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Clinical Chemistry 46: 543-550, 2000;
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(Clinical Chemistry. 2000;46:543-550.)
© 2000 American Association for Clinical Chemistry, Inc.

Articles

Clinical Outcomes of Point-of-Care Testing in the Interventional Radiology and Invasive Cardiology Setting

James H. Nichols1,a, Thomas S. Kickler1, Karen L. Dyer1, Sandra K. Humbertson1, Peg C. Cooper2, William L. Maughan3 and Denise G. Oechsle2

Departments of
1 Pathology and
2 Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD 21287.
3 Department of Cardiology, Bayview Medical Center, Baltimore, MD 21224.
a Address correspondence to this author at: Johns Hopkins Medical Institutions, 600 N. Wolfe St., Meyer B-125, Baltimore, MD 21287-7065. Fax 410-614-7609; e-mail jnichols{at}jhmi.edu


   Abstract
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 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Point-of-care testing (POCT) can provide rapid test results, but its impact on patient care is not well documented. We investigated the ability of POCT to decrease inpatient and outpatient waiting times for cardiovascular procedures.

Methods: We prospectively studied, over a 7-month period, 216 patients requiring diagnostic laboratory testing for coagulation (prothrombin time/activated partial thromboplastin time) and/or renal function (urea nitrogen, creatinine, sodium, and potassium) before elective invasive cardiac and radiologic procedures. Overall patient management and workflow were examined in the initial phase. In phase 2, we implemented POCT but utilized central laboratory results for patient management. In phase 3, therapeutic decisions were based on POCT results. The final phase, phase 4, sought to optimize workflow around the availability of POCT. Patient wait and timing of phlebotomy, availability of laboratory results, and therapeutic action were monitored. Split sampling allowed comparability of POCT and central laboratory results throughout the study.

Results: In phase 1, 44% of central laboratory results were not available before the scheduled time for procedure (n = 135). Mean waiting times (arrival to procedure) were 188 ± 54 min for patients who needed renal testing (phase 2; n = 14) and 171 ± 76 min for those needing coagulation testing (n = 24). For patients needing renal testing, POCT decreased patient wait times (phases 3 and 4 combined, 141 ± 52 min; n = 18; P = 0.02). For patients needing coagulation testing, wait times improved only when systematic changes were made in workflow (phase 4, 109 ± 41 min; n = 12; P = 0.01).

Conclusions: Although POCT has the potential to provide beneficial patient outcomes, merely moving testing from a central laboratory to the medical unit does not guarantee improved outcomes. Systematic changes in patient management may be required.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Point-of-care testing (POCT) is (defined as) "laboratory testing conducted close to the site of patient care". Its use has increased over the past decade in response to pressures for cost-containment, faster results and smaller sample volumes, and increasing acuity of inpatient populations (1)(2)(3). POCT has the potential to enhance clinical outcome (4). However, in many instances, POCT is an additional healthcare service rather than a replacement for central laboratory testing, leading to higher testing costs for reagents, operator training, and ongoing supervision (5)(6)(7)(8)(9). Without laboratory supervision, poor quality of POCT results and overutilization risk harming the patient and increasing costs (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21).

Few well-controlled studies have demonstrated the clinical outcomes of POCT (22). POCT glucose has been associated with decreased length-of-stay for patients with ketoacidosis and has improved the cost of managing inpatient diabetics (23)(24). However, these studies were uncontrolled and conducted before the institution of more stringent federal regulations for testing performance (25)(26). Blood gases, electrolytes, glucose, and hemoglobin in more controlled studies were shown to decrease time spent in a postanesthesia surgical recovery unit and in the emergency room (27)(28)(29)(30). Studies have also shown that coagulation testing is beneficial in the critically acute patient and postanesthesia recovery area for normalization of bleeding and reducing blood loss, use of blood products, and frequency of reoperation after cardiac surgery (31)(32). However, in other studies, the use of POCT for electrolytes, blood gases, urea nitrogen, and glucose in the emergency room setting did not significantly affect length of stay or clinical outcome (33)(34)(35)(36). The lack of effect was associated with both delays in physician acknowledgment of POCT results and failure to institute immediate therapeutic action (33) as well as a dependence of outcome on other factors in the patients’ care pathway, such as availability of diagnostic and radiologic procedures and beds (34)(35). The clinical outcome thus is a summation of multiple steps.

