Speakers
Katy Heaney
Fiona Riddoch
Bethan Phillips
Jonathan Kay
Lisa Vipond
UKMedLab23
Session Chair: Katy Heaney
9.00am Fiona Riddoch and Bethan Phillips, Neonatal jaundice assessment: Banana skins and snake pits
9.30am Lisa Vipond and Anthea Patterson, Hs-cTnI implementation: The POCT obstacle course
10.00am Jonathan Kay, POCT IT: Nailing down the great unknown
Point of care testing (POCT) is an expanding, yet challenging discipline of pathology that requires both in-depth analytical knowledge of the tests we use, and practical, operational understanding of how the tests can provide maximum patient benefit. This session brings some tricky topics to the table for a real-life discussion on the challenges faced in the service, delivered by experts in the field. A review of POCT jaundice assessment; a well-established POCT used for many years. Dr Fiona Riddoch sets the scene of interplay between laboratory and POCT methods, and Miss Bethan Phillips gives a scientific appraisal of transcutaneous jaundice assessment. New clinical services embracing community care of patients increases the requirement for POCT to be truly effective, and highlights the need for IT integration; we question whether our POCT systems are ready for this challenge. Long-awaited POCT HS-Troponin methods have emerged onto market; but now comes the challenge of implementing not just as a replacement for laboratory methods but into new ways of working to optimise their use and, bring clinical and operational benefit to the current NHS Emergency Department crisis.
Neonatal jaundice assessment: Banana skins and snake pits - Fiona Riddoch and Bethan Phillips
Multiple methods are available for the assessment of neonatal jaundice, not least visual checking of skin or sclera as a first line screen. However, jaundice can be easy to miss, particularly in babies with pigmented skin, so many midwife and neonatal services use transcutaneous jaundice meters to screen for and estimate the extent of jaundice. This testing can be easily performed within both acute and community settings to assess the need for a blood sample to be collected for bilirubin measurement, the results of which can be used to make treatment decisions.
Laboratory serum tests are often wet chemistry with spectrophotometric detection and may be traceable to the Doumas method and NIST 916, or 916b. This requires phlebotomy and 1-2mLs of blood, but this can often be utilised to perform a range of other tests. Point of care (POCT) plasma methods require a glass capillary from a skin prick (usually heel prick) and separation of serum/plasma using a centrifuge before dual wavelength spectrophotometric measurement of bilirubin pigment. POCT measurement of bilirubin can also be achieved on blood gas analysers. Lab and POCT tests require the baby to be present in the neonatal unit.
These methods all have their pros and cons but do offer flexibility around testing methodology, sampling and location. However, there are frequently discrepancies between the methods which can cause clinical confusion, over-testing and possible over- or under-treatment by phototherapy or exchange transfusion, when using non-method-specific NICE cut-offs (NICE CG98).
Like laboratory tests, device verification and acceptance criteria should be defined for the implementation of point of care tests. We will discuss in detail the analytical performance of the JM-105 (Draeger) transcutaneous jaundice meters observed within our network. Furthermore, we will consider potential approaches to derive a reflective acceptance criterion which may be used, alongside safety netting within clinical protocols, to allow these devices to be safely implemented and maximise benefit to patient care.
POCT IT: Nailing down the great unknown - Jonathan Kay
Hs-cTnI implementation: The POCT obstacle course - Lisa Vipond
Cornwall has one acute hospital with one Emergency Dept (ED), plus a network of community hospitals with Clinical Decision Centres (CDCs), Urgent treatment centres (UTC) and Minor injuries Units (MIUs).
The slide down and bump at the bottom: “Ambulance response times in Cornwall among worst in UK, 2022” Newspaper headlines like this make depressing reading and reflect the extreme difficulty in maintaining a safe service in such challenging times. Innovative ways of working, using new technology and clinical pathways were urgently needed.
The wall to be scaled: A POCT device that met the analytical criteria specified by NICE, for the diagnosis of Myocardial Infarction (MI), became commercially available in 2021. The POCT team at RCHT initiated the technical verification of the Atellica VTLi, working closely with the clinical teams to collect patient comparison samples and with UKNEQAS on the EQA evaluation.
Building Bridges: The stakeholders including lab representatives, ED Clinicians and acute GPs formed a multidisciplinary team to look at the use of the POCT device in UTC. A low risk cardiac chest pain pathway was developed that used clinical scoring and the hs-cTnI POCT result to triage patients; all of whom would formally have been transferred from the community to ED by ambulance.
