Growing pressures on emergency departments (EDs) and ambulance services in the UK have increased the need for new approaches that can help paramedics to triage patients in a variety of settings outside hospital. These intentions, which were set out in the Bradley reports (Department of Health and Social Care, 2005; Association of Ambulance Chief Executives (AACE), 2011) and confirmed as a policy objective in Transforming Urgent and Emergency Care (NHS England, 2015) are consistent with objectives of the NHS (2014)Five Year Forward View and remain largely unfulfilled.
The National Audit Office's (2017) study of ambulance services reported that the ambulance service's progress in modernising and implementing a model of care where paramedics deliver more ‘see and treat’ services had been patchy. The wide variation in conveyance rates and the resulting implications for efficiency and patient safety were raised again as an urgent matter requiring resolution in Lord Carter's Operational Performance and Productivity in English Ambulance Trusts: Unwarranted Variations (NHS Improvement, 2018).
Point of care testing (POCT) devices have the potential to enhance clinical decision-making, accelerate time to treatment, reduce inappropriate conveyance and reassure patients. They may, therefore, have an enabling role to play in urgent care delivery by out-of-hospital care services, including paramedics (Price et al, 2010; Price and St John, 2012).
At present, there is no nationally coordinated approach for ambulance services to harmonise or regulate the diagnostic POCT equipment they use. Although general guidance is available from the Medicines and Health Care Products Regulatory Agency (MHRA) (2013), clinical laboratories in the UK, such as Berkshire & Surrey Pathology Services (BSPS), work to the more exacting standards of ISO 15189 (British Standards Institution (BSI), 2012) and ISO 22870 (BSI, 2016) for POCT governance.
Training and continued competency of staff using POCT devices are ongoing challenges. Pre-analytical testing errors (e.g. incorrect calibration and poor sampling techniques) account for up to 70% of inaccurate results and are an indicator of competency (Lippi et al, 2011). Fewer errors were down to incorrect operator performance (i.e. when the person deviated from the standing operating procedure) for the test or because devices were faulty.
If POCT results cannot be recorded within an electronic patient record, testing is likely to be duplicated once the patient is transferred. This is common, as BSPS observes with all POCT services. A contemporaneous electronic audit trail is essential for good clinical governance and invaluable should patient management be called into question.
This joint project between South East Coast Ambulance Service NHS Foundation Trust (SECAmb) and BSPS involved paramedics operating at a specialist level of the College of Paramedics (2015) career framework. These individuals had received additional training and education in primary care, including a placement with GPs, to prepare them for a more expansive role in clinical decision-making and admission avoidance.
Aim and objectives
The specific aim of the current project was to safely reduce the number of patients conveyed by SECAmb to the ED and thereby improve the patient experience. Having reliable pathology diagnostics immediately available would assist paramedics in decision-making, which would promote care being provided in the community wherever possible. Financial system savings were also anticipated.
The key objectives required to achieve this aim were:
Project approach and methods
Product design
Labkit was designed by BSPS. It contains selected POCT devices and a minicomputer, powered from a single 240V source (available from an inverter) and kept in a temperature-controlled bag commissioned from Openhouse (Merseyside). The network information technology team at Frimley Health NHS Foundation Trust worked with Conworx (now part of Siemens Healthineers) to test the use of 3G and 4G network technology to capture results on Conworx POCcelerator software. Only robust, laboratory-evaluated, password-protected equipment was used during the project and non-disclosure agreements were signed with manufacturers.
A complete electronic audit trail of testing, using patient case numbers, was recorded in addition to all internal quality control (IQC) and external quality assessment (EQA) scheme results. No patient-identifiable data were transmitted. Remote electronic access to all data transmitted by BSPS enabled oversight of the quality of the results, troubleshooting advice and good governance.
Product development
Phases 1 and 2 (proof-of-concept and impact on paramedic workload) phases were performed with the first prototype LabKit bag; this contained eight POCT devices, which offered the analyses shown in Table 1. Feedback from these two phases informed further product development; phase 3 used the second prototype Labkit bag (Figure 1).
