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Point-of-care blood tests in decision-making for people over 65 with acute frailty

02 March 2019
Volume 11 · Issue 3

Abstract

Background:

National ‘see, treat and discharge’ rates for paramedics have increased. However, despite the rise in demand on paramedic decision-making, there have been few improvements to prehospital diagnostics. Patients aged over 65 years presenting with acute frailty syndromes are a notably complex clinical patient group for whom informed risk stratification in clinical reasoning is paramount.

Methods:

This was a single-site quality improvement project using point-of-care blood testing (POCbT) to help inform decision-making for patients aged above 65 years with acute frailty syndromes.

Results:

This quality improvement project showed a self-reported improved confidence in clinician decision-making and patient disposition with the use of POCbT. This confidence was validated by improved discharge on scene and recontact rates. An unintended outcome of the project was the accumulation of practical knowledge on the use of POCbT in the prehospital arena.

Conclusion:

Continued use of POCbT in the prehospital environment has promise but this is not without limitations. Prehospital services wishing to implement POCbT should focus on demographic identification, staff training and interpretation of results.

Point-of-care blood testing (POCbT) is an expanding worldwide market (Goodwin, 2008) and has become an established part of service improvement proposals within the NHS to reduce emergency department (ED) wait times and length of hospital stay, as well as improve illness prevention schemes (Hart, 2017). In the UK, point of care international normalised ratio (iNR) testing in primary care has been a topic of research since the early 1990s (Fitzmaurice, 2004) and point of care lactate monitors are being trialled for guided therapy for early sepsis (Morris et al, 2017). UK ambulance services have been identified as a service that would benefit from POCbT to guide patient management and care pathways (Di Serio et al, 2006; 2010; Goodwin, 2008). However, little evidence on the uses, benefits and health economics of POCbT in the prehospital environment has been published.

This paper will discuss a quality improvement project using POCbT to aid decision-making in patients over the age of 65 presenting to South Central Ambulance NHS Foundation Trust with acute frailty syndromes.

Background

National ‘see, treat and discharge’ rates for paramedics have increased since the Taking healthcare to the patient report was issued in 2005 (Department of Health and Social Care (DHSC), 2005), with discharge-on-scene rates rising by 4% over the past 6 years (NHS England, 2018). However, despite this increased demand on paramedic decision-making, there have been few improvements to prehospital diagnostics. The Committee on Diagnostic Error in Healthcare (CDEH) (2015) identifies diagnostic testing as an integral part of the diagnostic pathway and notes 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 (British Geriatric Society (BGS), 2014) for whom 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 and function, and medical deterioration (National Institute for Health and Care Excellence (NICE), 2013).

The combination of few diagnostic aids and clinical complexities in this patient group gives rise to the potential to increase the risk of poor decision-making and negative patient outcomes (CDEH, 2015). In ambulance services, this may translate into unnecessary admissions to the emergency department (ED) or deterioration after discharge on scene. POCbT is a natural addition to the diagnostic repertoire of a paramedic because it is commonly used within standard referral sites such as EDs and primary care services.

Results of a preliminary literature search revealed a paucity of evidence documenting the use of POCbT devices in the out-of-hospital environment (Di Serio, 2006; 2010; Goodwin, 2008). This search of the CINAHL, AMED, BNI and PubMed databases using the terms (‘point of care’ OR ‘POC’ OR ‘POCT’) AND (‘Ambulance’ OR ‘Prehospital’ OR ‘Pre-hospital’ OR ‘Paramedic’) returned 406 results, of which 15 were relevant to the use of POCbT devices in the prehospital environment. The majority of these results were dedicated to the evaluation of point-of-care lactate testing for sepsis and trauma or point-of-care troponin for myocardial infarction.

The most notable use of prehospital point-of-care testing was the Labkit Near Patient Diagnostics service tested with Berkshire and Surrey Pathology Services and South East Coast Ambulance Service. This project involved a three-phase trial that researched effective functionality, prehospital suitability and impact on patient management (NHS Pathology, 2016) but the outcomes are unclear. To date, there have been no peer-reviewed publications of this project's results to guide the use of POCbT in future projects.

