Folie 1 - Deauville

POC in ED:
Is there a benefit for patient care?
Which impact on ward internal organization?
PETRA WILKE, 5th congress of acute critical care testing and blood gas,
31. May 2012, Deauville
Klinikum Frankfurt (Oder) GmbH Rhön AG
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835 bed district hospital- privat
authority
level I trauma center
regional cardiac and stroke center
24 departments
ED:
27.000 visits - 85/d
9 critical care beds
4 bed Chest Pain Unit
fast track unit
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
2
owercrowding in European EDs
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16,6% Germany
17,2% ZNA FFO
28000
27000
26000
25000
24000
23000
2005
2006
2007
2008
2009
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
2010
2011
3
decision making: acuity
2500
4,4%
1800
1600
2000
1400
44,1%
1200
1500
1000
Sel bs tei nwei s er
68%
1000
38,7%
600
400
FFO-RTD 22%
500
0
Jan
800
MOL-RTD 2%
10,8%
0,6%
Ja n
Feb
Mrz
Apr
Mai
Jun
Jul
Aug
Sep
Okt
Nov
Feb
Mrz
Apr
Ma i
200
LOS-RTD 5%
Arzt 1%
Jun
Jul
Aug
Sep
Okt
Nov
0
Dez
Dez
• 48% low acuity patients
• 68 % selfadmissions
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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patient safety
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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Triage systems
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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first the symptom ... than the
diagnose...
ACS , pleuritis, spine
prolaps, pneumonia, LAE,
aortic dissection,
pneumothorax,
malignoma, zoster...
chest pain
lab request, POCT
diagnostic services
radiology
 differential diagnostic evaluation
 symptom based clinical pathways
 diagnostic profiles
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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Ab
do
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am
pf
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ec
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pf
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en
hl
or
se
ax
in
sc
be
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im
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At
wa
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tb
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el
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change- management
reduction of LOS
risk minimizing
key performing indicators
Plan
Act
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
Do
Check
120
100
80
60
40
20
0
8
ED pathway
accessment of admission data
Triage
vital signs
• pain accessment
• acuity accessment (MTS/ ESI...)
blood samples/ POCT/ urin sample
• application of analgetic drugs
waiting period depending on acuity
physicians examination
decision making with lab values
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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Erpath :
triage+ clinical pathway + lab
request
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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TAT in ED
pre-analytic phase:
analytic phase:
post-analytic
• gaining blood sample
• sample acceptance
phase:
• labeling
• clotextraction
• result approval
• approval IS
• zentrifugation
• perception
• sample transport
• Immunoassay
• interpretation
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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TAT analysis 2008
 central lab 5 min from ED
 short staff
 no delivery system (pneumatic tube system)
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blood count:
30 min
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blood glucose, electrolyts:
30 min
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TSH:
60-90 min
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troponin:
60-90 min
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clotting, D-Dimere, creatinine:
30 min
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lactat, BGA:
30 min
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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POCT maintanance by staff
 lab qualified personnel retrained for ED admission function
 internal control: daily (AQT, ABL) + weekly by ED staff
 external control: central lab
 reporting (remote control tools): central lab
 RiLiBÄK: guidelines national medical association
 POCT-coordinator: central lab
 annual staff training
 choice and preference of POCT devices
 getting used to selfresponsability (measurements fail)
 getting used to new values and cutoff definitions
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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How to optimize post-analytic phase:
POCT interface with Erpath
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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Case report
 male, 73 year old, admitted by general practictioner
 since 3 days signs of gastroenteritis: vomiting, weakness
 hypotension ( hypotensiv medication)
 Triage: unease- sudden occuring- yellow
 medical evaluation within 30 min
 vital parameter: RR 81/56 mmHg, HR 68/min, T: 35.8 C
 peripheral 02 saturation: 96%, Resp. Rate 14/min
 GCS 15
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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once upon a time...
admission
5 min
10 min
20 min
blood sample
30 min
transport
40 min
start central lab analysis
50 min
60 min
no diagnose after 70 min !
70 min
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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symptoms in elderly
LAD, RCX stenosis, RCA occlusion, EF: 30%
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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...with triage + POCT
5 min
admission
10 min
triage, blood sample (profiles)
POCT
20 min
30 min
40 min
test result
diagnose after 30 min:
NSTEMI, cardiogenic shock
50 min
intervention
60 min
70 min
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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Case report
 female, 62 years old, transmitted for neuosurgical evaluation
 since 1 day acute progressiv plegia
 time of admission: tetraplegic
 call the neurologist/neurosurgion for further evaluation?
 make a magnet resonance tomography?
BGA with every neurological symptom!
 in 2 min: glucose + 1.6 mmol/l K+
 clinical benefit
 economical benefit (resource management)
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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LOS reduction
 target : LOS < 3 h
 Fast Track Unit, POCT
 LOS median 2008:
2.3 h
2011:
1.8 h
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
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benefit
12
10
d: 1.61
8
d: 0.69
6
4
2
0
2006
2007
2008
dVWD stat. als Notfall über ZNA
Klinikum Frankfurt (Oder), Dr. med. Petra Wilke, POCT in ED
2009
2010
2011
dVWD stat. gesamt
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Merci bien pour votre attention !