Tucked in a shelf in the drug room at Hokianga Hospital is technology that helps both rural clinicians and patients sleep better at night.
Within minutes, clinicians can have blood test results to help them assess whether or not a patient’s chest pain is a heart attack, manage a diabetic patient with ketoacidosis, or decide whether a blood transfusion is required.
Patients can also have peace of mind that they can be treated close to home in Hokianga and a decision made whether the two-hour trip to Whangarei or four-hour trip to Auckland by road is warranted.
Point-of-care testing (POCT) devices allow blood tests to be carried out at the bedside or in a clinician’s room; tests that were once only available at a central laboratory.
Using POCT for acutely unwell patients is now well-established at Hokianga Hospital in Rawene. The community-owned, trust-run hospital includes 10 acute beds (along with long-stay and maternity beds) serving the predominantly Māori, socio-economically deprived communities located around the beautiful but isolated Hokianga Harbour.
Residents of these remote communities have high rates of long-term conditions such as heart disease, diabetes and renal disease. Being cut off by flooding is part of life in this region and, with no on-site laboratory, even in the best of conditions blood test results could take from eight hours to as long as 72 hours over a weekend, so pioneering the use of POCT analysers, which return results in two to 10 minutes, has had a particular appeal.
Nurse practitioner Catherine Beazley is one of two ‘super-users’ of POCT at Rawene – the other is fellow nurse and hospital services manager Christine Dorsey.
In the 16 years since Beazley began working at Rawene, she has gone from using a simple glucometer for measuring blood sugar to being the quality control guru for ‘half a shelf’ of increasingly sophisticated POCT technology, ranging in size from the handheld to a haematology analyser roughly the size of an Auckland telephone book.
Beazley says the big game-changer in being able to keep and treat patients locally was the trust’s purchase of the iSTAT analyser in 2008. The handheld device supported clinicians to assess suspected heart attacks to heart failure, and diabetic ketoacidosis to acute renal failure, by being able to carry out urgent blood tests for levels of blood gases, chemistries, troponin and BNP. Also on the shelf is an on-the-spot coagulation checker (Coaguchek), an HbA1C analyser (DCA Vantage) and a more recent addition is the haematology analyser (Emerald 22).
A 2010 study, led by Dr Kati Blattner of Hokianga Health, found that with having prompt access to POCT results patient transfers to Whangarei Base Hospital reduced by 62 per cent and patient discharges increased. Clinicians reported substantial (75 per cent) changes in the treatments that were offered.
Beazley reported another spinoff for the nursing staff, apart from the comfort of test results to support their clinical judgement and care plan, was fewer call backs to escort ambulance transfers. Before iSTAT, patients with undiagnosed chest pain were often transferred by ambulance to Whangarei, with urgent escorts adding a minimum of five hours to a nurse’s working day.
Yet something more to do?
At the outset nurses and doctors received comprehensive ‘herd’ training in using POCT with these clinicians keen to get on board, even offering their own blood.
However, as the novelty wore off, using the devices increasingly became part of the nurses’ role and now the majority of the 23 active users on the main POCT analysers are nurses. Adding amateur lab technician to a nurse’s job description could be viewed as stretching multi-tasking a little too far.
“When working rurally you have to have a generalist attitude,” says Beazley. Being trained to use POCT devices is now perceived as business as usual for nurses at this hospital.
Routinely, when a diagnostic test is ordered, a nurse not only takes the blood sample from the patient’s vein but usually carries out the test. For iSTAT the testing procedure involves inserting two or three drops of blood into the appropriate test cartridge, entering the required information (including the nurse’s council number as a user ID) and inserting the cartridge into the handheld analyser. Within two to 10 minutes (depending on the test) the results are ready.
Initially, nurses would stand anxiously waiting for the test results but now carry on with normal duties, returning to take a quick look at the results as they deliver them to the requesting doctor or NP (post-haste if they show elevated troponin results). While registered nurses don’t order or usually interpret POCT – senior nurses may take the initiative while inserting an IV line into an acutely unwell person to also take a blood sample in anticipation that POCT tests may be wanted.
Point-of-care testing may be fast but it is not cheap so the preferred approach remains waiting for a traditional lab test result. Last year clinicians ordered between 80–130 iSTAT tests a month and 35–60 haematology tests a month. As Beazley emphasises, POCT tests don’t replace good quality clinical assessment and care but do support clinicians to decide on the best management plan for an acutely unwell patient and can give increased peace of mind to both patients and clinicians.
“Sometimes it might be used to help adjust medication for someone such as renal or heart failure,” says Beazley. “Or you might be trying to determine whether a person has a chest infection/pneumonia-related shortness of breath/cough or whether it is heart-related.”
The New Zealand Society of Pathologists in a letter to the Ministry of Health last year acknowledged that modern medicine was impossible without POCT, but said that alongside the advantages of speedier access to diagnostic testing came challenges – including that POCT can appear to be “deceptively simple to use” but was not without risk and needed consistent quality control and risk management processes.
When the Hokianga team presented to the Rural Health Conference in March, Blattner spoke of the positives of POCT but also watching the nursing staff “working harder and harder” at making it work and to meet the ongoing treadmill of quality standards. She believes that funding and policy work is needed to make the benefits of POCT sustainable for settings like Hokianga.
Beazley acknowledges that carrying out quality control (working in tandem with Northland District Health Board’s point of testing coordinator Geoff Herd and the DHB’s medical laboratory), looking after the shelf of POCT devices plus the training and annual testing of users has become a routine part of her role. The organisation is reviewing this workload as part of a current research project and recommendations may be made in the near future about formal FTE hours being allocated to manage POCT devices at Hokianga.
Meanwhile, working at 9pm on a Monday night wearing her POCT ‘hat’ is not unknown for Beazley. The rural NP says what motivates her is the benefits that POCT testing brings to the hospital’s staff, patients and wider community by being able to provide a modern acute care service to an isolated population.
Should other nurses be ready to follow or wary of following the POCT path?
“I think it [POCT] is something to be embraced as a way forward in rural practice but it has to be done with the right supports in place and the right funding,” says Beazley. She suggests that nurses seek answers about who is going to do the ongoing training, fund the test supplies, coordinate quality control and be responsible for the day-to-day maintenance of devices.
While the diagnostic comfort that the shelf of devices in Rawene’s drug room can provide doesn’t come without costs, Beazley adds that along with the increased peace of mind also comes a great sense of community pride in what the hospital can deliver to the people of Hokianga.
POCT on way to rural general practices
A project to roll out point-of-care testing to rural practices from Great Barrier Island to Warkworth is also underway. The Rural Point of Care Testing (R-POCT) project aims to provide general practices in the Auckland Waitemata Rural Alliance with POCT analysers.
So far the Waitemata DHB has committed $1.02 million for the project over the next two and a half years. The alliance’s practices serve a rural population of nearly 60,000 people – mostly in rural north and west Auckland, including Great Barrier Island, Waiheke Island, West Rodney, Wellsford and Warkworth.
The project will make rapid on-the-spot blood test results available to help diagnose and decide whether acutely unwell rural patients can be cared for at their general practice or need hospital referral. It is being led by Waitemata DHB, whose POCT team will provide quality assurance and training for practice ‘champions’ in using the selected analysers.
The R-POCT project has identified that more than one analyser will be needed to carry out the required tests for troponin, D-dimer, INR (international normalised ratio) and a full blood count with a three-part differential.