Di Serio et al (2006; 2010) conducted two separate trials into the use of POCbT in prehospital services in Germany. The first used i-STAT troponin I to facilitate the early identification of non-ST segment elevation myocardial infarction and the second to monitor critical care patients during helicopter emergency medical services transfer to hospital. The troponin study found POCbT results to be accurate but not diagnostic because of the common requirement for serial troponin monitoring in hospital (Di Serio et al, 2006).

The second study into the use of POCbT on helicopter emergency transfers between hospitals identified a need for transfer of real-time results to achieve patient benefit (Di Serio et al, 2006; 2010). Both studies lack transferability to the UK prehospital ‘see and treat’ model because they focus on critically ill patients whose trajectory of care is predetermined by their potential or realised illness.

Organisations that use POCbT include the Oxford Academic Health Science Network collaboration with Oxford Health NHS Foundation Trust, which uses it in the out-of-hours primary care environment, ambulatory units and emergency medical units (Hart, 2017). Numerous other prehospital services anecdotally report using POCbT throughout the UK but have not published evidence on their experiences or findings for wider learning.

Acute frailty syndromes

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 medication side effects (BGS, 2014).

Falls are the most commonly encountered acute frailty symptom within the ambulance service (Darnell et al, 2012). 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 (NICE, 2013). While comprehensive geriatric assessment and falls risk assessments can be carried out in the absence of laboratory results (BGS, 2014), it is important to identify health problems that may increase the risk of falling (NICE, 2013). Altered or deranged laboratory results may indicate medication side effects or underlying illness (Basten, 2013).

Observation from practice identifies that patients with frailty in the ED are commonly investigated with basic blood tests, electrocardiography, observations and physical examination. In the absence of advanced assessment in the prehospital environment, staff may be susceptible to oversensitive triage of this patient group, which in turn can contribute to inappropriate admission (Campbell et al, 2013). Admission to hospital results in poor functional outcomes for patients living with frailty (Liscott, 2016), which demonstrates the need to avoid unnecessary admission from the prehospital environment. This background provided the basis for formulation of this quality improvement project.

Aims

This project aimed to improve prehospital diagnostics for patients presenting to the ambulance service with acute frailty syndromes. It was hypothesised that access to certain blood results would improve the ability to make safe and confident discharges while also ensuring that altered biochemistry could be investigated by primary care providers or emergency physicians.

The main objectives were:

  • Safer discharges: measured by recontact 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.
  • Methods

    This was a single-site quality improvement project implemented between September 2017 and March 2018 at South Central Ambulance Service NHS Foundation Trust. Four specialist paramedics (SPs) and four frailty paramedics were trained in the use of the Abbot i-STAT Alinity with CRG4+ and CHEM8 cartridges to test venous blood gas (VBG), urea and electrolytes (U&Es), lactate, haemoglobin and haematocrit levels.

    Patients were eligible for inclusion if they were >65 years old with a presenting complaint of falls, immobility or confusion and had an uncertain disposition after a standard examination. Patients were excluded from POCbT if their care pathway was clear from standard examination or in cases where POCbT would not make a difference to onward care or decision-making.

    Trained staff could use POCbT during their normal duties for any patient who met the inclusion criteria or could receive referrals. In addition to use during day-to-day SP rotas, the i-STAT Alinity was used weekly on a falls and frailty response service as this increased access to the required demographic, which would increase the effect of the project. Staff were trained in the use and interpretation of results from the device.

    Reference ranges compatible with local pathology services were programmed to the i-STAT Alinity with abnormal and critical results differentiated (Table 1). Abnormal ranges were automatically highlighted in amber while critical results were highlighted red. In recognition of normally abnormal biochemistry and haematology in this patient group, access to The Berkshire Integrated Clinical Environment (ICE) portal was obtained so the ranges adopted in this project would align with usual results in this patient group. Staff could contact a GP advice service for support in learning to interpret results and were encouraged to use this. Results were recorded on ambulance service electronic patient records with verbal handover to hospital or primary care clinicians.