| Device | Use |
|---|---|
| HemoCue WBC DIFF | White blood cell count with five-part differential: neutrophils, lymphocytes, eosinophils, monocytes, basophils |
| HemoCue Hb | Haemoglobin |
| Abbott i-Stat | CG4+ Cartridge: pH, pCO2, pO2, TCO2, HCO3, BE, SO2, lactate |
| Chem 8 Cartridge: creatinine, blood urea nitrogen, glucose, chloride, sodium, potassium, ionised calcium, haematocrit, TCO2, anion gap | |
| Nova StatStrip | Lactate |
| Nova StatStrip | Glucose, ketone |
| Roche CoaguChek | International normalised ratio (INR) |
| Roche Cobas H 232 | D-dimer |
| Menarini Aution Micro (Arkray Pocketchem PU-4010) | 10EA test strip urinalysis: glucose, protein, bilirubin, urobilinogen, pH, specific gravity, blood, ketones, nitrite, leucocytes |
Quality assurance
All devices in the Labkit diagnostics bag were independently evaluated by the BSPS team for acceptable analytical performance of the proposed tests. Verification testing of new batches of reagents was performed by BSPS before release, in accordance with BSPS standard operating procedures (SOPs).
Daily IQC testing was used initially, to assess device performance in the field, then weekly IQC testing (or cross-checking samples to quality-assured laboratory values) was mandatory for the managed devices. IQC testing was carried out by ‘make ready’ team operatives, paramedic practitioners or the BSPS POCT team. It was not necessary for liquid IQC material to be transported within the Labkit bag.
All managed devices were registered for EQA schemes. EQA samples were run by either paramedics or BSPS staff to ensure timely analysis and submission of results. BSPS provided training and competency-checking for all paramedics involved in the project and remained available to address any concerns arising throughout its duration.
All devices were capable of electronic result download except the Menarini Aution P4010 urinalysis device. Three Labkit bags were issued for use by 13 trained paramedics working from two ambulance stations.
Decisions on whether to place a bag in the rapid response vehicle were made each day, depending on: the availability of trained staff; the willingness and motivation of personnel to be involved in the initiative; the bag being fully serviced and ready for use; and work pressure, in that on occasions the crew were tasked before they could prepare the equipment so the Labkit could not be used even if available.
A member of the BSPS POCT team accompanied paramedics in their duties over a total period of 20 days during phases 1 and 2 to oversee use of the product, give technical advice and gather information for further development. LogTag temperature monitoring data were downloaded retrospectively when the Labkit bags were returned to the laboratory (LogTag Recorders, Auckland). Patient management was not changed during phases 1 and 2, based on Labkit results, unless these indicated that clinical risk could be mitigated by doing so.
Training
POCT training was offered at venues and dates convenient for paramedic staff and delivered in 3-hour sessions. Each paramedic was issued with a barcode password after they had completed training so they could access the password-protected POCT devices.
Training covered all three elements of testing and phlebotomy:
Phlebotomy training was provided by BSPS and all point-of-care blood tests performed in phase 3 were on venous samples.
The paramedics were issued with itemised certificates after completing training and their activity and competency were monitored from the results captured on the Conworx POCcelerator software. The final Labkit bag design was used for 6 months (December 2015–June 2016) in phase 3.
Clinical phase: phase 3
Deployment of Labkit was based on examination of the patient and physiological measurements followed by a decision on whether POCT diagnostic results could affect patient management.
The paramedics were familiar with testing regimens from their GP placement and worked to BSPS SOPs for the POCT devices as per their training. The paramedics had no previous experience of the specific POCT devices. The SOPs were provided as hard copies and as wipe-clean, easy-use guides in each bag. Practitioners also had access to a summary of 157 clinical conditions where POCT results could potentially be usefully employed, condensed from the Oxford Handbook of General Practice (Simon et al, 2010).
The introduction of the Labkit near patient-testing systems was a service-improvement study where pathology tests could be undertaken earlier in the patient pathway. While consent was sought from the patients who took part, ethics approval was not necessary as the POCT devices were already being used routinely to manage patients in both primary and secondary healthcare in accordance with their CE mark. Their use in prehospital care was therefore an innovation, but not fundamentally a radical one, provided that POCT safety and governance requirements were met. Computer-aided dispatch (CAD) numbers were used as the unique patient identifiers. IQC and EQA results were monitored by BSPS for compliance and any poor performance, with follow-up by the laboratory staff if concerns were identified.
A real-time temperature logger (PECO, Brough) became available after phase 3 had been completed. This temperature logger provides a thermostatic link to the integral heat pad with audible alarms to alert operators when the temperature inside the Labkit bag exceeds the set limits and consumables may start to deteriorate.
