BMJ 1998;316:1052-1057 ( 4 April )

Papers

Point of care testing: randomised controlled trial of clinical outcome

Jason Kendall, senior registrar in accident and emergency medicine, ^a Barnaby Reeves, senior lecturer in health services research, ^b Michael Clancy, consultant in accident and emergency medicine. ^a

^a Department of Accident and Emergency Medicine, Bristol Royal Infirmary, Bristol BS2 8HW, ^b Research and Development Support Unit, Department of Social Medicine, University of Bristol, Bristol BS8 2PR

Correspondence to: Dr Kendall Frenchay Hospital NHS Trust, Bristol BS16 1LE jason.kendall{at}cableinet.co.uk

Objectives: To describe the proportion of patients attending an accident and emergency department for whom blood analysis at the point of care brought about a change in management; to measure the extent to which point of care testing resulted in differences in clinical outcome for these patients when compared with patients whose samples were tested by the hospital laboratory.
Design: Open, single centre, randomised controlled trial. Blood samples were randomly allocated to point of care testing or testing by the hospital's central laboratory.
Setting: The accident and emergency department of the Bristol Royal Infirmary, a large teaching hospital which cares for an inner city population.
Subjects: Representative sample of patients who attended the department between April 1996 and April 1997 and who required blood tests. Data collection was structured in 8 hour blocks so that all hours of the day and all days of the week were equally represented.
Main outcome measures: The proportion of patients for whom point of care testing brought about a change in treatment in which timing was considered to be critical to clinical outcome. Mortality, the length of stay in hospital, admission rate, the amount of time spent waiting for results of blood tests, the amount of time taken to decide on management plans, and the amount of time patients spent in the department were compared between patients whose samples were tested at the point of care and those whose samples were sent to the laboratory.
Results: Samples were obtained from 1728 patients. Changes in management in which timing was considered to be critical occurred in 59 out of 859 (6.9%, 95% confidence interval 5.3% to 8.8%) patients in the point of care arm of the trial. Decisions were made 74 minutes earlier (68 min to 80 min, P<0.0001) when point of care testing was used for haematological tests as compared to central laboratory testing, 86 minutes earlier (80 min to 92 min, P<0.0001) for biochemical tests, and 21 minutes earlier (3 min to 44 min, P=0.09) for analyses of arterial blood gases. There were no differences between the groups in the amount of time spent in the department, length of stay in hospital, admission rates, or mortality.
Conclusion: Point of care testing reduced the time taken to make decisions on patient management that were dependent on the results of blood tests. It also brought about faster changes in treatment for which timing was considered to be critical in about 7% of patients. These changes did not affect clinical outcome or the amount of time patients spent in the department.

Key messages Point of care testing reduced the amount of time doctors spent waiting for results of blood tests when compared to the time spent waiting for results from the hospital laboratory in an accident and emergency department The time taken to decide on a management plan was also reduced as a result of the shorter time spent waiting for results of point of care tests About 7% of patients who needed urgent blood testing had changes in treatment in which timing was considered to be critical when point of care testing was used Patients did not spend less time in the accident and emergency department even when test results were available more quickly and patient management decisions were made more quickly. This suggests that the availability of test results is not the factor which slows down the arrangement of further care Improvements in process, such as a reduction in the time doctors wait for test results and the ability to make clinical decisions more quickly, do not seem to improve clinical outcome in this sample of patients

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© BMJ 1998
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