The idyllic New Zealand countryside is more synonymous with hiking than high-tech healthcare, but several rural towns have been the site of a world-first trial of point-of-care technology for troponin measurement.
Most city dwellers experiencing chest pain in New Zealand present to an emergency department and in 2014, the country's metropolitan emergency departments adopted accelerated chest pain pathways to rapidly exclude acute myocardial infarctions (AMI) in those patients.
At the time, only around a third of rural hospitals had access to a high-sensitivity troponin diagnostic test. And in rural settings, many people with chest pain present to their family doctor, rather than a hospital.
Rural sites also employed a wide range of decision-making protocols to determine whether a patient should be treated locally or transported via ambulance to a metropolitan centre for further care. Some rural hospitals and clinics with access to point-of-care troponin testing relied solely on that result. Others incorporated ECG reports into decision-making, while others transported anyone presenting with chest pain.
Dr Rory Miller is a researcher at the University of Otago with an interest in exploring rural health inequities who has led two trials aiming to streamline the process. The two studies are the first in the world to assess the role of troponin in rural patient treatment pathways.
"We ran a pilot project where 180 rural patients experiencing chest pain were assessed with two standardised tools: the Emergency Department Assessment of Chest Pain Score (EDACS), and point-of-care high-sensitivity troponin test. The decision on whether to treat locally or transport was based on those criteria."
The pilot showed high acceptability of the technology and good results interpretation among rural clinicians, whilst reducing unnecessary ambulance trips. The success of that proof-of-concept led to this recent larger study, which involved over 1,000 patients at 29 sites, including small local hospitals, general practices, and even vision care clinics.
Point-of-care testing has been widely used by rural health services in New Zealand, and the Abbott i-STAT is particularly popular due to its ability to run a variety of assays, affordability, and ease of use. Twenty-seven of the 29 sites involved already had i-STAT devices in use.
Dr Miller sees using results from point-of-care testing as a way to reduce some of the disparities between metropolitan and rural care.
"Avoiding a long trip to a city hospital is clearly great news for patients who aren't having a cardiac arrest. The results also give our rural doctors the confidence that they can provide this crucial healthcare at a level that is just as robust as their metropolitan counterparts, who often have access to 'bigger, better' technologies."
Dr Martin Than is the Director of Emergency Medicine research at Christchurch Public Hospital, a major receiving hospital for rural patients with suspected heart attacks. He routinely sees patients who have been involved in the study. He says, "Around 90 per cent of these patients aren't having heart attacks, which is of course a good thing. But when you add up the unnecessary burdens shouldered by them, and the impacts of having what is potentially the only ambulance servicing an entire regional area out of action for two or three hours, you realise there is a significant cost incurred.
"For the patient and their family, they lose time to treat the underlying condition, prolonged uncertainty and fear about the diagnosis, significant disruption to their daily life, and financial costs associated with ambulances, if they don't have insurance. For the local community, the risks of having the only available ambulance otherwise engaged are obvious."
The researchers have finalised their results and have submitted them to a major international medical journal and anticipate the article will be published before the end of 2021
Five benefits of the Abbott i-STAT system
1. TESTING DELAYS – Maximise resources by assessing renal function in minutes, enabling immediate care for routine and urgent cases.
2. RELIABLE ACCURACY – Lab-accurate results enable radiology clinicians to make patient care decisions with confidence.
3. SMALL SAMPLE SIZE – Just two or three drops of blood are required, making testing easier on staff and patients.
4. EASE OF USE – Simple, intuitive operation of the i-STAT system with the Creatinine and CHEM8+ cartridges make it ideal for busy imaging practices.
5. ON-SCREEN CALCULATIONS – i-STAT can be set to display a calculation such as eGFR automatically.
* Quoted comments are based upon this hospital's experience with i-STAT and may differ from those achieved by other institutions.
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