Key performance indicators
Diagnostic test results from the Labkit devices were sent electronically to Conworx POCcelerator software on a server at Frimley Park Hospital. Achievement against key performance indicators (KPIs) (Table 2) was assessed by BSPS staff.
| Test frequency by analyte/device | How often were specific tests/devices used? |
| Test frequency by operator | How many paramedics regularly used the product? |
| IQC frequency | Was the IQC run in accordance with SOPs? |
| Were the IQC results acceptable? | |
| Test failure rate | How often did devices fail to produce a result? |
| Error codes | What caused the devices to fail to produce a result? |
| Device down time | How often were the devices out of action? |
| IQC: internal quality control; SOPs: standard operating procedures | |
The test failure rates and frequency of error code generation give a good insight into operator competency and possible pre-analytical errors, in addition to reliability of the test systems.
Impact on patient pathway
A target patient demographic was not defined for phase 3. The paramedics made clinical decisions based on their training. This was aided by condensed information from the Oxford Handbook of General Practice (Simon et al, 2010) as to whether each patient's condition would benefit from immediate diagnostic tests and be suitable for this Labkit project.
A paper audit form was completed by the paramedics at each patient episode where Labkit was used. This form requested the following information:
.
Where paramedics reported an unequivocal change in their decision over whether to convey, based on results obtained from the use of the Labkit (in addition to their clinical assessment), this was recorded as such. Additional information was recorded where this was relevant to the decision; for example, when Labkit test results were discussed with a patient's GP to endorse the decision.
Three laboratory professionals from BSPS independently scrutinised and subsequently moderated the phase 3 data to assess whether Labkit had added value and/or altered patient management on each occasion it was used. This assessment was based upon documented changes in the patient pathway plus patient and paramedic comments given on the data collection audit forms.
Added value was inferred where Labkit results changed patient management or written statements on the audit forms demonstrated that it improved the patient, carer or paramedic experience.
No assumptions were made by the panel scoring the data. Any issues requiring clarity were referred back to the attending paramedic.
Results
Table 3 sets out data on frequency of use and demonstrates that device use differed considerably between the paramedics involved in the project.
| User | i-Stat CG4+ | i-Stat Chem 8 | Hemocue WBC | Hemocue Hb | Aution EA10 urinalysis | Total tests |
|---|---|---|---|---|---|---|
| Operator 1 | 3 | 2 | 3 | 3 | 1 | 12 |
| Operator 2 | 1 | 0 | 1 | 2 | 0 | 4 |
| Operator 3 | 0 | 0 | 1 | 2 | 1 | 4 |
| 0 | 0 | 2 | 2 | 0 | 4 | |
| Operator 5 | 3 | 3 | 1 | 2 | 1 | 10 |
| Operator 6 | 27 | 27 | 24 | 18 | 14 | 110 |
| Operator 7 | 3 | 3 | 8 | 6 | 1 | 21 |
| Operator 8 | 11 | 8 | 8 | 6 | 2 | 35 |
| Operator 9 | 25 | 23 | 25 | 26 | 9 | 108 |
| Operator 10 | 0 | 0 | 3 | 0 | 0 | 3 |
| Operator 11 | 3 | 3 | 3 | 1 | 0 | 10 |
| Operator 12 | 3 | 3 | 0 | 3 | 0 | 9 |
| Operator 13 | 7 | 8 | 8 | 9 | 1 | 33 |
| Total tests | 86/118 | 80/118 | 87/118 | 80/118 | 30/118 | 363 |
| % use | 73% | 68% | 74% | 68% | 25% |
Internal quality control frequency
SOPs instructed operators to run IQC samples (where available) through each managed device weekly. The HemoCue WBC test required operators to ensure that a laboratory comparison check was performed at least once per week. Paramedics performed the electronic IQC check on the Aution urinalysis devices.
With all three Labkit bags operational on and off throughout the project's duration period, compliance with IQC frequency was assessed by logging the number of patient tests and EQA samples run within 1 week of a previous IQC test.
The data for IQC compliance in Table 4 shows a wide range of 32–87%. As with uptake of the devices in general, significant variation was observed between ambulance stations and operators. Availability of BSPS staff to follow up on non-compliance, even when facilitated by remote download of results, also affected this KPI score.
| Test profile | i-Stat CG4+ | i-Stat Chem 8 | HemoCue WBC | HemoCue Hb |
|---|---|---|---|---|
| Labkit 1 | 64% (43/67) | 65% (43/66) | 69% (36/52) | 32% (8/25) |
| Labkit 2 | 43% (12/28) | 46% (12/26) | 53% (8/15) | 87% (13/15) |
| Labkit 3 | 82% (28/34) | 85% (28/33) | 46% (11/24) | 70% (39/56) |
| EQA: external quality assessment; IQC: internal quality control | ||||
The requirement for paramedics to submit WBC samples to the BSPS POCT team for cross-checking on other analysers was operationally difficult, as it depended upon ambulance crews reporting to the appropriate hospital at the appropriate time. Some delays were observed between the POCT analysis and the laboratory check which, in some cases, resulted in sample degradation, negating the validity of the result.