We examined patient delays occurring in a cardiovascular procedure setting as a performance improvement initiative. Although multiple criteria must converge before a patient is admitted for procedure, the availability of laboratory testing by the scheduled procedure time could be studied quantitatively. Through stepwise implementation of POCT, the impact of POCT on patients’ waiting times was carefully documented. To our knowledge, this is the first study examining the clinical impact of coagulation and renal function chemistry tests, particularly creatinine, in the cardiovascular procedure triage setting.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
The Cardiovascular Diagnostic Laboratory (CVDL) performs interventional radiology, invasive cardiology, and electrophysiology procedures for the Johns Hopkins health system and referral patients from Bayview Medical Center and several outpatient clinics, e.g., arteriograms (2000/year), vascular access device insertions (1300/year), coronary angioplasties (1000/year), coronary stent placements (800/year), coronary ablations (200/year), automatic implantable cardioconverter/defibrillator placements (70/year), and cardioversions (200/year). For patients arriving for elective procedures without recent laboratory results (same or previous day), physicians usually order three types of laboratory tests; prothrombin time and/or activated partial thromboplastin time; sodium, potassium, urea nitrogen, and creatinine; or a hematology panel with platelets. Because we had no means of delivering rapid platelet counts and/or platelet function studies at the point-of-care, patients requiring hematology results were excluded from the study.

In the core laboratory, prothrombin time and activated partial thromboplastin time were analyzed using citrated plasma on an MLA Electra 1600 analyzer (Medical Laboratory Automation, Pleasantville, NY), and chemistry tests were performed on serum using Roche reagents and a Roche/Hitachi 917 analyzer (Roche Diagnostics, Indianapolis, IN). Specimens were transported a distance of five floors and two buildings by courier. For POCT, whole blood analysis used the TAS analyzer (Bayer, Tarrytown, NY) for coagulation, and the Nova 16 analyzer (Nova, Waltham, MA) for renal tests. Each instrument was analytically validated by the Pathology Department before clinical use in this study. Slope offsets of -2% and 6% for potassium and urea nitrogen, respectively, were used to harmonize the Nova 16 results with the central laboratory. Sodium required a -2% slope and -3.0 mEq/L intercept adjustment, whereas creatinine did not require any offsets. All POCT samples analyzed during the study were further split to revalidate the instrument factor adjustments and ensure POCT to central laboratory comparability on an ongoing basis.

The initial phase 1 of the study (Fig. 1 ) investigated factors that contribute to patient delays in the preprocedure, triage area of CVDL. Delays that caused patients to miss their scheduled procedure time led to open procedure rooms, staff inefficiencies, increased costs, and patient dissatisfaction. Because the laboratory was noted as a major contributor to patient delays, management paths that involved the laboratory became the focus of this performance improvement initiative, which grew to a stepwise examination of POCT. Workflow and patient management were detailed (Fig. 2 ). One hundred thirty-five patients who underwent elective procedures required laboratory data and had complete timing data over a 95-day period.



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  		Figure 1. CVDL study phases.



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  		Figure 2. CVDL patient workflow.

*, steps affected by implementation of POCT and workflow improvement initiatives. IV, intravenous drip; Coag, coagulation; Chem, chemistry; LIS, laboratory information system.

