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Point-of-Care Testing Pediatric Emergency Department

Money saved, time saved and smoother handling of patients with new testing routines

For three years now, Dr. Jussi Niemelä and his colleagues at Turku university hospital in Finland have performed rapid point-of-care tests of total white blood cells (WBC) and C-reactive protein (CRP). This saves both time and money. So much money in fact, that the department has employed an additional physician during rush hours.

The most significant cost savings come from decreased nighttime laboratory costs. With the money saved, there is now an extra physician at the department between four and ten pm.

It is very helpful with an extra pair of hands during our busiest hours. Shorter time in the waiting room is of course a good thing for both patients and parents. It is rewarding to, as soon as possible, be able to examine and treat a child that is not feeling well. Shorter time at the hospital among other sick children decreases the risk of catching other diseases.

Unnecessary referral to university hospital

In Finland, C-Reactive Protein (CRP) tests are a common tool for point-of-care diagnostics in doctor's offices. These tests are used to detect inflammation or infection, with elevated CRP values often leading to referrals to university hospitals for further examination. However, Dr. Niemelä questions the necessity of this practice. He advocates for the importance of clinical evaluations as the primary basis for referring patients. According to him, CRP and White Blood Cell (WBC) counts should be considered in the context of these evaluations. Moreover, he suggests that if smaller hospitals and doctor's offices had access to rapid WBC tests, they could more effectively diagnose conditions and make immediate treatment decisions on their own. This approach emphasizes the need for a more holistic evaluation of patients, integrating both clinical assessments and laboratory tests to ensure appropriate and efficient patient care.

“Together with clinical signs, the combination of CRP and WBC can help us distinguish between viral and bacterial infections and help us avoid overuse of antibiotics. Some viral infections cause an increase in CRP but not in leukocyte count/level. If CRP is only slightly elevated, a WBC result can confirm the diagnosis. A high WBC and a low CRP is important to find, since this can be an early sign of a pneumococcal infection which can develop into sepsis very rapidly. It is reassuring that the combination of CRP and WBC can help me find something I might otherwise miss. It helps me decide whether to treat an infection or not, and how severe it is. If the values are normal there is time to wait a while and see how things develop, whereas if the values are high it is more acute. When I tell parents that I have examined their child and performed tests and everything points toward a viral infection, they usually know that there is no need for antibiotics.”

A good experience for doctors

The idea that the physicians themselves were to perform the point-of-care testing, originally came from the head of department Professor Jussi Mertsola. At first, Dr Niemelä and his colleagues were not too positive about it. One of the concerns among the physicians was that it might harm the contact with patients.

“We were worried to be regarded as ‘the bad doctor’ sticking the child. But this hasn’t happened. Finger tests seem to be better tolerated than venous samples. A long needle can be frightening for a child. I also think it is a good experience for us doctors, and if there is no nurse around it is good to be able to take the test yourself.”

No routine testing in children

There is no routine testing of children at the Pediatrics department in Turku. The patient always needs to see a physician before any testing is performed. Rapid point-of-care testing there and then, saves time since results are available immediately. Dr Jussi Niemelä experiences that handling of patients is definitely more efficient now.

“Even if you get used to always having patients waiting, it is neither convenient for me, nor for the families. Everything simply runs smoother when patients don’t have to wait”.

Differential white blood counts are ordered when considered needed, such as for neonates, immuno suppressed children, or patients where test values do not correlate with clinical signs. Dr Niemelä recalls one occasion when he was especially pleased having the rapid tests at hand. A family came in a hurry with a sick child just before going abroad. They needed help to decide whether to catch the ferry or not.

“After clinical evaluation of the child and performing POC tests, we did not have to wait for more laboratory testing. I could reassure them that it was OK to travel since the child only had a viral infection. And they did catch the ferry. This might not be clinically the most relevant case, but it was absolutely relevant for real life.”

“It is rewarding to, as soon as possible, be able to examine and treat a child that is not feeling well. Shorter time at the hospital among other sick children decreases the risk of catching other diseases.”

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