Towards Sustainable Point-of-Care Testing in Remote Australia Brooke Spaeth BMedSc (Hons)
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2 Towards Sustainable Point-of-Care Testing in Remote Australia Brooke Spaeth BMedSc (Hons) Device and Quality Coordinator Flinders University International Centre for Point-of-Care Testing jointly with Community Point-of-Care Services Flinders University, Adelaide, Australia
3 Northern Territory of Australia Very remote and geographically isolated 75% of Australia landmass is Remote, but only 4% of population reside in remote locations Ref: Zhao et al. 2006
4 Northern Territory of Australia The Average Remote Health Centre: Located 275 kilometres from the nearest hospital (range 100 to 700km) Service a population of 523 people
5 Northern Territory of Australia The Average Remote Health Centre: Staff include: 3-4 full time Remote Area Nurses; 1-2 Aboriginal Health Workers; no regular medical practitioner or specialist services 35 visits by a doctor and 8502 patient attendances per year Remote Health Centre Emergency Rooms
6 Northern Territory of Australia Emergency services provided by on-call Doctors: 1800 phone calls per month, 50% resulting in an emergency medical retrievals Air transport to hospital emergency department = $4,000 to $16,000 each Remote Health Centre Airports
7 Origin of the Northern Territory Point-of-Care Testing Program Top End In the Top End 10 out of 28 remote health centres had daily access to pathology services, 8 had access two times per week, 2 had access once a month and the remaining 8 had variable access (determined by weather) Central In Central Australia almost no remote health centres had daily access to pathology services and many relied on weekly mail plane services NT Government sought Point-of-Care Testing as a solution 30 Abbott i-stat devices purchased from grant funding Flinders Community Point-of-Care Services (CPS) unit contacted to manage and coordinate network of Abbott i-stat devices
8 Methods - Governance Currently in NT POCT Program: 33 remote health centres enrolled Management Committee Program Manager: Prof Mark Shephard Program Coordinator: Brooke Spaeth Clinical Advisor: Dr Vinod Daniel Top End Regional Coordinator: Amanda Lingwood Central Australia Regional Coordinator: Malcolm Auld 15 District Trainers Area Service Managers
9 Methods - Training Now over 500 staff trained as Point-of-Care Operators Options for Training Delivery: Primary Training Workshops delivered by POC coordinators Mobile on-site training delivered by regional and district trainers Self-directed training available on NT Government Intranet On-line training delivered via GoToMeeting Training Resources Primary training manual Patient and Quality Testing Posters DVD PowerPoint presentation
10 Methods - Training Competency Assessment Written and Practical Competency checklist Competency Certificate Competency register
11 Methods Quality Testing
12 Results - Operational Effectiveness Year Patient Tests QC Tests TOTAL Tests Year 1: Aug 08 July Year 2: Aug 09 July Year 3: Aug 10 July Year 4: Aug 11 July
13 Results Additional Operational Support Services
14 Support Services Telephone Support Year 3 of the program: 189 telephone communications (34% incoming and 66% outgoing). Newsletter Support Produced and distributed by NT POCT Management Committee. Includes: a technical bulletin; POCT operator of month; training updates; interesting clinical cases; overall statistics.
15 Results - Analytical Quality Analyte Units Quality Control Level Year 1 n Year 1 CV% Year 2 n Year 2 CV% Year 3 n Year 3 CV% Year 4 n Year 4 CV% Goal# CV% Sodium mmol/l Potassium mmol/l Chloride mmol/l Glucose mmol/l INR n/a * ph n/a Lactate mmol/l # median imprecision achieved by laboratories in RCPA Blood Gas and Co-oximetry QAP, Cycle 48, 2012 *Analytical Goal for INR recommended by the Australian Government
16 Results Satisfaction Health Centre staff satisfaction with pathology service: between 29% and 54% when the laboratory was used between 84% and 100% after the i-stat was introduced
17 Results Clinical Effectiveness Clinical Application of i-stat in Northern Territory: Cartridge Sample Volume Test Profiles Time for Result Chem8+ 95µL Electrolytes, total CO 2, urea, creatinine, glucose, ionised calcium, haemoglobin 2 minutes ctni 17µL Cardiac Troponin I 10 minutes CG4+ 95µL Blood gases and lactate 2 minutes PT/INR 20-45µL International Normalised Ratio 5 minutes
18 i-stat Clinical Effectiveness History Presentation Clinical Investigation 73 year old Male tourist with a history of cardiac problems Presented to the Health Centre with strong recurring chest pain ECG (electrocardiogram) and i-stat Troponin I test performed Results Diagnosis ECG showed no major changes Troponin I = 0.12ng/mL (negative <0.08ng/mL) - Evacuated Laboratory Troponin I increased to 0.44 ng/ml (positive >0.4ng/mL) Patient diagnosed with non-stemi (non-st Elevation Myocardial Infarction) Summary The clinical outcome was good and the diagnosis may have been missed if the Troponin I test was not done on the spot (as ECG results normal). This highlights the importance of having an i-stat at ALL remote health clinics. A big win for the patient and the i-stat
19 i-stat Clinical Effectiveness 53 year old female of Aboriginal descent The INR target range for atrial fibrillation between 2.5 and tests over 6 months (76% within therapeutic range) Serial INR Results 8 INR Target range Date of INR Test
20 Personal Perspective NT POCT Program stated as Honours project in 2009 Now Point-of-Care Coordinator Visit and engage with remote communities Positive feedback demonstrates need and effectiveness Research is diverse and rewarding Trained members of the Australian Army Translate NT POCT Program to other states in Australia
21 Challenges for Sustainability High rate of staff turnover Limited funding for program Reimbursement for testing cartridges Logistical issues Short expiry of QC material Inappropriate QC matrix
22 Conclusion Operationally effective Analytically sound Clinically effective Culturally effective Well-received by health professional staff
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