Aution urinalysis results could not be downloaded. Manual interrogation of each Aution device could not differentiate which results were from patient tests and which were from electronic IQC results so very little performance data could be retrieved from this unmanaged device.
The SECAmb paramedics were keen to have urinalysis available as part of the working product because of the high incidence of urinary tract infections encountered so, in the absence of any viable alternative (mainly owing to size constraints), the Aution device was included in the Labkit bag as an unmanaged device. This was on the understanding that full governance could not be provided by BSPS and results would require documentation under existing SECAmb protocols.
Internal quality control performance
When IQC samples were tested according to protocol, the results were rarely out of range. As shown in Table 5, the one notable exception was for the i-Stat CG4+ cartridges, where IQC success was below 70% because a significant number of high pO2 results were generated by users of all three Labkit bags. This is a typical scenario for this device/cartridge where correct pre-analytical preparation of the IQC material is critical, and the high pO2 levels indicate overvigorous mixing of the sample.
| Test profile | i-Stat CG4+ | i-Stat Chem 8 | Hemocue WBC | Hemocue Hb |
|---|---|---|---|---|
| Labkit 1 | 64% (18/28) | 95% (21/22) | 95% (21/22) | 96% (23/24) |
| Labkit 2 | 69% (11/16) | 100% (11/11) | 100% (3/3) | 92% (33/36) |
| Labkit 3 | 65% (22/34) | 89% (17/19) | 100% (6/6) | 98% (43/44) |
Test failure rate
If a diagnostic test is performed incorrectly or the POCT device detects a problem that will affect the quality of results, an error message may be produced and no results will be available.
During phase 3 of the Labkit project, error codes were generated by the POCT devices on 39 occasions (Table 6). If this failure rate is considered in relation to the 118 instances of clinical use, it suggests that problems were experienced in a maximum of 33% of cases. On these occasions, the problems were logged and patients managed without the benefit of Labkit results.
| Device | Error | Frequency |
|---|---|---|
| i-Stat | Cartridge handling | 14 |
| Unable to position sample | 7 | |
| Overfilled cartridge | 9 | |
| Underfilled cartridge | 8 | |
| HemoCue WBC | – | 0 |
| HemoCue Hb | High dark level | 1 |
| Aution EA10 | – | 0 |
| Total error codes | 39 | |
Error codes
It can be seen from Table 6 that the most common failure was with the i-Stat device giving a cartridge handling error. This error is not uncommon for the i-Stat as it is quite easy to squeeze the test cartridges too hard upon insertion and damage the small pouches of reagent within them. Over- and under-filling of the cartridges was also observed. These are competency issues that improve with experience. The two HemoCue devices and the Aution urinalysis proved robust in this respect.
Device down time
No device down time was experienced for any of the devices throughout the study.
Impact on patient pathway
The SECAmb paramedics deployed Labkit in 25% of patient episodes where a bag was available. This was typically for three patients in each 24-hour period.
The outcome data recorded using three Labkit bags, deployed in two ambulance stations, are summarised in Table 7.
| Data recorded | Frequency |
|---|---|
| Total Labkit events | 100% (118) |
| Total valid audit forms | 82% (97/118) |
| Excluded audits, incomplete data or no paperwork | 18% (21/118) |
| Equivocal information—unable to clarify retrospectively | 1% (1/97) |
| Paramedic decision supported | 68% (66/97) |
| Paramedic decision changed, conveyance to ED avoided | 21% (20/97) |
| Paramedic decision changed, conveyance to ED required | 10% (10/97) |
| Cases where Labkit added value | 97% (94/97) |
From the 118 instances of Labkit use, 97 valid audit forms were completed by the 12 paramedics who continued to engage with the product. In 15 of the 97 cases, the laboratory professionals scoring the audit data were unable to make an unequivocal assessment and these instances were referred back to the paramedic coordinating the study who was able to consult the paramedic who had completed the record and obtain absolute clarification.
The most common conditions stated for Labkit investigations being used were urinary tract infection (25%), lower respiratory tract infection/chronic obstructive pulmonary disease (22%) and sepsis (13%).