In phase 2, POCT was implemented. Ten nurse-operators were trained in the operation of the TAS and Nova analyzers, and two obtained advanced training for Nova 16 maintenance. To determine the potential savings for POCT, baseline timing data were collected in this phase, including patient wait (arrival to procedure), time for sample collection (arrival to phlebotomy/sample collection), result availability (phlebotomy to laboratory result), and discharge to procedure (laboratory result to procedure). Data were examined by analyte to determine the contributions of each laboratory area (central coagulation laboratory vs central chemistry laboratory) to patient delays. During phase 2, patient management decisions continued to be made on central laboratory results while the clinical staff familiarized themselves with the operation of the POCT analyzers in their routine workflow. Thirty-eight patients were monitored during a 6-week period (n = 14 for renal and n = 24 for coagulation tests).

In phase 3, 22 patients were managed with POCT results (n = 9 for renal and n = 13 for coagulation) during 3 weeks. Timing data and patient outcomes were documented for comparison to phase 2 data. In phase 4, the final phase, the clinical staff were requested to implement any workflow and organization changes in patient management that would optimize the utilization of POCT results. Twenty-one patients were timed during a 3-week period (n = 9 for renal and n = 12 for coagulation), and split specimen, timing, and outcomes continued to be monitored. This study was conducted in accordance with the current revision of the Helsinki Declaration of 1975 and was deemed exempt from patient consent by our institutional review board.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
All CVDL patients are requested to arrive 60 min before scheduled procedure time. Those patients requiring laboratory testing are requested to arrive an additional hour or a total of 120 min before procedure. Monitoring of patient workflow in phase 1 noted that 44% of laboratory test results were not available before the scheduled procedure time. The mean patient wait was 167 ± 83 min (n = 116; median, 155 min) from arrival to procedure. This consisted of 52 ± 24 min (n = 139; range, 10–145 min) from arrival to delivery of blood to the central laboratory and 91 ± 28 min (n = 99; range, 36–165 min) from arrival to availability of laboratory results. Phase 1 did not seek to distinguish between delays attributable to renal testing or coagulation testing (i.e., distinguishing between effects of different laboratories on patient wait times).

Phase 1 outlined the flow of patients through the CVDL (Fig. 2Up ). When a procedure is scheduled, the referring doctor is requested to order the admission tests. If the results do not arrive 24–48 h before procedure, the CVDL staff check with the referral laboratory, and, if results are still unavailable, request the patient to arrive 2 h early so that testing may be done the day of the procedure. A ward clerk registers the patient while the nurse coordinator schedules an examination room. Once the exam room opens, the patient meets with a physician to learn about the procedure, ask questions, and give consent. An examination is done, an intravenous drip is started, and samples for laboratory testing are obtained if necessary. If testing is required, the patient returns to the waiting room with an intravenous drip and waits for test results to be reviewed. Otherwise with POCT, the results are reviewed during the physician visit, the type of procedure is finalized (or canceled based on the test results), and the patient is scheduled into the next available procedure room by the floor coordinator. Because this phase implicated the core laboratories in patient delays, a formal study was constructed with the help of the Pathology Department to streamline the workflow of patients in the CVDL through the implementation of POCT.

Phase 2 studies allowed the establishment of baseline timing and patient outcome data for comparison by analyte after implementation of POCT. The results are summarized in Table 1 . Overall wait times were almost 3 h (188 ± 54 min for renal and 171 ± 76 min for coagulation testing; SDs and ranges are listed in Table 1 ). This wait time was separated into components: for renal testing, arrival to phlebotomy, 37 min; phlebotomy to POCT, 17 min; phlebotomy to central laboratory result, 120 min; POCT result to procedure, 133 min; and central laboratory result to procedure, 41 min. Coagulation showed similar central laboratory delays: arrival to phlebotomy, 41 min; phlebotomy to POCT result, 7 min; POCT result to procedure, 123 min; central laboratory result to procedure, 65 min. With central laboratory testing, only 8% of patients who required renal testing actually met the scheduled procedure time compared with 29% of patients requiring coagulation testing. On the basis of the turnaround time differences for POCT and central laboratory results, a potential savings of 110 min for renal testing and 59 min for coagulation POCT (difference between central laboratory and POCT results excluding the transportation time) could be predicted. If the maximum savings were achieved, 92% of patients could potentially meet scheduled time (P <0.001).


