The U.S. healthcare system continues its rapid transition from a transactional, fee-for-service-based economic model, to one based on quality and outcomes. Healthcare system payers are rewarding providers that can demonstrate value by improving patient outcomes and reducing the cost of healthcare delivery. Although EMS represents a small percentage of healthcare expenditures, we drive (literally) substantial downstream costs of healthcare.
One of the keys to success for the EMS system in the new healthcare landscape is to improve patient outcomes by assuring the right patient receives the right care at the right time and in the right setting. Accurate clinical assessments and critical decision-making is a crucial ingredient in the demonstration of value. Point-of-care (POC) testing can be an essential tool for enhancing patient assessments in the out-of-hospital setting.
Your patient is a 78-year-old female complaining of fever, nausea, vomiting, chills and a decreased urine output from a Foley catheter, according to the family. Your assessment reveals a heart rate (HR) of 128, respiratory rate (RR) of 30 and shallow, clear lung sounds, and a blood pressure (BP) of 94/50. Her skin is cool and diaphoretic with a temperature of 96.3 degrees F. Her ECG is unremarkable and her Glasgow coma scale (GCS) score is 13.
From the information and assessment above, you consider a few possible working diagnoses, but one additional assessment tool will help your field assessment significantly: the patient’s lactate level.
Lactate is a marker for cellular hypoxia and one of the definitive assessments for sepsis. A level above 4.0 mmol/L is associated with a 27% mortality rate, compared with a mortality rate of 7% for patients with a lactate level of 2.5-4.0 mmol/L and a death rate below 5% for those with a lactate level below 2.5 mmol/L.1
There’s evidence that early recognition and treatment of severe sepsis, including early delivery of antibiotics, is associated with improved outcomes.2 Knowing this information in the prehospital setting allows EMS providers to provide a more complete assessment and, if appropriate, activate a “Code Sepsis” if processes are in place to speed assessments and treatments for septic patients.
Code Sepsis is designed to facilitate early recognition of severe sepsis in floor patients and then rapidly deliver a bundle of care based on the Surviving Sepsis Campaign Resuscitation Bundle,3 including drawing a lactate level, obtaining blood cultures before antibiotics, giving antibiotics within one hour, and providing fluid resuscitation in cases with hypotension or high lactate levels.
You’re on an unscheduled home visit for an enrolled patient in the readmission prevention service line of your Mobile Integrated Healthcare (MIH) program. The patient called your nonemergency number requesting the visit because of increased dyspnea on exertion. During your assessment you note that since your last visit two days ago, the patient has gained six pounds and has +2 dependent edema. An assessment reveals an HR of 90, RR of 24 and slightly labored with rales bilaterally at the bases, and a BP of 152/100. The patient’s skin is warm and diaphoretic with a temperature of 99.5 degrees F. ECG is unchanged from the last tracing and GCS score is 15.
Based on these findings, you initially determine the patient to be a candidate for the diuresis protocol jointly authorized by your agency’s medical director and the patient’s cardiologist. The protocol requires contact with the patient’s primary care physician (PCP) and a POC test to assess the patient’s blood urea nitrogen (BUN), creatinine and potassium levels to ensure the patient’s kidney function will handle the diuresis.
You take out your i-STAT POC testing device, draw the appropriate blood sample for analysis and find the following:
- Potassium (K+): 3.7
- BUN: 20 mg/dL
- Creatinine: 1.0 mg/dL
You call the patient’s PCP and report your assessment findings. Based on the assessment and the i-STAT readings, the PCP authorizes use of the diuresis protocol and says she’ll see the patient tomorrow morning in her office for follow-up.
All patients enrolled in MedStar’s MIH programs for readmission prevention have baseline i-STAT readings conducted and documented.
MedStar Mobile Healthcare in Fort Worth, Texas, has been conducting MIH programs since 2009. Through our High Utilizer Group (HUG) and Readmission Prevention programs, we often assist patients with congestive heart failure (CHF) with management of their disease process in the post-acute setting. The readmission prevention program has demonstrated a 72% reduction in preventable readmissions and the HUG program reduces ED visits by 48%. These outstanding results are the product of an evolution of trial and error in managing patients with chronic illnesses such as CHF.