    Assay Ranges Common causes of abnormalities
    Critical Warning Research Warning Critical
    High Low High High
    Sodium 120 120–133 133–146 146–160 160 Dehydration, diruetic side effects, malnutrition, acute kidney injury (AKI), vomiting and diarrhoea, hyperglycaemia
    Potassium 2.5 2.5–3.5 3.5–5.1 mmol 5.1–6.0 6 Gastrointestinal losses, diuretic side effects, laxative side effects, malnutrition, thyrotoxicosis, AKI, beta-blockers, crush injury/rhambdomyolsis
    Chloride 70 70–98 98–106 mmol 106–120 120 Low: overhydration, congestive heart failure, vomiting or chronic diarrhoea, chronic respiratory acidosis, burns High: dehydration, excessive infusion of normal saline solution, kidney dysfunction metabolic alkalosis, respiratory acidosis, Addison's disease
    Anion gap N/A 0–10 10–20 mEq/litre 20–50 N/A Diabetic ketoacidosis, lactic acidosis, diarrhoea, starvation, renal failure, shock, renal tubular acidosis, lower intestinal fistulas, salicylate poisoning, methanol/ethylene toxicity, excess administration of chloride
    Ionised calcium 0.7 0.7–1.2 1.2–1.32 mmol/litre 1.32–1.6 1.6 Renal disease,, hyperparathyroidism, malignancy, hypertension and pancreatitis
    Blood urea nitrogen 0 0–5 mg/dl0–1.7 mmol/litre 5–23 mg/dl1.7–8.3 mmol/litre 23–50 mg/dl8.3–17.85 mmol/litre 2 Liver failure, shock, dehydration, congestive heart failure, myocardial infarction, gastrointestinal bleeding, starvation, sepsis
    Creatinine 0 0–0.5 mg/dl0–45 mmol/litre 0.5–0.95 mg/dl45–84 mmol/litre 0.95–2 mg/dl84–175 mmol/litre 2 Dehydration, AKI, pyelonephritis
    Lactate 0–0.5 0.5–1.6 1.6–4 4 Hypoperfusion secondary to shocked states (sepsis, trauma, obstructive shock etc) severe liver disease, poorly controlled diabetes
    Haematocrit 27 27–37 37–47 47–70 70 Overhydration, anaemia, blood loss; can be raised in cardiovascular and renal disorders
    Haemoglobin 100 100–115 115–180 >180 N/A
    pH <7 7–7.35 7.35–7.45 7.45–8 >8 The acid-base balance is maintained by the respiratory, cardiovascular and renal systems. The body, under normal circumstances, is able to maintain a balance between the acids produced as part of metabolism and the bases that are necessary to neutralise and promote excretion of acids. Renal, respiratory and metabolic disorders, such as kidney failure, chronic obstructive pulmonary disease and diabetes, may lead to acid-base imbalances.
    PCO2 <4.27 4.27–6.4 kPa >6.4 >8
    TCO2 15 15–24 24–29 mEq/litre 29–50 50
    HCO3 <18 18–23 mmol/litre >23
    Base excess (−3) −(+3)

    PO2 or SO2 not included as all test are venous

    Source: NHS Improvement, 2010; NICE, 2015

    Staff completed an online survey after each use of POCbT with the following questions:

  • 1: Patient sex
  • 2: Presenting complaint
  • 3: Was there uncertainty about patient disposition before POCbT? If not, why were bloods done?
  • 4: Did POCbT assist decision-making? If no, why not?
  • 5: Were any POCbT results outside of normal reference range? 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, do you feel that access to POCbT results improved your (or your colleagues’) confidence in disposition?
  • Results

    The quality improvement project recruited 78 patients aged 65–97 years, with an average age of 85 years. Women made up 51.3% (n=40) of patients and men 48.7% (n=38). The majority of presenting complaints were attributed to falls (79.5%, n=62).

    Paramedics reported uncertainty in disposition 85.6% (n=67) of the time before POCbT with decision-making being improved in 84.6% (n=66) of cases and improved confidence in disposition reported in 75.6% (n=59) of cases.

    Results outside reference ranges were found in 55.1% (n=43) of the cases with 53.5% (n=23) of these requiring clinical referral or action; of these, 60% (n=14) required transportation to the ED, with the remainder receiving a primary care or outpatient frailty-specific referral. Outpatient frailty referrals were to a falls clinic, a Parkinson's specialist team or a rapid access clinic for the older person.

    Patients admitted to the ED were all subsequently admitted to a specialty hospital area and had a mean length of stay of 4.4 days (range 1–29 days). Those discharged on scene had a 5.1% (n=4) recontact rate within 48 hours and an 11.5% recontact rate within 7 days. Discharge-on-scene and recontact rates from the 2016 falls and frailty response project without POCbT were on average 49.7% for discharge on scene with a 7–day recontact rate of 14.7% (Winch et al, 2016).

