Point of Care Testing: Mobilizing Pathology for the Benefit of Patients & Caregivers

Students at South Bronx High School don't need to search for a nearby clinic or anxiously wait for days to know if they have Strep A, are pregnant or infected with HIV. Their school is one of the 17 high schools and middle schools that utilize Montefiore Medical Center's Point of Care Testing (POCT) services. With 200 satellite sites around the city, Montefiore's POCT service – run through the department of pathology – is one of the largest such programs in the country. (Pathologists help care for patients by performing diagnostic evaluations of urine, blood and other bodily fluids and tissues to help diagnose illness and to monitor the health of patients.)

Amy Fox, M.D."It's changed the way we practice here," said Dr. Amy Fox, associate professor of pathology and of clinical pediatrics, and director of virology and point of care testing at Montefiore Medical Center. 

In 2000, the state-of-the-art program began as a fledgling service; it now performs an estimated 1.8 million tests per year.  

Typically, urine and blood samples are taken from patients in a clinical setting and sent to one of several core labs for analysis - a process which often takes days. With POCT, small, portable devices offering a broad menu of analytes are used, allowing tests to be performed anywhere - from a hospital room or children's health center to a helicopter or cruise ship. The system allows diverse medical needs to be met on the spot, as well, with fast results, ranging from seconds to minutes. 

In Montefiore's bustling emergency rooms and intensive care units, "point of care plays a crucial role in patient care, providing information to clinicians making on-the-spot treatment decisions," explained Dr. Fox.  

A point-of-care testing deviceThroughout Montefiore's Moses, Weiler and North hospitals, inpatient bedside glucose testing is available on wards, from pediatrics to neurosurgery, and in outpatient clinics, from dentistry to dialysis. Additionally, a hand-held device that uses tiny disposable cartridges to test a patient's coagulation status is a lifesaver in the Moses cardiac operating room. 

"It's like a laboratory in your hand," noted Dr. Fox, demonstrating the portable scanner that allows for quick blood testing conducted beside the patient. 

Rapid results can also help shorten the length of a hospital stay, eliminate the need for a return office visit and alleviate patient anxiety. 

"In the case of Strep A, a child diagnosed at school or in a children's health center can be sent home with an antibiotic and will feel better, sooner," said Dr. Fox, noting that POC service currently oversees the performance of over 50,000 Strep A tests per year.  

Effective Community Outreach

A rapid HIV test performed at school makes it possible for concerned teenagers to get pre-test and post-test counseling, their test results, and any medical referrals they may need, all in one visit.  This easy access could be potentially lifesaving for high school students, who may not readily seek out a clinic. Through Montefiore's Adolescent AIDS Program (AAP), directed by Dr. Donna Futterman, approximately 50 Einstein medical students involved with the student-run group HIV Education and Rapid Testing (HEART) receive training in the administration of HIV tests and counseling.  The HEART students assist with POCT and educational efforts at local high schools and colleges, supervised by AAP staff.

"The community-based counseling and testing experiences enhance the medical students' clinical skills, no matter their chosen specialty," noted Dr. Futterman.

Improving the Process

POCT also prevents errors related to transfer of data and transcription, enabling emergency results and simplifying the logistics of frequent monitoring.

With guidance from the AAP, Einstein students learn to administer and review HIV testsWhile POCT is a big consumer of pathology resources, it's also an essential investment, since it enhances the efficiency of the physician community while providing a high level of customer satisfaction," observed Dr. Ira Sussman, vice chair of pathology and professor pathology and of medicine.

"As medicine moves away from fee-for-service, outreach programs like POCT will promote health and early diagnosis, ultimately lowering the cost of patient care,"  he added. 

To oversee the POCT operations, Dr. Fox relies on a small but supportive staff, including two senior supervisors, three supervisors and a technologist. 

"I'm on the road by 6:30 a.m.," said senior supervisor Vilma Padilla, who on any given day, drives to a handful of satellite sites, from a private practice on Park Avenue to a women's health clinic in the Bronx. 

Once on site, Ms. Padilla ensures that all POC devices are properly maintained; if the device is broken, it's the responsibility of POC staff to replace it. In addition, she monitors compliance to strict guidelines to ensure patient safety standards are being met throughout the entire process. 

The staff is also responsible for training, evaluating the performance and competency of staff for more than 4,000 end-users in the Montefiore network, including nurses, medical technologists and some physicians. 

All POC tests must be validated against the standards set by the core lab facilities before they are utilized. To that end, Dr. Fox relies on the expertise and consultation of Dr. Jacob Rand, director of the hematology core lab, and Dr. Herbert Rose, director of the chemistry core lab. 

In recent years, decentralized patient care and access to testing in underserved areas have been key elements in the evolving expansion of POCT. 

In addition, by helping to reach the medically underserved, its use could also lower costs in the healthcare industry.

"The tests are restricted to sites where we feel we will make a difference," said Dr. Fox. 

The concept for the POCT service evolved from Dr. Fox's participation in Einstein's Clinical Research Training Program where she explored predictors of Chlamydia infection. 

"Expanding diagnostics to the bedside was a natural evolution," she explained.

The POCT field continues to evolve, with exciting potential and many advances on the horizon. Among them is wireless technology that could automatically update medical records. Dr. Fox also hopes to see improved rapid POCT for sexually transmitted infections, for which there is a high prevalence in the Bronx. 

Dr. Fox said, "most imperative, though, is that the POC results are accurate and reliable. 

She and her team continue to collaborate with manufacturers to test new state-of-the-art technologies and devices.  Not all, however, are suitable for the job.  She recalled the day when a new urine analysis machine they were testing showed "the water was pregnant." 

"It's got to be perfect," she said.  "There's a long way between complying with regulations and doing first-class work. We do first-class work."