Paramedics also recognised the benefits of having extra diagnostics available for patients with dementia, where recall of signs and symptoms could be unreliable.
With 21% of ED admissions avoided and 10% of patients conveyed who would otherwise have been left at home, a total of 31% of the paramedics' decisions were changed by having the Labkit pathology diagnostic test results available immediately.
The avoidance of ED admissions included patients where infection or sepsis was excluded, urinary tract infection was confirmed and treated locally or a requirement for blood transfusion could be ruled out.
The patients who had accelerated conveyance because of Labkit diagnostic results included detection of acute kidney injury, electrolyte imbalance, severe anaemia, infection and deranged blood gas status.
In one instance, a patient was admitted directly to a hospice, negating a visit to the ED for blood tests and, in another, a patient was fast-tracked directly to the intensive care unit. This streamlined the patient journey to their inevitable destination with inherent savings to the service and benefits to patient care.
Patient satisfaction and added value
Each patient who consented to having Labkit tests performed to inform their care was asked to score their satisfaction with the process on a scale of 1–5, with 5 being 100% satisfied. A total of 75 patients (or their carers) were able to respond and an average patient satisfaction score of 4.9 was achieved (the lowest score was 4).
Because they had test results to hand, the paramedics reported greater confidence in conversations with GPs, other health professionals, patients, relatives and care home staff. It also gave greater confidence to those being consulted about any recommendations made by the paramedics.
On the occasions where the Labkit results simply confirmed the original diagnosis or reassured the patient and family in any other way, this was assessed as adding value, even though patient management was unchanged.
The moderated result was that Labkit was well received and added value on 97% of the occasions it was deployed. However, this finding must be regarded as only indicative; further in-depth work was beyond the scope of this project and it would need to be verified in repetitions of the project.
Potential system impact of Labkit
Based on information from SECAmb and phase 3 audit data, the use of one Labkit bag in a single rapid response vehicle could have a positive system impact, as shown in Table 8.
| Call-out frequency (rapid response vehicle) | 12 times/24-hour period (4380/year) |
| Frequency Labkit likely to be required | 3 times/24 hours (25% of calls) (1095/year) |
| From phase 3 | 21% not conveyed because of Labkit |
| 0.21 × 1095 = 230 patients/year | |
| From phase 3 | 10% fast tracked to clinical area because of Labkit |
| 0.10 × 1095 = 110 patients/year |
The Labkit therefore offers the opportunity to improve 340 patient pathways every year for each bag that is in operation. The impact on the wider health economy has not been considered. Although a preliminary cost-benefit analysis looks favourable, it did not form part of the current project.
Discussion
This project has successfully combined the strengths of two healthcare professions whose paths rarely cross although each has much to teach the other. The POCT expertise at BSPS has been channelled to create a product that has been through several development stages and performed well, and offers opportunities for future development. All paramedics involved in the project were experienced in the use of the tests involved, having undergone post-registration training including work in GP practices.
Assuring the quality of the POCT results enabled paramedics to be confident in the information provided and to adapt patient management. Oversight by BSPS enabled issues such as bags being left unplugged overnight to be identified and action taken to replace consumables that may have perished because of low temperatures.
KPI data confirmed that the POCT devices chosen for Labkit for the evaluation were appropriate. Although device selection remains flexible to fit end-user requirements, it was operationally difficult to ensure trained operators had adequate opportunities to use the Labkit products as soon as they had completed their training, and this is reflected in the emergence of key local champions or super-users, as happens for POCT device use in secondary care.
The IQC compliance figures from the study were disappointing, with the ability to perform weekly IQC as low as 32%. This project was instigated when staffing pressures on the ambulance and pathology services were stretched, a situation that continues. Additional complexity was introduced by having to check POCT WBC results on a laboratory analyser because of the lack of IQC material.
When IQC tests were run, the results were generally very good and continue to support the concept that the Labkit has a role to play in triaging patients. As with any POCT project, adequate staffing is essential to embedding the governance processes required. The target for IQC compliance must be 100% for the Labkit vision to succeed. Ideally, all EQA samples should be analysed by the end-users of the devices, rather than the laboratory support staff, and the logistics of being able to do this require further attention.
Inadequate levels of pathology and specialist paramedic staff could be a major limiter to the success of this approach, even though system savings are possible down the line.
Labkit proved to be a robust POCT solution suitable for use by paramedics in primary and urgent care roles. There was some resistance to incorporating blood glucose monitoring devices within the Labkit bags as this test is already well established across all ambulance services. However, governance for blood glucose monitoring by paramedics is frequently inadequate. The MHRA (2013) guidance requires a full audit trail of results and regular IQC, EQA and training/competency records, and commonly used critical diagnostic testing should be high on the list for future consideration.