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  		Table 1. CVDL POCT timing summary.1

These predictions were tested in phase 3, where clinical management could be based on POCT results. The data are summarized in Table 1Up . Despite the small sampling size, a decreasing trend in overall patient wait time was noted (not significant, n = 9 for renal and n = 13 for coagulation testing). Only the times from renal POCT result availability to procedure significantly differed from phase 2 to phase 3: 133 vs 88 min (P = 0.033).

After discussions with the CVDL managers, changes were made to improve patient flow by eliminating patient waiting times for laboratory results and improving communication between the triage nurse coordinators and procedure room floor coordinators (Fig. 2Up , steps indicated by ). Improved communication specifically included wireless transmitters to coordinate that patients were prepared and POCT test results were available between the triage and procedure areas of CVDL, better utilization of an existing comment section of our computerized daily scheduling program for test results, and staff re-education on the need for rapid communication and acknowledgement of results by the patient managers. Patient wait time was significantly improved for those requiring coagulation testing (phase 4): the phase 4 wait time was 109 ± 41 min compared with a phase 2 wait time of 171 ± 76 min (n = 12; P = 0.014). Additionally, the length of time between availability of coagulation POCT result and therapeutic action (procedure started) decreased from 123 ± 65 min to 64 ± 38 min (n = 12; P = 0.007). Although renal testing did not improve over phase 3 data, when the data from both phase 3 and 4 were combined (where POCT was utilized for treatment decisions), waiting times for patients requiring renal testing decreased from 188 ± 54 min to 141 ± 52 min (n = 18; P = 0.023). No difference in timing was noted between phase 3 (treating on POCT results) and phase 4 (optimizing the use of POCT results) for renal testing. Despite improvements in patient waiting times and in time between result and procedure, the percentage of patients meeting scheduled time did not improve significantly, nor were the predictions from phase 2 met (for 92% of patients achieving scheduled procedure time).


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The allure of POCT includes rapid results and the potential for quicker therapeutic action. Beneficial outcomes have not always followed, however, because delays in clinical acknowledgment of the POCT results and other components of care can negate the potential of POCT (33)(34)(35)(36). For the triage area of our CVDL unit, multiple factors must come together before the patient is admitted to the procedure. Delays in any single step can lead to patients missing scheduled procedure times, open procedure rooms, and patient backlogs with the need for juggling other patients’ schedules, potential rescheduling of patients, and staff stress and inefficiencies.

We chose to measure the effect of laboratory testing on the final CVDL process outcome, patient wait time. Although this outcome is dependent on several factors, significant improvements in wait time were documented from the implementation of POCT. To our knowledge, this is also the first time that POCT for renal function (electrolytes, urea nitrogen, and creatinine) has been shown to impact patient outcome in this setting. We did not attempt to translate these outcomes to a cost savings because these types of extrapolations can be biased by viewpoint and by failure to include all associated costs (6).

These outcomes, however, could not have been achieved without integrating POCT into clinical management on the CVDL unit. Merely substituting POCT for central laboratory testing did not guarantee maximum efficiency and beneficial outcomes, as noted in phase 3. Systematic changes in workflow surrounding the utilization of coagulation testing in phase 4 were required to achieve the greatest improvement of patient wait times. POCT must, therefore, be integrated into the clinical management pathways to fully exploit its advantages. Because of this dependence on therapeutic practice, similar outcomes should not be predicted in other settings without consideration of how the result will be utilized in patient care. Additionally, result turnaround time comparisons between POCT and a central laboratory may predict a potential for improvement (as in phase 2), but trial implementation is required to determine whether a change is realized.

To fully exploit its advantages, POCT must harmonize with results from the central or more distant laboratory. Concerns over the quality of POCT have been widely publicized and are the motivation for federal and state regulations surrounding the performance of POCT (12)(13)(15)(16)(21)(25)(26)(37)(38)(39). A primary concern is the equivalence of POCT results obtained from nurses (40)(41)(42). Staff training, laboratory supervision, and complexity of the testing device can directly affect the quality of the final result (43). Clinical staff have primary responsibilities for patient care and may not have a full appreciation of preanalytic, analytic, and postanalytic variables (44). Simpler devices thus tend to be more successful than instruments when operated outside the central laboratory by clinical staff (43).