    Cases described below show a range of benefits of POCbT to patient care and disposition throughout the quality improvement project.

    Case examples

    Case 1

    An 84-year-old woman with learning disabilities, hypertension and osteoporosis presented with an explained fall in the early hours of the morning. On initial assessment, the patient was uninjured and fully mobile; however, signs and symptoms suggestive of unresolved chest infection were identified. Owing to her pre-existing cognitive impairment, evaluation of severity was complicated and thought was given to providing oral antibiotics and discharging on scene.

    However, POCbT results, when compared with results taken 10 days earlier (via the ICE portal), revealed sodium levels had fallen to 122 from 136; haemoglobin was down from 128 to 82; as well as respiratory acidosis with metabolic compromise.

    Because of these findings, it was deemed necessary to admit the patient to the ED so the underlying cause of these acute findings could be investigated. The patient was admitted to the medical team from ED, who gave positive feedback regarding the use of POCbT on this job.

    Case 2

    A 92-year-old woman presented to the ambulance service after a fall in which she was not injured. She was seen by an ambulance crew who referred to the falls and frailty response vehicle as she was a regular faller and did not appear to have had any input from the falls team nor any package of care. The initial crew on scene found the patient's blood pressure (BP) to be 218/98 but she refused admission. On examination, her BP remained elevated, but she was asymptomatic and POCbT discovered a haemoglobin of 84. The patient was reporting some fatigue but no heart failure symptoms. She had not had a full blood count done since 2015.

    A referral was made back to her GP, who advised an increase in BP medication and booked a haemoglobin review. The ambulance service saw her a few months later because she had fallen again; this time, her BP was managed within normal limits and her haemoglobin level had improved.

    Case 3

    An 87-year-old woman presented with her second fall within a week. Her observations and physical examination results were within normal limits but her family was concerned about a recent increase in falls. POCbT revealed a metabolic alkalosis with mild hyponatraemia secondary to indapamide use for hypertension.

    The patient's GP was contacted, her indapamide stopped for a short period of time, and repeat blood tests were scheduled in the community. In addition, her BP would be reviewed while the indapamide was stopped. The patient did not contact the ambulance service within the next month.

    Case 4

    The crew received a referral from an ambulance crew for POCbT and the falls and frailty response service. A 94-year-old female patient with dementia had spent an unknown length of time on the floor where she had been found by carers that morning. Because of her known vascular dementia, the patient had no recollection of the fall but was uninjured, mobilising as normal and had no red-flag clinical findings on examination suggestive of syncope requiring further investigation.

    The carers said that the patient has previously not had good experiences with admission. Under normal conditions in the absence of POCbT, this patient would need conveying for creatine kinase (CK) levels to be measured to exclude acute kidney injury secondary to rhabdomyolysis from lying down for a long time. Point-of-care bloods enabled the ambulance crew to compare CK levels with a recent result (1 week earlier) and apply the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) (Lafayette, 2019) criteria for acute kidney injury. As there was no acute rise in creatinine, a GP referral was made to do a repeat set of renal function bloods to check that this had not changed.

    Discussion

    Results from this quality improvement project showed a self-reported improved confidence in clinician decision-making and patient disposition. This was validated by improvements in discharge-on-scene and recontact rates, and by patient onward management after referral. These results look promising for the continued use of POCbT in the prehospital environment. However, they are not without limitations and should not be interpreted at face value.

    The results showed high percentages of reported increased confidence and improved decision-making throughout the project. The yes/no format to measure confidence may mean the overall improvement was overstated but no increase in confidence was reported in only a few cases. Results may also have been affected by trained staff becoming used to administering POCbT and therefore reliant on results to maintain the same threshold of confidence in discharge.

    A significant number of tests returned results outside reference ranges but not all required clinical action or referral. Results that did not require action could be confirmed as normally abnormal or explained by medical history and comorbidities. Interpretation of results required complex clinical decision-making and should be the focus of any further projects using POCbT in the prehospital environment. For example, identification of respiratory acidosis may be attributed to a chronic condition such as chronic obstructive pulmonary disease or a severe pneumonia (Di Serio, 2010) but each requires a different pathway of care.

