Solving point of care testing challenges? Learnings from the NHS

Tony Cambridge, Lead Biomedical Scientist

Pathology Management

Solving point of care testing challenges? Learnings from the NHS

17 June 2020

Quick Takes

  • Point of care testing (POCT) can help to obtain diagnostic information earlier in the patient pathway, which may be linked to reduced healthcare costs and improved patient outcomes

  • Pathology networks that enable POCT throughout a region of the UK have been implemented to alleviate health system pressures

  • A successful POCT network needs a common governance structure and accreditation to ensure quality and reliability of services, appropriate leadership and resources, and connectivity and informatics to provide effective service oversight

Point of care testing delivery within pathology networks     

The healthcare system is under extreme pressure to deliver effective patient care at the right point in the care pathway. National initiatives in the United Kingdom (UK) to reduce the number of patients cared for in hospitals have not succeeded, with attendances at emergency departments across the National Health Service (NHS) at an unsustainable level.

Point of care testing (POCT) has the power to disrupt traditional pathways and support improved patient outcomes by:
  • Enabling patients to access diagnostics early, before their symptoms indicate a hospital visit
  • Enabling community based healthcare to manage conditions outside of the secondary care setting
  • Enabling first responders to gather diagnostic information about the patient before reaching the hospital
  • Enabling Emergency Departments to triage patients effectively avoiding admissions where possible
  • Enabling secondary care entry points to assess which specialty service the patient requires
  • Reducing delays in obtaining medical information in emergency and routine settings, allowing earlier discharge driving down length of stay and freeing up capacity

Obtaining diagnostic information earlier in the patient pathway has been shown to reduce the cost of subsequent healthcare.1

Patients attending an ambulatory care setting may require a hospital visit for specialist assessment. Many will need a treatment plan requiring further attendances at the hospital, but this does not mean they need to be admitted to receive that care plan. Therefore the target should be zero admissions and zero days length of stay for patients not needing admission. 

Some patients are given a bed whilst not receiving any further care during their stay. Laboratory results are awaited and reviewed the next day. The health economy would benefit if hospitals can regularly save bed days and avoid cancellation of elective procedures, whilst ensuring capacity issues do not impact on the operational flow of the hospital including discharges.                                                                                           

In order for POCT to help improve health system efficiency and reduce hospitalization, we would need the following:
  • POCT teams need to be adequately resourced to support services in the community, hospital, general practitioner (GP) offices and health centers
  • Providing the level of governance required to support decentralized testing is challenging. The development and funding of cross-organizational teams should be high on the agenda of healthcare leaders aiming to improve overall patient management and hospital flow

Case study: South 1 region in the UK

Establishing pathology networks to enable POCT 

NHS Improvement (NHSI) has defined that pathology networks must be formed. 29 networks have been established across England adopting a hub and spoke model for pathology laboratories in each network region, where appropriate. 

establishing pathology networks to enable POCT

NDHT: Northern Devon Healthcare NHS Trust; RCHT: Royal Cornwall Hospitals NHS Trust; RD&E: Royal Devon & Exeter NHS Foundation Trust; SDFT: South Devon Healthcare NHS Foundation Trust; UHP: University Hospitals Plymouth NHS Trust

Laboratory services have concentrated on working collaboratively and consolidating workload. Decentralized testing must also be considered when defining healthcare strategies within each network. 

The most effective POCT services in the UK are those with:
  • Well-defined leadership
  • Clinical and managerial support
  • Effective governance structures
Focused network POCT groups should be set up to:
  • Review the current provision of POCT across the network
  • Standardize tests
  • Adopt POCT where evidence suggests it would be impactful
  • Deliver change within the network to support improved patient outcomes

A common governance structure is key to improving quality, and ensuring patient safety. This includes standardized devices, training and competency, and documentation. Harmonizing services across regions is also in line with the Get It Right First Time (GIRFT) program, which aims to improve the quality of care in the NHS through removal of avoidable errors in processes. A well governed service model promotes the removal of unwarranted variation, the driver for collaborative working detailed by NHSI.

Opportunities of POCT to improve healthcare services and patient outcomes

Point of care testing has the potential to provide respite to patient services that could be delivered somewhere more appropriate. Difficulties in providing GP consultations has resulted in improved access initiatives within the primary care networks (PCNs). These initiatives include longer opening hours including weekends, increased phlebotomy availability, and more specialist nurses employed who are trained to prescribe. 

Longer opening hours will put additional strain on diagnostic services and those services supporting disease management, unless the working practices are redesigned, further adding to the economic burden within the healthcare system. On the other hand, patients are likely to develop worsening symptoms if a consultation with a healthcare professional is delayed through lack of availability, resulting in a hospital visit or stay. 

If alternatives for patients were well publicized, and an increased awareness of access to rapid diagnostics when symptoms first present, there would be a reduction in hospital and home visits for these patients. The knock on effect would be a reduction in admissions with associated cost avoidance.

In order to achieve this, diagnostics would need to be available in multiple locations as shown in the diagram below. Pharmacies, GPs and health centers in networks could access equipment situated at the most convenient location within that group. 