Our study supports these observations. We obtained POCT results that allowed the CVDL staff to triage their patients based on pathways developed previously from central laboratory testing without modification. This required initial and ongoing validation to correct the POCT biases to match the central laboratory methods. Operationally, however, the Nova and TAS were not equivalent in maintenance problems and downtime. Over the 12-week trial, we experienced problems with both analyzers in the hands of the nurse-operators that led to 29 instances of >1 h where the device was not operational. The maintenance and staff technical competency requirements as well as the low volume of patients requiring testing at this site (only 1–2 tests per day) led us to explore alternative means of delivering faster result turnaround times than performing the testing in the CVDL area.

One alternative would use the Nova 16 and TAS devices in our stat laboratory, under the supervision and performance of medical technologist staff. This site will be connected by pneumatic tube to the CVDL unit within a few months. The acquisition of a Nova 16 analyzer offers an additional advantage to other medical units of a "whole blood" creatinine and urea test at faster turnaround time than a central laboratory serum analysis.

A second, more attractive alternative would utilize existing central laboratory equipment and the new pneumatic tube system to provide "plasma" rather than "serum" creatinine and urea through the central laboratory (i.e., change from red-top serum collection tubes to green-top heparin tubes, eliminating the wait time for blood to clot). Although this alternative would delay result turnaround compared with a Nova whole-blood analyzer, because of the required centrifugation and aliquoting steps, it does not incur additional costs in analyzer acquisition and maintenance. Given the time required to prepare a patient for procedure after obtaining test results (range, 36–72 min; phase 3 and 4 data), the addition of 10 min for centrifuging a plasma specimen is not predicted to impact the final outcome given comparable transportation times in the new pneumatic tube.

The final choice selected for our institution was to maintain the TAS analyzer in CVDL and to utilize the pneumatic tube system to transport plasma samples to the central chemistry laboratory for electrolytes and renal tests. We continue to monitor the percentage of patients who do not meet scheduled procedure time. Although we have not made significant improvements over the initial phase 2 baseline, the percentage of patients meeting their scheduled time has improved over the past 9 months (37% for September 1999; n = 41). Patient satisfaction surveys parallel the actual timings: the perceived wait time beyond scheduled procedure has dropped from a mean response of 2.85 to 2.19 (n = 454) on a 1–6 scale, where 6 = >120-min delay beyond scheduled procedure time, 5 = 90–120 min, 4 = 60–90 min, 3 = 30–60 min, 2 = 15–30 min, and 1 = 0–15 min. The actual timings and clinical outcomes will continue to be monitored in future months.

In conclusion, optimal utilization of POCT must not only consider clinical needs but also staff motivation; how the test is delivered, maintained, and supervised; and most importantly, the impact on patient outcome.