    While improvement on discharge-on-scene and recontact rates when POCbT was used have been seen, it would be difficult to determine causation because of confounding variables such as targeted patient selection, partnership with the falls and frailty response service and advanced assessment and clinical reasoning of the SP role.

    Anecdotally, cases that showed the most benefit from the use of POCbT involved patients with significant cognitive impairment or who were uncooperative to thorough physical examination or history-taking.

    Clinicians reported that combining biochemical and haematological markers with history, observations, electrocardiography and physical examination more accurately identified patient acuity and so assisted decision-making.

    Cases that did not benefit from the use of POCbT were those that required assessment of infection and the identification of sepsis. Because inflammatory markers, such as white cell count and c-reactive protein, are not included in the i-STAT Alinity assays, these cases often returned normal results yet had a high recontact rate. Lactate in these instances was not useful because it indicated hypoperfusion instead of inflammation so would often only be raised in septic shock (Andersen et al, 2013). Staff were therefore advised not to use POCbT to support the decision to discharge on scene in these cases.

    General learnings

    An unintended outcome of the project was the accumulation of practical knowledge on the use of POCbT in the prehospital environment, which could be disseminated to other services wishing to implement similar projects. Specific areas that should be considered by these services are the initial set-up and maintenance of the device and cartridges, correct demographic identification and training and interpretation of results.

    Initial set-up should ensure that ranges for action are consistent with those used by local hospitals and pathology laboratories to avoid inappropriate referrals. It is recommended to highlight ranges that trigger action as they assist with quick interpretation and reduce human error. For the benefit of data-gathering and to avoid duplication of investigations, the i-STAT Alinity should have access to a network when docked for charging with results transmitted to a local pathology laboratory.

    During project development, the target demographic should be carefully considered to maximise health economics. This project aimed to facilitate discharge on scene and/or earlier disease recognition to reduce the overall cost of care. With the initial financial outlay of the device and the ongoing costs of cartridges, it is unlikely that the addition of any POCbT device to all ambulance vehicles without targeted demographics is a realistic aim for the future. The use of specialist services such as SPs, team leaders, clinical mentors or critical care paramedics may mean that its use is targeted sufficiently without the patient demographic needing to be precisely defined.

    Maintenance of the device, cartridges and project pose logistical challenges for prehospital services. The i-STAT Alinity requires a device temperature of >15°C to operate, which can mean delays on scene during the winter months. In addition, cartridges must be stored strictly at 2–8°C and, once warmed to room temperature before use, have a reduced expiry time (CRG4=2 months;CHEM8+=14 days) and cannot be returned to cold storage. This could pose problems for ambulance stations who do not have a secure, temperature-monitored fridge.

    Finally, training and accurate interpretation of results significantly affect the outcomes of patients and the project. Access to pre-existing results is invaluable in the adequate interpretation of patients' results; paramedics should have access to senior medical advice during the use of POCbT.

    Conclusion

    While further studies are required, this quality improvement project shows that POCbT has positive effects on patient disposition, clinician confidence and earlier disease management. The project's results, while taken from a small sample and of limited transferability, look promising for the continued implementation of POCbT in the prehospital environment and in the field of frailty.

    Dissemination of lessons learned could encourage POCbT adoption in other prehospital services, ultimately leading to better patient care and outcomes, improved referrals and greater cost-benefit to the services using them.

    Key points

  • Point-of-care blood testing (POCbT) is a growing consideration in emergency services but there is limited published evidence on its use in the prehospital environment
  • Patients presenting with acute frailty syndromes can require clinically complex decisions regarding onward care and referral
  • This quality improvement project on the use of POCbT aimed to improve clinician confidence and decision-making for patients presenting with acute frailty syndromes
  • During the implementation of POCbT, many lessons were learned regarding its use in prehospital emergency care, which may be useful for other services considering its use
  • The results of the project showed that continued use of POCbT looks promising in the field of frailty but requires formal research to validate its use
  • CPD Reflection Questions

  • Reflect on other presentations seen prehospitally that might benefit from POCBT in the future.
  • Consider how you might access blood tests in a timely manner for your patient without conveyance to ED.
  • Some biochemical causes of frailty syndromes are listed in this article - what are some other common and uncommon causes?