The finishing line: Audits are on-going, however early data shows the use of the chest pain pathway has resulted in at least a 50% reduction in transfers of patients to AE from community settings, with no clinical harm having been observed. This initiative has significantly reduced the burden on the ambulance service and on ED, but most significantly, patients who would otherwise have had to endure a prolonged wait in ED can be sent home, safely.
Mrs Katy Heaney MSc DipRCPath
Consultant Clinical Scientist, Specialty lead Point of Care Testing
Frimley Health NHS Foundation Trust
Berkshire and Surrey Pathology Services
Katy has been working in the NHS and its services for 19 years in Clinical Biochemistry and Point of Care Testing (POCT). Currently employed as the Consultant Specialty lead for POCT for Berkshire and Surrey Pathology Services, the service covers 5 NHS Trusts, with 6 acute medical sites and multiple community services and the Clinical Director of the dedicated ISO accredited POCT EQA scheme, Qpoint. At the end of 2020 Katy was seconded to the Department of Health and Social Care, then later UKHSA, Operational Supplies team as the Point of care workflow programme lead, with the primary aim of providing technical and scientific leadership in the deployment of rapid covid testing into NHS Emergency departments.
Working in POCT requires technical, scientific and clinical expertise from the healthcare scientist workforce. The training day session has opportunity for trainees to gain practical training on POCT kit, understand the technical limitations of the most common of POCT tests and assess the clinical impact of their abilities.
Fiona trained as a Clinical Scientist in Biochemistry. Currently employed as a Consultant Clinical Scientist for POCT in Berkshire and Surrey Pathology Services (BSPS); the service covers 5 acute NHS Trusts, and multiple community services. Over the last 5 years she has developed multidisciplinary clinical and technical expertise needed for POCT, and in particular focussing on IT, risk management and analytical & clinical verification of POCT analysers, using these skills to support the BSPS POCT team in achieving accreditation against ISO:15189(2022) for our multi-site blood gas analyser service. She has led the BSPS POCT team on national verification projects, including multiple SARS-CoV-2 and winter multiplex methods on behalf of NHS England, being an exemplary verification and implementation site for POCT in Hospital@Home services; working to provide evidence that can be used nationally to support implementation of POCT CRP and high-sensitivity troponin. She has won national awards for quality improvement projects and clinical audit, by demonstrating clinical impact and patient benefit of pathology services.
Following a placement with the Point of Care team during her STP training, Bethan has continued to develop her expertise within Berkshire and Surrey Pathology Services, Point of Care and Rapid Respiratory Testing Service, since 2021. Taking advantage of the unique multi-disciplinary opportunities offered, Bethan’s focus is on POCT device analytical and clinical performance - leading on the verification of devices, monitoring ongoing result quality, and ensuring user-friendly reporting of results into electronic patient records.
Jonathan Kay spent most of his career as a chemical pathologist in Oxford. He has also been Clinical Informatics Director at NHS England, Professor of Health Informatics at University College London and City University London, and Chair of the Faculty of Clinical Informatics.
His research interests include the process of clinical investigation, medical knowledge management, and everyday technology at the point of care. With Ian Smith he developed the point of care testing implementations across the Oxford hospitals and the Oxfordshire Emergency Multidisciplinary Assessment Units. He has been a board member of Lab Tests Online UK since its creation.
He spends as much time as possible acting, walking and cycling.
Lisa has worked in Clinical Biochemistry for nearly 20 years, starting her career as a biomedical scientist, and then becoming POCT coordinator, introducing connectivity and developing POCT services beyond the standard well versed format. After nearly 8 ½ years as a coordinator & manager Lisa moved back into the laboratory management progressing to her current role as Pathology Service Manager. POCT has remained an interest and she continues to be involved at Trust, Network, and regional levels.
She currently teaches on the certificate of expert practice in POCT for the IBMS with a small cohort of others and has a keen interest to develop POCT into the right clinical settings supported by a good governance structure. She is keen to ensure the patient is at the heart of pathology services.
After completing my Ph.D I took up a clinical scientist training post at the LGI in Leeds. I stayed in the city for my first job, moving the few miles across to St James, where I spent a further twelve happy and productive years in Biochemical Genetics, principally overseeing the Newborn screening service. In 2011 my next move was south and west, to a consultant post at the Royal Cornwall Hospital. I am specialty lead for Clinical Chemistry and the clinical lead for POCT. With only one acute hospital, Cornwall affords unique opportunities to get involved in the patient journey and really make a difference. I am particularly interested in innovative changes to patient pathways with the use of POCT equipment, test optimization and clinical support technology.