Phase 3 demonstrated that using the Labkit reduced the conveyance of patients to EDs and an unexpected benefit of fast-tracking deteriorating patients. Effective risk stratification of patients was also evidenced.
The present study supports the notion that real-time pathology test results can deliver potential benefits within an optimised system. Armed with additional diagnostic test results, paramedics were able to convey more detailed information to other healthcare providers, opening options for community care rather than conveyance to the ED. Primary care colleagues were appreciative of the additional information and patient satisfaction was high.
The patients who were identified as requiring conveyance only because of the POCT were likely to have triggered a subsequent call or had a more complex pathway with the potential for a worse outcome or longer hospital stay without it.
Previous instances of service improvements based on the use of new technology (e.g. 12-lead electrocardiogram (ECG) devices) were slow to be adopted but are now essential tools in the provision of optimal patient care by ambulance services. As the role of the paramedic expands, the use of supporting technologies, such as Labkit, are likely to become more central to safe paramedic practice.
Limitations
This service evaluation was a small-scale but complex project, which benefited from the ability to deploy experienced paramedics who were familiar with the standard tests involved from their previous training. These personnel were able to use established technology adapted for out-of-hospital use under expert remote guidance from the pathology service.
Paramedics were considered to be sufficiently experienced regarding the indications for a test to be undertaken but were provided with an aide-memoire of 167 common conditions matched to potentially useful tests. They also had an extensive array of additional procedures beyond the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance to assist them. There was no suggestion that clinical decisions were in any way questionable. Nevertheless, further investigation of the integration of POCT into paramedic clinical decision-making may be appropriate in the future.
Patient pathway-tracking was largely facilitated by the fact that, in most cases, patient encounters occurred within the catchment area of one large district general hospital, which was also the base for the regional pathology service. Nevertheless, tracking was time-consuming and could be revisited on a much larger scale with more detailed endpoints, and powered to discriminate between a wider range of variables. Given that this project was conceived as a service evaluation, taking existing technology to patients in a community (the ambulance service patient population setting), it was not resourced to enable the definitive follow-up of individual patient outcomes. While the data indicate only positive effects and no adverse outcomes, further, more detailed evaluation of Labkit and its impact upon patient pathway selection is indicated. Similar limitations exist in respect of establishing patient satisfaction, which would benefit from more rigorous assessment.
Great emphasis was, correctly, placed upon the reliability of the tests employed, especially in relation to quality assurance, as would be the case in a hospital environment. In practice, maintaining standards to this level proved possible but somewhat difficult and, although this paper provides some indications as to why this might be the case, further attention needs to be given to this important area.
Possibly related to this finding is the variation in the use and availability of Labkit. The employment of POCT showed much more variation than was anticipated, and this could not be adequately explained within this project, although any change to process always takes some time to be fully accepted. It is therefore an area worthy of further elaboration.
Finally, before any large-scale application of POCT technology in a paramedic-led, out-of-hospital environment could be contemplated, detailed consideration as to the health economics of any such routine augmentation to clinical practice would be appropriate. Such elucidation would need to be conducted by those with the relevant expertise in cost-benefit analysis.
Conclusions
Valuable insights have resulted from two groups of health professionals pursuing a shared objective that was attainable only through the close collaboration of both professions. Progress in integrating POCT into the practice of paramedics, with the intention of safely reducing the number of patients conveyed to the ED, was made. Preliminary data suggest but cannot yet confirm that economic system benefits may also be derived from this approach.
Other environments that may benefit from the use of the Labkit are unlikely to be as challenging as that reported in this project. Hence this work may have implications for urgent care centres, mental health institutions, prisons, care homes and larger health centres. Further studies will require a more in-depth examination of the complete patient pathway, including clinical outcomes and comparison of two parallel services, with and without the Labkit, for demographically matched patient populations.
Analysis of the health economics and the impact of conveying patients who may have deteriorated if left at home is also required.
Nonetheless, this project has helped to not only establish the feasibility of bringing POCT to patients who rely upon paramedics and the ambulance service for their care but also to frame the scope of future comprehensive evaluation efforts.
The limitations of this service evaluation are recognised and the need for detailed research involving a larger group of patients acknowledged. Notwithstanding these considerations, early indications suggest that the inclusion of POCT to the armamentarium of specialist paramedics holds the prospect of improving patient care and economic efficiency.