The influence of undetected hemolysis on POCT potassium results in the emergency department.

OBJECTIVES: This study aimed to evaluate discrepancies in potassium measurements between point-of-care testing (POCT) and central laboratory (CL) methods, focusing on the impact of hemolysis on these measurements and its impact in the clinical practice in the emergency department (ED). METHODS: A retrospective analysis was conducted using data from three European university hospitals: Technische Universitat Munchen (Germany), Hospital Universitario La Paz (Spain), and Erasmus University Medical Center (The Netherlands). The study compared POCT potassium measurements in EDs with CL measurements. Data normalization was performed in categories for potassium levels (kalemia) and hemolysis. The severity of discrepancies between POCT and CL potassium measurements was assessed using the reference change value (RCV). RESULTS: The study identified significant discrepancies in potassium between POCT and CL methods. In comparing POCT normo- and mild hypokalemia against CL results, differences of -4.20 % and +4.88 % were noted respectively. The largest variance in the CL was a +4.14 % difference in the mild hyperkalemia category. Additionally, the RCV was calculated to quantify the severity of discrepancies between paired potassium measurements from POCT and CL methods. The overall hemolysis characteristics, as defined by the hemolysis gradient, showed considerable variation between the testing sites, significantly affecting the reliability of potassium measurements in POCT. CONCLUSIONS: The study highlighted the challenges in achieving consistent potassium measurement results between POCT and CL methods, particularly in the presence of hemolysis. It emphasised the need for integrated hemolysis detection systems in future blood gas analysis devices to minimise discrepancies and ensure accurate POCT results.

Association of physiological stress markers at the emergency department to readmission and death within 90 days: a prospective observational study.

Background: Predicting the risk of readmission or death in patients at the emergency department (ED) is essential in identifying patients who would benefit the most from interventions. We aimed to explore the prognostic value of mid-regional proadrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), copeptin, and high-sensitivity troponin T (hs-TnT) to identify patients with a higher risk of readmission and death among patients presenting with chest pain (CP) and/or shortness of breath (SOB) in the ED. Methods: This single-center prospective observational study included non-critically ill adult patients with a chief complaint of CP and/or SOB who visited the ED at Linköping University Hospital. Baseline data and blood samples were collected, and patients were followed up for 90 days after inclusion. The primary outcome was a composite of readmission and/or death from non-traumatic causes within 90 days of inclusion. Binary logistic regression was used and receiver operating characteristics (ROC) curves were constructed to determine the prognostic performance for predicting readmission and/or death within 90 days. Results: A total of 313 patients were included and 64 (20.4%) met the primary endpoint. MR-proADM > 0.75 pmol/L (odds ratio [OR]: 2.361 [95% confidence interval [CI]: 1.031 - 5.407], P = 0.042) and multimorbidity (OR: 2.647 [95% CI: 1.282 - 5.469], P = 0.009) were significantly associated with readmission and/or death within 90 days. MR-proADM increased predictive value in the ROC analysis to age, sex, and multimorbidity (P = 0.006). Conclusions: In non-critically ill patients with CP and/or SOB in the ED, MR-proADM and multimorbidity may be helpful for the prediction of the risk of readmission and/or death within 90 days.

Failure Mode and Effects Analysis (FMEA) at the preanalytical phase for POCT blood gas analysis: proposal for a shared proactive risk analysis model.

OBJECTIVES: Proposal of a risk analysis model to diminish negative impact on patient care by preanalytical errors in blood gas analysis (BGA). METHODS: Here we designed a Failure Mode and Effects Analysis (FMEA) risk assessment template for BGA, based on literature references and expertise of an international team of laboratory and clinical health care professionals. RESULTS: The FMEA identifies pre-analytical process steps, errors that may occur whilst performing BGA (potential failure mode), possible consequences (potential failure effect) and preventive/corrective actions (current controls). Probability of failure occurrence (OCC), severity of failure (SEV) and probability of failure detection (DET) are scored per potential failure mode. OCC and DET depend on test setting and patient population e.g., they differ in primary community health centres as compared to secondary community hospitals and third line university or specialized hospitals. OCC and DET also differ between stand-alone and networked instruments, manual and automated patient identification, and whether results are automatically transmitted to the patient's electronic health record. The risk priority number (RPN = SEV × OCC × DET) can be applied to determine the sequence in which risks are addressed. RPN can be recalculated after implementing changes to decrease OCC and/or increase DET. Key performance indicators are also proposed to evaluate changes. CONCLUSIONS: This FMEA model will help health care professionals manage and minimize the risk of preanalytical errors in BGA.

Point-of-care testing in the overcrowded emergency department--can it make a difference?