In the early implementation of our CHF readmission program, we weren’t as successful as we wanted to be, primarily because although we were able to help patients identify when their CHF was worsening, we didn’t have any definitive medical interventions available. Then came a conversation in 2012 with the cardiologist member of our medical control board, Farhan Ali, MD, MA, MPH, FACC, FSCAI, RPVI. Ali worked with numerous area cardiologists to develop a first-of-its-kind in-home diuresis protocol for use by MIH providers to enhance the ability to reduce preventable ED visits and readmissions.
The cardiologists felt that in order to safely implement a field diuretic protocol, the physician would need to know the patient’s BUN, creatinine and potassium levels. After extensive research and recommendations from our partner agencies, we decided the i-STAT POC testing system was the most appropriate device for this application for several reasons.
First, its Chem 8+ cartridge is waived by the clinical laboratory improvement amendments (CLIA) and can measure the requested blood labs. CLIA-waived tests are defined by the Centers for Disease Control and Prevention as simple tests with a low risk for an incorrect result. These tests are therefore approved for waiver by the Food and Drug Administration using the CLIA criteria, making them eligible to be performed in the prehospital setting. The most common is the use of glucometers to assess a patient’s blood sugar level. Without a CLIA waiver, the test and testing process would need to be performed by a full laboratory, most often in the full laboratory.4
Second, it’s easy to use in the field, essentially not much different than the glucose monitors we’re accustomed to using. Third, the price point for the device-$10,000-was reasonable for a fledgling MIH program to build a business case for. And, fourth, many of our partner hospitals use the i-STAT for POC testing in their EDs. As such, the physicians we interface with are aware of the device and its reliability.
Today, all patients enrolled in our MIH programs for readmission prevention have baseline i-STAT readings conducted and documented. We use five units in the field and are often requested by the patients’ physicians to perform a Chem 8+ to gain a better understanding of the patient’s clinical presentation. We also re-test patients at various times during the enrollment to determine any trends in the lab values, as well as have those comparison readings if we need to do a comparative assessment prior to a diuretic protocol implementation. This is an invaluable assessment tool for the effective management of these patients.
Further Uses of POC Testing
The i-STAT’s Chem 8+ cartridge is the only cartridge we use in the field, primarily because it’s the only CLIA-waived cartridge. However, our partner agencies have routinely asked about the use of other cartridges for coagulation, hematology and cardiac markers that would be able to test labs such as prothrombin time (PT), international normalized ratio (INR), hematocrit (Hct), hemoglobin (Hgb), troponin (cTnl) and lactate levels. These tests would be exceptionally valuable for patients receiving anticoagulant or blood transfusion therapy, experiencing a cardiac event or being assessed for possible sepsis.
Because POC testing has been shown to alter prehospital care in up to 30% of its uses,5 it may be logical for prehospital systems to consider implementing a POC testing system. Information gleaned from the i-STAT data can be used to treat electrolyte imbalances, adjust medications and ventilator settings, and even change IV fluid use. MIH providers can also use the data from POC testing to provide important feedback to physicians about enrolled patients.
All of these uses support critical clinical decision making by field EMS providers, and will perhaps even help promote the value proposition we’re all striving for in our EMS delivery models.
1. Boschert S. (November 2007.) Is it septic shock? Check lactate level. American College of Emergency Physicians. Retrieved April 18, 2016, from www.acep.org/Clinical—Practice-Management/Is-It-Septic-Shock–Check-Lactate-Level/.
2. Jones C, Currie‐Cuyoy M, Jackson T. Code sepsis: Rapid identification and treatment of severe sepsis in floor patients [abstract]. J Hosp Med. 2013;8(suppl 2): [e-pub before print.]
3. Surviving Sepsis campaign. (n.d.) Bundles. Retrieved April 18, 2016, from www.survivingsepsis.org/Bundles/Pages/default.aspx.
4. Centers for Disease Control and Prevention. (March 16, 2016.) Clinical Laboratory Improvement Amendments (CLIA). Retrieved April 19, 2016, from wwwn.cdc.gov/clia/resources/waivedtests/.
5. Gruszecki AC, Hortin G, Lam J, et al. Utilization, reliability, and clinical impact of point-of-care testing during critical care transport: Six years of experience. Clin Chem. 2013;49(6):1017-1019.