   Acknowledgments
 
All reagents, controls, and supplies were donated by the manufacturers for performance of this study.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Seamonds B. Medical, economic and regulatory factors affecting point-of-care testing: a report of the conference on factors affecting point-of-care testing, Philadelphia, PA, 6–7 May, 1994. Clin Chim Acta 1996;249:1-19.[ISI][Medline] [Order article via Infotrieve]
  2. Bickford GR. Decentralized testing in the 1990s: a survey of United States hospitals. Clin Lab Med 1994;14:623-645.[ISI][Medline] [Order article via Infotrieve]
  3. Gray TA, Freedman DB, Burnett D, Szczepura A, Price CP. Evidence based practice: clinician’s use and attitudes to near patient testing in hospitals. J Clin Pathol 1996;49:903-908.[Abstract/Free Full Text]
  4. Nichols JH. POCT. A viable solution to turnaround time delays [Editorial]. Med Lab Obs 1998;30(Suppl):4-5.
  5. Baer DM, Petersen J, Belsey RE, Eyberg R. Quality management of bedside glucose testing. Med Lab Obs 1993;25:46-58.
  6. Nichols JH. Cost analysis of point-of-care laboratory testing. Weinstein RS eds. Advances in pathology and laboratory medicine 1996:121-134 Mosby Chicago, IL. .
  7. Lee-Lewandrowski E, Laposata M, Eschenbach K, Camooso C, Nathan DM, Godine JE, et al. Utilization and cost analysis of bedside capillary glucose testing in a large teaching hospital: Implications for managing point-of-care testing. Am J Med 1994;97:222-230.[ISI][Medline] [Order article via Infotrieve]
  8. Greendyke RM. Cost analysis bedside blood glucose testing. Am J Clin Pathol 1992;97:106-107.[ISI][Medline] [Order article via Infotrieve]
  9. Nosanchuk JS, Keefner R. Cost analysis of point-of-care laboratory testing in a community hospital. Am J Clin Pathol 1995;103:240-243.[ISI][Medline] [Order article via Infotrieve]
  10. Winkelman JW, Wybenga DR, Tanasijevic MJ. The fiscal consequences of central vs distributed testing of glucose. Clin Chem 1994;40:1628-1630.[Abstract/Free Full Text]
  11. Wu AHB. Reducing the inappropriate utilization of clinical laboratory tests. Conn Med 1997;61:15-21.[Medline] [Order article via Infotrieve]
  12. Cohen FE, Sater B, Feingold KR. Potential danger of extending SMBG techniques to hospital wards. Diabetes Care 1986;9:320-322.[ISI][Medline] [Order article via Infotrieve]
  13. Bell DSH. Hazards of inaccurate readings obtained by self-monitoring of blood glucose. Diabetes Care 1990;13:1131-1132.[ISI][Medline] [Order article via Infotrieve]
  14. Zilva JF. Is unselective biochemical urine testing cost effective?. Br Med J 1985;291:323-325.
  15. Rutala WA, Kennedy VA, Loflin HB, Sarubbi FA. Serratia marcescens nosocomial infection of the urinary tract associated with urine measuring containers and urinometers. Am J Med 1981;70:659-663.[ISI][Medline] [Order article via Infotrieve]
  16. Kocka FE, Roemisch E, Causey WA, O’Dell A. The urinometer as a reservoir of infectious organisms Am J Clin Pathol 1977;67:106–7..
  17. Del Mar C, Badger P. The place of routine urine testing on admission to hospital. Med J Aust 1989;151:151-153.[ISI][Medline] [Order article via Infotrieve]
  18. Fraser CG, Smith BC, Peake MJ. Effectiveness of an outpatient urine screening program. Clin Chem 1977;23:2216-2218.[Abstract/Free Full Text]
  19. Baer DM, Berner M. Physicians’ response to abnormal results of routine urinalysis [Letter]. Can Med Assoc J 1977;117:1262.
  20. Jeng LL, Moore RM, Kaczmarek RG. How frequently are home pregnancy tests used? Results from the 1988 National Maternal and Infant Health Survey. Birth 1991;18:11–3..
  21. Summerton AM, Summerton N. The use of desk-top cholesterol analysers in general practice. Pub Health 1995;109:363-367.
  22. Rainey PM. Outcome assessment for point-of-care testing [Editorial]. Clin Chem 1998;44:1595-1596.[Free Full Text]
  23. Zaloga GP. Evaluation of bedside testing options for the critical care unit. Chest 1990;97:185S-190S.[Abstract/Free Full Text]