The most effective POCT services in the UK

Further opportunities exist within the emergency services with ambulances, including the air ambulance service. Testing made available to those healthcare professionals, backed up by clinical interpretation, could avoid a hospital visit or provide emergency department physicians with important clinical information on arrival.     

Key features of a successful POCT network

Governance and quality

POC tests are now showing laboratory level accuracy or are accurate enough to provide a clinician with adequate information to make a decision on the needs of that patient. A result of sufficient quality, more rapidly obtained, can have a positive impact on patient management and improved outcomes. 

A well designed quality program is required to meet the governance challenge. The following elements are central to sustaining quality across the service:
  • Establish a POCT management group. The International Organization for Standardization (ISO) state a POCT management group should be in place which deals with day-to-day operational issues and reports directly to a POCT governance group that has the responsibility for approving new services and critically reviewing service performance. This group reports to higher level governance within the organization
  • Seek support from a governance group. Responsibilities must be defined through a Service Level Agreement (SLA)
  • Create a training plan. Quality and safety are paramount when offering diagnostics away from the traditional laboratory especially when non-laboratory staff conduct the testing, review results and potentially change patient management and treatment. Practices common to trained laboratory staff are not so well understood by staff in patient facing roles. This includes activities such as calibration, internal quality control, maintenance procedures and external quality assurance. Staff must be well trained in these practices and follow standard operating procedures that define how a test is delivered to ensure the accuracy and validity of results

Accreditation

Compliance with ISO standards (ISO 15189:2012 and 22870:2016, soon to be combined) indicates a service is effectively managed, with the appropriate levels of safety and quality assured. Compliance with the standards is an ongoing commitment with a requirement to regularly generate a range of evidence to assure that processes are well controlled.

Accrediting both hospital and community activities requires multi agency buy in, cooperation and dedicated leadership. Accreditation can be applied for in steps and this should be discussed at an organization level within networks.

The standards state that the pathology quality manager is responsible for ensuring that POCT activities conform to the quality standards of the laboratory. The appointed quality manager for the laboratory needs to be invested in the delivery of the POCT service as much as that of the laboratory, and should view the accreditation process and subsequent assessment cycle as part of the departmental objectives.

Leadership and resources

A collaborative approach within pathology networks and the community is required to deliver a common vision for point of care services in that region. Networks may benefit from centralized leadership but this is a regional decision.

The development of local hospital and community initiatives is a joint clinical and managerial decision. Careful consideration is required in order to:
  • Establish an effective workforce, increasing the number of support workers, scientific, managerial and clinical grades, not necessarily from pathology
  • Quality management time is essential so that international standards are continuously met
  • A holistic approach to workforce funding must be agreed to avoid working in silos that has previously created barriers to POCT progress
  • A workforce proposal is required detailing the activities that staff will undertake and where community staff fit into the overall structure. The end goal is a fully operational team that works across the existing boundaries of community and acute care

Connectivity and informatics     

New data managers are now available, designed to provide the informatics to meet ISO requirements and provide effective service oversight.

Community areas are able to connect to hospital hosted middleware. The use of cellular networks is being explored in ambulances and paramedic vehicles. Connection to traditional middleware can also be achieved if firewall issues are addressed with the organization’s information and communications technology (ICT) departments who must work with POCT teams to achieve effective system integration.

A complete electronic patient record (EPR) is essential to support continuous care across different healthcare providers. Gaps in the EPR leads to rework, wasted resources and increased cost associated with retesting. Clinicians would rely on electronic rather than paper records which are prone to inaccuracies or omissions. POCT results must be labelled clearly to show when and where they were generated, and by whom. Batch numbers of reagents and consumables must also be traceable.

Connectivity solutions give full traceability of a test result. A joint procurement between acute care and the community is required in order to adopt the appropriate solution. Community locations and devices can be added over time, cross charging the connections and licensing.

Next steps for healthcare leadership to support the development of POCT services

Patients and healthcare workers require choice around where and when diagnostics can be accessed. Hospital and community executives need to support the development of POCT services to maximize the potential improvements in patient care.

Well governed services will deliver significant improvements in patient outcomes and efficiency savings to support the healthcare economy. Managing patients outside of the hospital setting will reduce overcrowding and alleviate the pressure on emergency departments, leading to financial savings linked to fewer attendances and admissions.

Healthcare leaders must consider the following:

1A set of goals and objectives for pathology networks to achieve to include decentralized testing
2Prove the concept by initiating hospital and community based trials of POCT services
3Develop a workforce plan that will support the successful delivery of the objectives
4Establish the leadership within the service
5Measure progress and define a reporting structure to share lessons learned

The challenge remains to expand services and remove unwarranted variation, along with increasing public awareness of accessibility.

Tony Cambridge, Lead Biomedical Scientist is the Managing Director of Thornhill Healthcare Events and Consultancy, and Lead Biomedical Scientist in the Pathology Management team of a busy acute care hospital in England. He frequently speaks at national and international healthcare events and is a key opinion leader for point of care testing. He recently cowrote the British Society of Haematology’s point of care testing guideline for general hematology and remains active across healthcare platforms offering advice and guidance. He is also a member of a global diagnostics company’s scientific advisory committee.

References

1. Weihser and Giles. (2018). Br J Hosp Med 79, 520-523