The onset of cold weather can exacerbate respiratory system diseases and incidences of ‘seasonal illnesses’, such as flu and norovirus, also rise. Post pandemic, winter pressures and planning are now an even greater issue for acute, mental health, community and ambulance service trusts. Particularly since in recent years pressure has been building not only over the winter period, but throughout the year.
To help alleviate increasing pressures over the approaching winter period, particularly in Urgent and Emergency Care (UEC), NHS England this year started even earlier in their planning to increase capacity and operational resilience. The NHS provides care to over 100,000 UEC patients each week, but despite their best efforts, pressures have meant that there have been too many occasions when staff have not been able to provide timely access for patients in the way they would have wanted [1]. Over this winter period there is a significant risk that these numbers will increase, as shown by UEC sitrep data from acute trusts published weekly by NHS England from the end of November in previous years.
NHS England has therefore been looking at ways by which these pressures on urgent and emergency care can be alleviated [1]. Some key objectives to achieving this include:
- Reduce crowding in A&E departments and target the longest waits in ED, by improving use of the NHS directory of services, and increasing provision of same day emergency care and acute frailty services.
- Reduce hospital occupancy, through increasing capacity by the equivalent of at least 7,000 general and acute beds, through a mix of new physical beds, virtual wards, and improvements elsewhere in the pathway.
- Ensure timely discharge, across acute, mental health, and community settings.
Improving patient pathways with POCT
To help to achieve these objectives, the correct management of patient pathways is crucial, and timely clinical diagnostics plays a key part in this. Given the ongoing pressures on the NHS, there has certainly been a need and value established for point-of-care testing (POCT), not only clinically but also for the benefit of patients. Improving the patient pathway and experience are major considerations when introducing POCT.
The importance of near-patient testing is reflected in the NHS’s Diagnostics Transformation Plan (2022-23) and has prompted a shift towards community diagnostics centres [2]. In addition to the new centres, other community settings where POCT is now increasingly being implemented include GP surgeries, community hospital clinics and frailty units. POCT is also of great value in acute care settings, particularly within UEC.
By implementing rapid diagnostics using POCT in such settings, this can enable earlier diagnoses, supporting more rapid clinical decision-making and helping to reduce unnecessary hospital visits or admissions. Diverting patients away from acute hospitals enables them to focus on treating urgent patients effectively. Ultimately POCT can ensure improved patient flow by facilitating quicker specialty referrals, admissions and discharges.
Combined POCT result for CRP + FBC
Figure 1. Microsemi CRP LC-767G POC haematology analyser | There are many instances where very rapid access to results using POCT can make a tangible difference to patient care and diagnosis. HORIBA’s Microsemi CRP (Figure 1), for example, is a POC haematology analyser that delivers within four minutes laboratory-accurate, a three-part differential full blood count (FBC) uniquely combined with a C-reactive protein (CRP). CRP is a common blood test used to support clinical decision-making, particularly as a proxy indicator of bacterial infection or inflammation. When combined with a FBC with white blood cell differentiation, it can aid the distinction between bacterial and viral illnesses, as well as other applications highlighted in the scientific literature. For example, for triage, in addition to the early recognition of sepsis, CRP can assist in: guiding subsequent investigation in children with unexplained limping or pseudoparalysis; the detection and differential diagnosis of acute abdominal syndromes, particularly appendicitis; and recently, risk stratification and management of Coronavirus patients. It is crucial to exclude bacterial infection and sepsis quickly in emergency care and POC clinics in order to obtain a swift diagnosis for appropriate therapy. This also supports judicious antibiotic prescribing, not only for cost savings by reducing antibiotic usage but also addressing antimicrobial resistance (AMR) challenges. By providing information of great clinical value to enable quicker and more accurate medical decision making at the point-of-care, the Microsemi CRP’s features all combine to make it a highly effective tool for patient triage. |
Proven in many settings
Microsemi CRP analysers have been installed across many primary and secondary care settings, including community hubs, emergency departments, paediatrics and assessment units where it is operated by multidisciplinary healthcare teams. In these varied locations they have been shown to relieve pressures by delivering rapid results and supporting informed patient flow decisions. Thus, minimising hospital admissions, improving patient outcomes and reducing costs.
CRP in the community
For instance, several Microsemi CRPs have been very effectively employed in community settings across Cornwall to support the rapid near-patient distinction between bacterial and viral illnesses, as well as other acute applications [3]. Here, a single hospital based in Truro covers an extremely large geographic area. As local GPs now have more and relevant information to aid clinical decision making - such as whether to admit or whether to prescribe antibiotics - many patients no longer need travel long distances for medical attention. Moreover, it has helped to avoid costly and unnecessary hospital admissions which is a benefit to the patient, particularly with children and the elderly, and of course this in turn serves to save valuable hospital resources and reduce pressures on them.
A recently published study also explored the use of POCT within a busy GP group practice [4]. Using the Microsemi CRP, the Brookside Group Practice (Lower Earley, Berkshire) aimed to relieve winter flu pressures and to meet local CCG demands to reduce unnecessary hospital visits and admissions. Its results demonstrated tangible benefits for urgent care clinical decision making and cost savings by using this POC technology in primary care.