  24. Trundle DS, Weizenecker RA. Capillary glucose testing: a cost-saving bedside system. Lab Manage 1986;24:59-62.
  25. Department of Health and Human Services, Health Care Finance Administration. Clinical laboratory improvement amendments of 1988, final rule. Fed Regist, 1992;Feb 28:7001–288..
  26. Department of Health and Human Services, Health Care Finance Administration. Medicare, Medicaid and CLIA programs: CLIA program fee collection: correction and final rule. Fed Regist 1993;Jan 19:5211–37..
  27. Goodwin SA. Point-of-care testing in a post anesthesia care unit. Med Lab Obs 1994;26:15-18.
  28. Tsai WW, Nash DB, Seamonds B, Weir GJ. Point-of-care versus central laboratory testing: an economic analysis in an academic medical center. Clin Ther 1994;16:898-911.[ISI][Medline] [Order article via Infotrieve]
  29. Woo J, McCabe JB, Chauncey D, Schug T, Henry JB. The evaluation of a portable clinical analyzer in the emergency department. Am J Clin Pathol 1993;100:599-605.[ISI][Medline] [Order article via Infotrieve]
  30. Krensichek DA, Tanseco FV. Comparative study of bedside and laboratory measurements of hemoglobin. Am J Crit Care 1996;5:427-432.
  31. Zeler KM, McPharlane TJ, Salamonsen RF. Effectiveness of nursing involvement in bedside monitoring and control of coagulation status after cardiac surgery. Am J Crit Care 1992;2:70-75.
  32. Despotis GJ, Santoro SA, Spitznagel E, Kater KM, Cox JL, Barnes P, Lappas DG. Prospective evaluation and clinical utility of on-site monitoring of coagulation in patients undergoing cardiac operation. J Thorac Cardiovasc Surg 1994;107:271-279.[Abstract/Free Full Text]
  33. Saxena S, Wong ET. Does the emergency department need a dedicated stat laboratory? Continuous quality improvement as a management tool for the clinical laboratory. Am J Clin Pathol 1993;100:606-610.[ISI][Medline] [Order article via Infotrieve]
  34. Parvin CA, Lo SF, Deuser SM, Waver LG, Lewis LM, Scott MG. Impact of point-of-care testing on patients’ length of stay in a large emergency department. Clin Chem 1996;42:711-717.[Abstract/Free Full Text]
  35. Kendall J, Reeves B, Clancy M. Point of care testing: randomised, controlled trial of clinical outcome. Br Med J 1998;316:1052-1057.[Abstract/Free Full Text]
  36. Heyningen C, Watson ID, Morrice AE. Point-of-care testing outcomes in an emergency department [Letter]. Clin Chem 1999;45:437-438.[Free Full Text]
  37. . CAP Laboratory Accreditation Program. Inspection checklist (section 30): point-of-care testing 1996 College of American Pathologists Northfield, IL. .
  38. . JCAHO. CAMH comprehensive accreditation manual for hospitals 1998 Joint Commission on Accreditation of Healthcare Organizations Oakbrook Terrace, IL. .
  39. . COLA. Laboratory accreditation manual 1997 Commission on Office Laboratory Accreditation Columbia, MD. .
  40. Belsey R, Morrison JI, Whitlow KJ, Baer DM, Nelson S, Hardwick DF. Managing bedside glucose testing in the hospital. JAMA 1987;12:1634-1638.
  41. Hilton S, Rink E, Fletcher J, Sibbald B, Freeling P, Szczepura A, et al. Near-patient testing in general practice: attitudes of general practitioners and practice nurses, and quality assurance procedures carried out. Br J Gen Pract 1994;44:577-580.[ISI][Medline] [Order article via Infotrieve]
  42. Nanji AA, Poon R, Hinberg I. Near-patient testing: quality of laboratory test results obtained by non-technical personnel in a decentralized setting. Am J Clin Pathol 1988;89:797-801.[ISI][Medline] [Order article via Infotrieve]
  43. Nanji AA, Poon R, Hinberg I. Comparison of hospital staff performance when using desk top analyzers for "near-patient" testing. J Clin Pathol 1988;41:223-225.[Abstract/Free Full Text]
  44. Lamb LS, Parrish RS, Goran SF, Biel MH. Current nursing practice of point-of-care laboratory diagnostic testing in critical care units. Am J Crit Care 1995;4:429-434.



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