality 1 study significant reduction in hospital LOS 1 study no reduction in hospital LOS 2 studies significant reduction in time to treatment

with antibiotics and intravenous fluids

Plerhoples et al,75 2004

Pregnancy Before and after implementation of POCT

ED-LOS no significant change NS NXP

Blairon et al,76

2019 Renal,

creatinine Prospective,

nonrandomized Changed the prescription of NSAIDs in almost

25% of patients with previously unknown renal function without extending ED-LOS by ordering main lab result

NR NS

Abbreviations: AA, acute appendicitis; ACS, acute coronary syndrome; AMI, acute myocardial infarction; CBC, complete blood count; CI, confidence interval; CL, central laboratory; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; DKA, diabetic ketoacidosis; DVT, deep vein thrombosis; EAT, emergency assessment team; ECG, electrocardiogram; i-STAT, commercial handheld multianalyte POCT device (Abbott); IQR, interquartile range; IV, intravenous; LOS, length of stay; MACE, major adverse cardiac event; NOS, not otherwise specified; NR, not reported; NS, nonsignificant; NSAID, nonsteroidal anti-inflammatory drug; NXP, no other parameter evaluated (only ED-LOS evaluated); RCT, randomized control trial; RR, relative risk; SIG, significant.

Arch Pathol Lab Med—Vol 145, March 2021 Point of Care Testing in the ED—Alter 317

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