Can using point of care blood tests help inform decision making in patients over 65 presenting with acute frailty syndrome?
UK ambulance services have been identified as potential beneficiaries of point of care testing (POCT) to guide patient management and care pathways, but there is little published evidence on the uses, benefits and health economics of POCT in pre-hospital settings. The Oxford AHSN, along with eight specialist paramedics based at the Royal Berkshire Hospital in Reading, conducted a quality improvement study to look at utilising POCT to aid decision-making in patients aged over 65 presenting to South Central Ambulance Service with acute frailty syndrome.
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Point of care blood testing (POCT) is an expanding worldwide market that has become an established part of service improvement proposals within the NHS to reduce Emergency Department (ED) times, length of hospital stay and improve illness prevention schemes. In the United Kingdom (UK), Point of care International Normalised Ratio (INR) testing in primary care has been a topic of research since the early 1990’s and point of care lactate monitors are being trialled for early sepsis guided therapy. UK ambulance services have been identified as a service that would benefit from POCT to guide patient management and care pathways however there is little published evidence on the uses, benefits and health economics of POCT in the pre-hospital environment. This paper will discuss a quality improvement project utilising POCT to aid decision-making in patients over the age of 65 presenting to South Central Ambulance service with acute frailty syndromes.
The national ‘see, treat and discharge’ rates for paramedics has increased since the ‘Taking healthcare to the patient’ report in 20058 with discharge on scene rates rising by 4% over the last 6 years. However, despite this increased demand on paramedic decision-making there have been limited improvements to pre-hospital diagnostics. The committee on diagnostic error in healthcare identify diagnostic testing as an integral part of the diagnostic pathway and note that a clinician’s ability to risk stratify can be affected by access to results.
Patients over the age of 65 years living with frailty are a notably complex clinical patient group for which informed risk stratification in clinical reasoning is paramount. This patient group can present to the ambulance service with acute frailty syndromes that require careful assessment and management to avoid loss of independence, function and medical deterioration. The combination of reduced diagnostic aids and clinical complexities in this patient group has potential to increase the risk of poor decision-making and negative patient outcomes . In the ambulance service this may translate into unnecessary admissions to the Emergency department (ED) or deterioration after discharge on scene. Point of care blood testing is a natural addition to the diagnostic repertoire of a paramedic due to its common use within standard referral sites such as emergency departments and primary care services.
Acute frailty syndromes are defined as seemingly benign symptoms that can mask serious underlying illness. These are identified as falls, immobility, confusion/delirium, incontinence and susceptibility to side effects of medications . Falls are the most commonly encountered acute frailty symptom within the ambulance service . In the older person, falls are typically multifactorial and consideration should be given to environmental causes, underlying illness, polypharmacy, neurological impairments, gait and balance decline and visual impairments. Whilst the comprehensive geriatric assessment and falls risks assessments can be carried out in the absence of laboratory results , it is important to identify health problems that may increase the risk of falling. Altered or deranged laboratory results may indicate medications side effects or underlying illness .
How did the Innovation Exchange help?
Oxford AHSN provided the devices and cartridges for the evaluation. We assessed the impact on safer discharges, earlier disease management and increased clinician confidence. Only trained operators used the Abbott iStat for patients over 65 presenting with a complaint of falls or immobility or confusion and had an uncertain disposition post standard examination.
The project aimed to improve pre-hospital diagnostics for patients presenting to the ambulance service with acute frailty syndromes. It was hypothesized that access to certain blood results would increase the ability to make safe and confident discharges while also ensuring that altered biochemistry could be investigated appropriately either by primary care providers or emergency physicians. The main objectives were:
- Safer discharges (measured by re-contact rates and results affecting decision-making)
- Earlier disease management (measured by onward referrals and hospital length of stay)
- Increased clinician confidence (measured by self report in response to qualitative questions)
This was a single site quality improvement project implemented from September 2017 to March 2018 within an NHS ambulance service. Four specialist paramedics and four frailty paramedics were trained in the use of the Abbot iSTAT Alinity with CRG4+ and CHEM8 cartridges providing Venous blood gas (VBG), Urea and Electrolytes (U&Es), lactate, Haemoglobin and Haematocrit. Patients were eligible for inclusion if they were >65 years old with a presenting complaint of Falls OR immobility OR confusion and had an uncertain disposition post standard examination. Patients were excluded from POCT if their care pathway was clear from standard examination or in cases where POCT would not make a difference to onward care or decision-making.
Impact & Outcomes
Patients >65 presenting with acute frailty syndromes (confusion, immobility and falls) can be a clinically challenging cohort of patients and as such might be transported to hospital for further assessment and monitoring. The British Geriatric Society notes that frailty syndromes can mask serious underlying illness and as such these patients require comprehensive investigation. The investigation of patients with frailty in the emergency department typically involves blood testing, thus creating an inequality of care between in hospital and pre hospital patients. In conclusion, this quality improvement project showed POCT to have a positive impact on appropriate patient disposition, clinician confidence and earlier disease management. The projects results, whilst taken from a small sample size and show promise for the on going implementation of POCT in both the pre-hospital environment and in the field of frailty. Dissemination of these learnings aims to lead to on going and improved use of POCT within other pre-hospital services ultimately leading to better patient care and outcomes, improved referrals and greater cost benefit to the services using them.
In conclusion, this quality improvement project showed POCT to have a positive impact on appropriate patient disposition, clinician confidence and earlier disease management. The projects results, whilst taken from a small sample size and show promise for the on going implementation of POCT in both the pre-hospital environment and in the field of frailty. Dissemination of these learnings aims to lead to on going and improved use of POCT within other pre-hospital services ultimately leading to better patient care and outcomes, improved referrals and greater cost benefit to the services using them.