Department of Pathology News

Montefiore's Point of Care Testing Service

Monday, June 11, 2012

Students at South Bronx High School don't need to search for a nearby clinic or anxiously wait days to know if they have Strep A, are pregnant or infected with HIV. It is one of the 17 high schools and middle schools - and among the 200 satellite sites around the city - that utilizes Montefiore Medical Center's Point of Care Testing services, making it one of the largest POCT programs in the country. "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. The state-of-the-art program began as a fledgling service in 2000, and 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 the core labs for analysis - a process which often takes days. Using small, portable devices with a wide menu of analytes, point of care testing can 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, 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, Dr. Fox said. Throughout Montefiore's Moses, Weiler and North hospitals, in-patient bedside glucose testing is available in wards from pediatrics to neurosurgery, and in outpatient clinics, from dentistry to dialysis. A handheld 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," Dr. Fox said, while demonstrating the portable scanner that allows for quick patient-side blood testing. Rapid results can also help shorten the length of a hospital stay, eliminate the need for 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, faster," Dr. Fox said, noting that POC service currently oversees the performance of over 50,000 Strep A tests per year. 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. POCT also prevents errors related to transfer of data and transcription, enabling emergency results and simplifying the logistics of frequent monitoring. Dr. Ira Sussman, vice chairman of pathology and professor of pathology and medicine, said POCT is a big consumer of pathology resources. Still, it is an essential investment as it enhances the efficiency of the physician community while providing a high level of customer satisfaction. “As medicine moves away from fee for service, programs like outreach POCT will promote health and early diagnosis, ultimately lowering the cost of patient care,” Dr. Sussman said. To oversee the POC 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 Ave. to a women's health clinic in the Bronx. Once on site, Padilla ensures that all POC devices are properly maintained; if the device is broken, it’s the responsibility of the POC staff to replace it. In addition, she also monitors compliance to strict guidelines to ensure patient safety standards are being met throughout the entire process. The staff is also responsible for training and evaluates 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 of the POC tests must be validated against the core lab facilities before it is utilized. To that end, Dr. Fox relies on the expertise and consultation of Dr. Jacob Rand, director of the hematology core lab, and Chemistry core lab director Dr. Herbert Rose. In recent years, decentralized patient care and access to testing in under-served areas are key elements in the evolving expansion of POC. In addition, 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 will make a difference,” Fox said. Running a Point of Care Service wasn't always on the horizon for Dr. Fox, who was trained as an infectious disease specialist at the University of Chicago, but gave up working in a basic science lab to come to New York in 1989. In 1998, an opportunity presented itself when Dr. Ed Burns, executive dean, asked Dr. Fox to apply to the clinical research training program and was accepted into the first class. Her thesis, under the direction of Dr. Eran Bellin, professor of medicine and of epidemiology and population health, explored predictors of Chlamydia infection. "Expanding diagnostics to the bedside was a natural evolution," Fox said, who took over the fledgling service when Dr. Janet Piscatelli left Montefiore. Today, POC is an exploding field, with exciting potential and many advances on the horizon. Among them is wireless technology that would automatically update medical records. Fox hopes to see improved rapid POC testing for STI's, which have high prevalence in the Bronx. But that's all in good time. Most imperative, Dr. Fox said, is that the POC results are accurate and reliable. The group continues to collaborate with manufacturers to test new state-of-the-art technologies and devices. Not all, however, are suitable for the job. Fox recalled the day when a new urine analysis machine they were testing showed "the water was pregnant." "It's got to be perfect," Dr. Fox said. "There's a long way between complying with regulations and doing first class work. We do first class work."

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