Emergency departments (EDs) face several challenges in maintaining consistent quality care in the face of steadily increasing public demand. Improvements in the survival rate of critically ill patients in the ED are directly related to the advancement of early recognition and treatment. Frequent episodes of overcrowding and prolonged waiting times force EDs to operate beyond their capacity and threaten to impact upon patient care. The objectives of this review are as follows: (a) to establish overcrowding as a threat to patient outcomes, person-centered care, and public safety in the ED; (b) to describe scenarios in which point-of-care testing (POCT) has been found to ameliorate factors thought to contribute to overcrowding; and (c) to discuss how POCT can be used directly, and indirectly, to expedite patient care and improve outcomes. Various studies have shown that overcrowding in the ED has profound effects on operational efficiency and patient care. Several reports have quantified overcrowding in the ED and have described a relationship between heightened periods of overcrowding and delays in treatment, increased incidence of adverse events, and an even greater probability of mortality. In certain scenarios, POCT has been found to increase the number of patients discharged in a timely manner, expedite triage of urgent but non-emergency patients, and decrease delays to treatment initiation. This review concludes that POCT, when used effectively, may alleviate the negative impacts of overcrowding on the safety, effectiveness, and person-centeredness of care in the ED.

Cutting costs: the impact of price lists on the cost development at the emergency department.

It was shown that physicians working at the Swedish emergency department (ED) are unaware of the costs for investigations performed. This study evaluated the possible impact of price lists on the overall laboratory and radiology costs at the ED of a Swedish university hospital. Price lists including the most common laboratory analyses and radiological investigations at the ED were created. The lists were distributed to all internal medicine physicians by e-mail and exposed above their working stations continually. No lists were provided for the orthopaedic control group. The average costs for laboratory and radiological investigations during the months of June and July 2007 and 2008 were calculated. Neither clinical nor admission procedures were changed. The physicians were blinded towards the study. Statistical analysis was performed using the Student's t-test. A total of 1442 orthopaedic and 1585 medical patients were attended to in 2007. In 2008, 1467 orthopaedic and 1637 medical patients required emergency service. The average costs per patient were 980.27 SKR (98€)/999.41 SKR (100€, +1.95%) for orthopaedic and 1081.36 SKR (108€)/877.3 SKR (88€, -18.8%) for medical patients. Laboratory costs decreased by 9% in orthopaedic and 21.4% in medical patients. Radiology costs changed +5.4% in orthopaedic and -20.59% in medical patients. The distribution and promotion of price lists as a tool at the ED to heighten cost awareness resulted in a major decrease in the investigation costs. A significant decrease in radiological costs could be observed. It can be concluded that price lists are an effective tool to cut costs in public healthcare.

Cost awareness among Swedish physicians working at the emergency department.

BACKGROUND: In Sweden the public health system is subject of increasing budget problems. Medical training in Sweden does not yet focus on the cost aspects in patients diagnoses and treatment. STUDY OBJECTIVES: This study was carried out to survey the general knowledge among physicians working in the emergency department about the cost of the usual diagnostic tests used in ruling out pulmonary embolism. METHODS: Knowledge about costs among Swedish physicians was evaluated in the context of the emergency department of a university hospital. Thirty physicians answered an anonymous questionnaire about the costs for several items used in the diagnosis of pulmonary embolism. Answers within +/-25% of the real costs were regarded as correct. Evaluation took into consideration the physicians' specialty and experience as emergency physician, house officer or consultant in internal medicine. Statistical analysis was carried out using the Student's t-test, Kruskal-Wallis test and Mann-Whitney U test where applicable. Probability levels of less than 0.05 were accepted as significant. RESULTS: Mean deviation to the real cost was 52% with a correct estimation of an average 28%. No significant difference could be detected in this study among emergency department physicians, house officers and consultants in internal medicine regarding the cost awareness towards the items considered. CONCLUSION: Generally cost awareness was considered low among all participating doctors. The level of experience seemed not to be related to better knowledge about prices. Younger doctors generally tended to underestimate the costs of investigation. Further education will be necessary to raise the level of cost awareness among hospital doctors.

[Burning feet]. / Hier hat der Boden unter den Füssen gebrannt.

After walking barefoot over hot sand, a 75-year-old man developed second-degree burns on the soles of both feet. His case history revealed diabetes mellitus with diabetic polyneuropathy and macroangiopathy. Since wound healing was protracted, antibiotic treatment was initiated. Even after ten days of this, residual defects were still present. Diabetics walking barefoot over hot surfaces are highly prone to sufferfrom burns on the soles of the feet. In particular when such persons are about to go on holiday, they should be counseled to keep their feet dry, so as to reduce heat conduction, and to wear shoes when temperatures are high.