ICU Management & Practice, Volume 16 - Issue 3, 2016

Redesigning Emergency Ambulatory Care with Point-of-Care Testing: Reduced Costs and Length of Stay

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Many patients presenting to the hospital ‏emergency department do not need ‏to stay overnight. Ambulatory emergency ‏care (AEC) may optimise identification ‏and management of such patients by delivering ‏streamlined, efficient patient care within ‏one working day. This may improve clinical ‏outcomes, patient experience and lower costs.


At James Paget University Hospital, the acute ‏medicine unit (AMU) was organised into two ‏units. The Emergency Assessment and Discharge ‏Unit (EADU) immediately reviewed and treated ‏patients who were likely to need therapies and ‏investigations as an inpatient. The Ambulatory ‏Emergency Care (AEC) unit served patients ‏with fewer needs. As the AEC service could not ‏keep up with demand, the hospital management ‏redesigned the patient management streams and ‏established a new unit, the Ambulatory Care Unit ‏(AmbU) where point-of-care testing (POCT) was ‏a core component of the new service.


Process Redesign


The project team included hospital staff, with ‏industry partner support and sponsorship from ‏Abbott Point-of-Care, Radiometer® and Operasee ‏Limited.


The redesign process comprised (Figure 1):

1. Demand and Process Activity Mapping to understand ‏how the current system worked and to identify ‏an evidence-based, ideal future state of ‏the service, which could fulfil demand. This ‏identified leverage points on which to focus, ‏such as POCT, to catalyse change.

2. Failure Mode Effect Analysis (FMEA), a step-by-step ‏approach to identifying all possible failures in ‏a design, process, product or service. FMEA ‏was used to get input from multiple stakeholders ‏to identify, quantify, prioritise and ‏resolve potential issues in terms of how severe ‏they might be, how often they might occur ‏and how they could be detected.


To reach the goal of reduced length of ‏stay (LoS), the new service implemented the ‏following:


• POCT, including the i-STAT® System*;

• Appropriate treatment/discharge planning;

• Early senior clinical decision maker input;

• Condition-specific management algorithms.


POCT fulfilled over 85% of patient diagnostic ‏needs in the AEC setting. The i-STAT® System was ‏used for a variety of common tests, with the ‏following cartridges used most widely:


• CHEM8+ to test blood electrolytes, basic ‏haematology parameters and TCO2; ‏

• CG4+ to test lactate and blood gases;

• PT/INR to test prothrombin time.


In addition the CELL-DYN Emerald® analyser ‏was used for full blood count testing and the ‏Radiometer® AQT90 FLEX for D-dimer tests.


Improved LoS


The new AEC pathway started in August 2014 ‏(Monday through Friday, 08:30–18:30). The ‏three-month pilot led to dramatic improvements ‏in patient flow and reductions in LoS (Figure 2). ‏These improvements continued after the pilot ‏and after the AmbU moved into a newly built ‏space located within the AMU with additional ‏staff to support the extended service (Figure 2). ‏Emergency care was improved as a result ‏of the new outpatient AEC service, in both the ‏EADU and the AmbU. The rate of patients going ‏home on the same day increased and the rate of ‏patients admitted for 1, 2 or 3 days decreased, ‏demonstrating that fewer patients required ‏overnight stays. The reduced LoS was achieved ‏despite the patient admission rate remaining ‏constant (Figure 3).


Cost Benefit > £1 million


Following the pilot’s success, a business case ‏was approved to provide 7-day AEC services, ‏with operational hours extended from 08:30– ‏18:30 to 08:00–21:30. It was calculated that the ‏extended AEC services would save 15.87 Trust ‏beds per day within the EADU (Figure 4).


Despite the decrease in overnight stays, ‏which reduced Trust income, but represented a ‏£557,146 saving for the Clinical Commissioning ‏Group, and the cost of providing the service ‏(increased staffing and POCT diagnostics, etc.), it ‏was estimated that implementation of the service ‏would result in a net Trust saving of £42,265 ‏per year in the acute setting— through the safe ‏removal of 10 unwarranted escalation beds. ‏The remaining capacity (approximately 5.87 ‏beds) could be used to improve elective service ‏capacity. This equates to a total economic cost ‏benefit of £1,176,751 per annum (Figure 5). ‏ ‏


Benefits for Patients, Staff

Additional POCT benefits experienced at this site included:

• Patient data integration within the hospital information system;

• Senior clinical decision maker review within one hour;

• Static readmission rates;

• Positive patient feedback with 79% “extremely likely” to recommend the service;

• Under 10 minutes to initial review.


In the hospital setting, inefficient triage ‏systems, prolonged radiology and central laboratory ‏turnaround times, along with insufficient/ ‏non-flexible staffing, contribute to inefficient ‏operations and patient queuing. By incorporating ‏process redesign changes, the AmbU has become ‏an integral part of the emergency care system ‏within the JPUH.


Following the pilot, some staff felt that the ‏i-STAT® System gave them more time with the ‏patient. They also felt that it increased their ability ‏to communicate with the patients about their ‏results. ‏




The new AEC service at JPUH concentrated on the ‏implementation of POCT and process redesign. ‏Integrated POCT devices, such as the i-STAT® ‏System (providing multiple traditionally laboratory- ‏associated tests on a portable single platform), ‏are designed to provide rapid diagnostic ‏information that enables faster clinical management ‏decisions. Within the new AEC service, this ‏helped reduce LoS and costs. Other benefits may ‏also be realised when POCT is incorporated into ‏a workflow that allows real-time availability of ‏results, including improved patient satisfaction ‏and clinical outcomes.


The results shown here are specific to one healthcare ‏facility, and may differ from those achieved by other ‏institutions.


For in vitro diagnostic use only ‏

For intended use and complete product ‏information, visit


© Abbott Point of Care Inc.


i-STAT and CELL-DYN Emerald are registered trademarks ‏of the Abbott Group of Companies in various jurisdictions. ‏POCcelerator is a trademark of CONWORX Technology ‏GmbH. Radiometer is a registered trademark of ‏Danaher Medical ApS.


James Paget University Hospital

Great Yarmouth, Norfolk, UK ‏
Catchment area: 240,000 residents
‏Emergency admissions per year: 67,000



AEC ambulatory emergency care

AmbU ambulatory care unit

AMU acute medicine unit

EADU emergency assessment and discharge unit

LoS length of stay

POCT point-of-care testing

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