The analysers were operated by a variety of clinical staff: GPs, nursing staff and paramedics, demonstrating the ease with which the instrumentation can be operated. The study confirmed that the introduction of POCT at the GP practice fully supported the clinical decision-making process for a range of urgent care needs. It increased clinical confidence in diagnosis within the practice’s urgent care clinic, leading to more appropriate patient referrals to secondary care. Furthermore, indicative modelling on the costs of testing and secondary care referrals against instances where referrals were avoided established potential cost savings of over £26,000 annually.
Improving patient management in ED
Figure 2. Sepsis progression in children | Another example of patient pathway improvements enabled by the Microsemi CRP is within paediatric emergency departments (ED). Here to co-ordinate patient flow effectively, it is essential to rapidly determine which patients have minor injuries and illnesses and which patients need emergency attention.CRP results alone can sometimes be misleading in paediatric patients but the addition of full blood count provides a more comprehensive profile. Sepsis, for example, necessitates rapid intervention as any delay to its diagnosis and treatment represents a huge clinical risk (Figure 2). It is particularly dangerous for children and their symptoms can be more difficult to detect, as exemplified by a recent case where a 3-month-old patient was brought in to the Guy’s & St Thomas’s Hospital Paediatric ED [5]. The patient’s behaviour was atypical and they had elevated temperature, however, all other basic observations were within normal range. POC CRP analysis using the Microsemi CRP quickly determined that the white blood cell count (WBC), neutrophil count, and CRP were extremely high, indicating sepsis. The ability to diagnose the patient within minutes allowed the ED to make rapid, potentially life-saving decisions about patient treatment. |
In a counter scenario, a 7-year-old patient was referred by his GP to the ED with suspected appendicitis. In this case, POC testing using the Microsemi CRP allowed doctors to quickly rule out appendicitis and discharge the patient safely with the appropriate treatment and a follow-up GP appointment. Having rapid POCT results in this case sped-up and reinforced the clinical decision-making process to prevent an unnecessary admission.
There is considerable pressure in EDs to deliver high level healthcare and maintain patient flow through the department while managing a busy and often, overcrowded environment. Because POCT enables more rapid clinical decision making in the process of diagnosis, it represents an approach that assists rapid operational decisions and resource utilisation – not only alleviating pressures, but ultimately, improving patient care.
Streamlining assessment in Frailty Hubs
Combined POC CRP with FBC analysis has also been demonstrated to improve local healthcare for frail patients and reduce unnecessary A&E admissions. Within Buckinghamshire Healthcare NHS Trust, Microsemi CRP analysers were installed in the Trust’s Frailty Assessment Hubs located in both Thame and Marlow Community Hospitals [6].
These POC analysers have enhanced the quality of service delivered to patients and helped streamline existing diagnostic pathways in the community. Through accurate determination of the presence of bacterial infection and inflammation, and given the rapidity of results delivered, patients receive the treatment they need immediately without admission, or are referred appropriately and without delay.
This fully supports the aims of the Frailty Assessment Hubs which offer a ‘one-stop shop’ for frail patients in the locality to receive the care they need closer to home. It also has the added benefit of reducing pressure on the local acute sites by cutting needless admissions, particularly during the busier winter months.
To conclude
The point-of-care Microsemi CRP haematology analyser provides unique, fast, laboratory quality results that enable healthcare professionals to make immediate informed decisions about patient care. Combined with its compactness and portability, the rapid turnaround times it delivers can improve patient outcomes in a range of settings while helping healthcare organisations safely meet targets.
The clinical utility of these POCT analysers is evident and appropriate use can improve the quality and effectiveness of patient management. Combined FBC and CRP POCT has been demonstrated to speed up the clinical decision-making process and improve patient pathways. This is turn can optimise discharge times, prevent unnecessary admissions and help control antibiotics administration to where it is really necessary. This new generation of POC haematology analysers can certainly benefit healthcare organisations, particularly when facing extreme winter pressures.
References:
1. NHS England (2022). Next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter. https://www.england.nhs.uk/next-steps-in-increasing-capacity-and-operational-resilience-in-urgent-and-emergency-care-ahead-of-winter/#performance-and-accountability
2. UK Government (2021). 40 community diagnostic centres launching across England. https://www.gov.uk/government/news/40-community-diagnostic-centres-launching-across-england
3. Campbell M (2020). Role of POC CRP during the pandemic. Clinical Services Journal, p65-67, August 2020. https://www.clinicalservicesjournal.com/story/33504/role-of-poc-crp-during-the-pandemic
4. Checketts G, Okhai N, Bajre M, Sharma A, Edwards A, Hart J (2020). Introducing point of care (POC) testing in a primary care urgent care pathway to improve clinical service delivery. Oxford Academic Health Science Network. https://www.oxfordahsn.org/wp-content//static.horiba.com/uploads/2020/11/Use-of-POC-testing-in-a-GP-Urgent-Care-Pathway-Report-Final-22-10-20.pdf
5. HORIBA UK (2022). Enabling a Better Point-of-Care Diagnosis. HORIBA Connect Webinar Series, May 2022. https://www.horiba.com/gbr/medical/support/webinars/horiba-connect-webinar-series-enabling-a-better-point-of-care-diagnosis/
6. Pathology in Practice (2018). Point-of-care CRP testing reduces unnecessary admissions. February 2018. https://www.pathologyinpractice.com/story/25115/point-of-care-crp-testing-reduces-unnecessary-admissions