Beazley Catherine, Blattner Katharina, Herd Geoffrey (2021) Point-of-Care Haematology Analyser Quality Assurance Programme: a rural nursing perspective. Journal of Primary Health Care 13, 84-90.
An open access paper that is full of wisdom from the Hokianga. While we can reduce inequalities with near to patient technology, it is important not to neglect safety – QA! – and consider how that looks for your place: what is the resource?
BACKGROUND AND CONTEXT: Rural health services without an onsite laboratory lack timely access to haematology results. Set in New Zealand’s far north, this paper provides a rural nursing perspective on how a health service remote from a laboratory introduced a haematology analyser suitable for point-of-care use and established the associated quality assurance programme.
ASSESSMENT OF PROBLEM: Five broad areas were identified that could impact on successful implementation of the haematology analyser: quality control, staff training, physical resources, costs, and human resource requirements.
RESULTS: Quality control testing, staff training and operating the haematology analyser was more time intensive than anticipated. Finding adequate physical space for placement and operation of the analyser was challenging and costs per patient tests were higher than predicted due to low volumes of testing.
STRATEGIES FOR IMPROVEMENT: Through a collaborative team approach, a modified quality assurance programme was agreed on with the supplier and regional point-of-care testing co-ordinator, resulting in a reduced cost per test. The supplier provided dedicated hours of staff training. Allocated time was assigned to run point-of-care testing quality assurance.
LESSONS: Having access to laboratory tests can reduce inequalities for rural patients, but natural enthusiasm to introduce new point-of-care technologies and devices needs to be tempered by a thorough consideration of the realities on the ground. Quality assurance programmes need to fit the locality while being overseen and supported by laboratory staff knowledgeable in point-of-care testing requirements. Associated costs need to be sustainable in both human and physical resources.
Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.
Not a great surprise: most rural hospitals do not have timely access to the same troponin assays that metropolitan hospitals rely on, instead reliant on less sensitive point-of-care troponin. A significant number of NSTEMI maybe missed using POC troponin at the manufacturer’s cut-off and we have an observational study underway evaluating a pathway that will limit these missed AMI.(1,2) This pathway has been shown to be effective in a pilot run in a low-risk primary care population.(3) There is also hope as discussed previously that a new high precision point-of-care assay will bring rural chest pain assessment in line with urban hospitals.(4)
“The results of this survey reinforce the importance of considering the context and resources of all New Zealand hospitals when making recommendations at a national level, such as the adoption of ADPs. Failure to do so can confuse clinical practice in our small rural hospitals that have access to fewer resources and risks exacerbating existing inequities.”
AIMS: Accelerated diagnostic chest pain pathways (ADP) have become standard of care in urban emergency departments. It is, however, unknown how widely they are used in New Zealand’s rural hospitals because ADP require immediate access to contemporary or high-sensitivity troponin (hs-Tn). We aimed to determine for rural hospitals the troponin assay being used, if they were using an ADP and if they had access to on-site exercise tolerance testing (ETT).
METHODS: An online survey was sent to 27 rural hospitals providing acute care in New Zealand.
RESULTS: Most rural hospitals (23/27, 85%) responded to the survey. Most (17/23, 74%) used point-of- care cardiac troponin (POC-cTn) and the majority of these hospitals (15/17, 88%) were reliant on this assay 24-hours per day. All hospitals that had timely access to hs-Tn (8/23, 35%) used an ADP but only a minority (4/17, 24%) of hospitals using POC-cTn used an ADP. Only a minority of the larger rural hospitals (7/23, 30%) had access to on-site ETT.
CONCLUSIONS: Most New Zealand rural hospitals rely on POC-cTn to assess chest pain and are not using an ADP. There are limited data available to support this approach in rural settings especially with patients who are not low-risk.
1. Miller R, Nixon G. The assessment of acute chest pain in New Zealand rural hospitals utilising point-of-care troponin. Journal of Primary Health Care. 2018;10(1):90–2.
2. Schneider HG, Ablitt P, Taylor J. Improved sensitivity of point of care troponin I values using reporting to below the 99th percentile of normals. Clinical Biochemistry. 2013 Aug;46(12):979–82.
3. Norman T, Devlin G, Than M, George P, Young J, Egan G, et al. Measured Implementation of an Accelerated Chest Pain Diagnostic Pathway in Primary Care. Heart, Lung and Circulation. 2018 Jan;27:S4–5.
4. Pickering JW, Young JM, George PM, Watson AS, Aldous SJ, Troughton RW, et al. Validity of a Novel Point-of-Care Troponin Assay for Single-Test Rule-Out of Acute Myocardial Infarction. JAMA Cardiology. 2018 Oct;
Pickering JW, Young JM, George PM, et al. Validity of a Novel Point-of-Care Troponin Assay for Single-Test Rule-Out of Acute Myocardial Infarction. JAMA Cardiol. Published online October 17, 2018. doi:10.1001/jamacardio.2018.3368
Second troponin paper for the day:
A first look at a new POC assay from Abbott by a group well known for their work in chest pain assessment. This preliminary study performed in Christchurch ED (urban population) shows a single test (used in a laboratory) on presentation (that takes 15minutes to run) effectively excludes Type 1 myocardial infarction in low-risk patients – with the same Sens/NPV as a laboratory based . Need to wait to see real world performance but promising for rural GP and hospitals reliant on point-of-care troponin when assessing chest pain. Not calling it high-sens yet… Semantics