Abstract & Commentary
Source: Mainor BH, et al. Evaluation of a portable clinical analyzer in the pediatric emergency department: Analysis of cost and turnaround time. South Med J 2002;95:634-638.
Recent advances in point-of-care testing have shown promise in reducing turnaround time in adult emergency departments (EDs). Now, Mainor and colleagues present data on the impact of a handheld portable clinical analyzer (PCA) evaluated in the pediatric ED.
The researchers enrolled 20 patients, from birth to age 16, who were seen at Children’s Hospital of Alabama in Birmingham. Each child had clinical indicators of serious illness warranting laboratory evaluation. Diagnoses included volume contraction (six cases), altered mental status with or without trauma (five cases), diabetic ketoacidosis (DKA) (three cases), seizure (three cases), congenital heart disease with respiratory distress (two cases), and possible sepsis (one case). Whole blood samples were processed utilizing the i-STAT PCA, a 21x6x5-cm battery-powered device weighing 520g. Individual chemical tests were determined by disposable cartridges containing calibrated biosensors standardized for 12 tests per cartridge. The range of tests included sodium, potassium, chloride, bicarbonate, glucose, blood urea nitrogen (BUN), pH, pC02, p02, oxygen saturation, ionized calcium, and hemoglobin. All PCA tests conducted by ED personnel were run parallel to samples submitted simultaneously to the central hospital laboratory.
The average turnaround time for PCA testing was 2.2 minutes, compared to the central laboratory time of 56.3 minutes, for an average time difference of 54.2 minutes (p < 0.001; 95% CI -44.12 to -64.25 min). Average PCA cost was $9 per cartridge vs. hospital laboratory cost of $10.65 per test grouping, for a mean difference of $1.65 (p = 0.02). Average blood volume required for PCA testing was 0.29 mL, vs. 2.62 mL for standard laboratory analysis, for a difference of 2.32 mL (p < 0.001, 95% CI -1.66 to -2.96 mL). The authors conclude that the i-STAT PCA employed in the pediatric ED generated results significantly faster than the central laboratory.
Commentary by Michael Felz, MD
The handheld device was less expensive to operate and required significantly less whole blood per patient. This study captured my attention for several reasons. First, the idea of point-of-care testing, with results available within two minutes of phlebotomy or finger stick, is quite appealing for faster decisions and earlier intervention at the bedside of ill children. What a boon to management it would be to have evidence for volume contraction, or DKA, or hypercarbia in fewer than five minutes, and with only 1/3 mL of blood. The authors comment that they even utilized failed IV access or a "blown" vein to obtain enough blood for handheld cartridge analysis.
Second, the application of PCA methodology could eliminate many hassles, including staff required to draw, handle, and transport blood vials; excess demand on already stressed laboratory technologists; and erratic phone or electronic relay of lab results to physicians. Third, parents of ill children would marvel at the ease of obtaining a mere 0.3 mL of blood (by fingerstick, not venipuncture), and the revolutionary concept that results take only two minutes—even at midnight in a crowded ED. Fourth, I foresee more incisive decision-making, more rapid and specific intervention, and enhanced patient flow, all of which would benefit patients in rooms as well as those waiting to be seen. Finally, it seems to me that administrators monitoring health care expenses would view i-STAT performance capability as a promising investment in hospital cost containment.
I recommend that we stay tuned for expanded studies of PCAs on the horizon. One of my adult ED colleagues carries an i-STAT in his pocket, persuaded that it makes him a finer physician. And so, for my money, in evaluation of the sick child requiring analysis of electrolytes, fluid balance, or blood gases in the ED, the user-friendly handheld PCA wins—hands down.
Dr. Felz, Associate Professor, Department of Family Medicine, Medical College of Georgia, Augusta, GA, is on the Editorial Board of Emergency Medicine Alert.
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