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An unmet need in acute units
In this video, Dr Kay Roy discusses some of the challenges present in acute settings and the important implications of using rapid syndromic testing.
So within the acute admissions unit, rapid syndromic testing has important implications. We’ve discussed the value of point-of-care testing – the closer the test is to the patient – but also the closer the test is to the start of the patient’s symptoms, the start of their journey in the hospital, or even within the community, that’s where we’re going to make the most gains and gain the most benefit for the patient, really. There are practical issues we have identified in the previous talk around point-of-care testing in ensuring that testing meets quality standards, is cost-effective, and practical issues around personnel and having the right workforce. But we know the value of syndromic testing in ensuring that there’s a fast turnaround time.
Within the ED department, we can isolate, cohort, triage patients accordingly before they enter the main hospital, and even discharge, reducing the spread of nosocomial infection and avoiding unnecessary isolation of patients who may, in fact, not have influenza, for example. And again, the negative tests are just as valuable here within the syndromic panel as the positive ones are.
There have been outcome studies performed in an effort to quantify the benefit of syndromic panels within the acute setting.
And we could say that, theoretically, the detection of other viral targets aside from influenza or RSV could benefit patients by reducing their clinical suspicion of a bacterial infection and preventing initiation or promoting, in fact, the discontinuation of antibiotic therapy. So there is a value in, as we’ve mentioned earlier in the previous studies, in the RespPOC study, that there is a value in identifying other viruses at the front door. However, there aren’t enough studies or evidence to really confirm all of this and quantify its benefit in patient care. Some studies have, in fact, shown that syndromic panels decrease antibiotic therapy, length of hospital stay, additional tests, additional imaging, for example. But some studies have not shown that much benefit.
And mainly, the benefits has related to a positive influenza test result, showing that limited testing may just be sufficient for most patients, apart from syndromic testing. So we do need to identify, possibly with diagnostic stewardship, who to apply a syndromic panel to to maximise benefit and reduce the efficiency cost-wise as well.
So looking at outcomes here in patients with severe bacterial infection in relation to appropriateness of antibiotic therapy, we can see here that particularly in pneumonia or sepsis, having a test that is slow, that is imprecise does not allow patients to be on the right treatment, and this translates into increased mortality. So it is very, very essential and almost critical that patients receive effective antibiotics in that first hour of diagnosis – and hence the need for syndrome panels and point of care test at the front door in acute settings, such as emergency department or acute admissions unit.
Any delay can have a significant impact, and although broad-spectrum antibiotic therapy can be de-escalated at 48 hours, once we’ve got the conventional lab data available, there are cases where, as we know, the organism isn’t grown in more than 3/4 of cases. And again, there are the behavioural factors we’ve seen in the previous talk about ensuring that physicians have the confidence to change therapy once it’s started as well. But radical accelerations have been achieved with molecular methods. We’ve seen this in other disease groups, such as tuberculosis, sexually transmitted infections. And we know that these immediate test results have – moving from tissue to molecular diagnosis – have a tremendous impact in rapid decision making processes. So speed is of the essence.
I’ve discussed in my previous talk about implementing point-of-care tests with syndromic panels in the community. And we know here that treatment is almost entirely empirical, where, in a primary care setting, it is completely, in many cases unguided by any bacterial results in the laboratory. Around 3% of community respiratory infections in the community have laboratory investigation results, and so even more important in our drive to ensure we deliver good antimicrobial stewardship is this need to deliver tests as early as possible in the patient’s journey from start of symptoms, to prevent overtreatment.
We can see here the ruling in, ruling out of a diagnosis is essential in that treatment choice monitoring the prognosis, but also in the trust in operational decision-making processes, resource utilisation – and hence the importance of delivering these panels within the ED setting. And the rapid access of these results can have an important impact, as we’ve discussed, operationally – as it’s time and setting-based – in making decisions about discharging patients from ED or putting them into the relevant cohorting bay.
But if we take this one step further, delivering this approach within a primary care or an urgent care centre within the community also can prevent attendance in ED altogether, reducing the time and the obvious impact on resources in the hospital itself.
Earlier in the week, we explored how syndromic testing can be used appropriately, as part of a full clinical picture and with good clinical judgement, to maximise patient benefit and eliminate associated risks. In this video, Dr Kay Roy discusses some of the challenges present in acute settings and the important implications of using rapid syndromic testing in such settings.
The value of POCT in bringing diagnostics closer to the patient has previously been discussed. Importantly, such tests hold the most benefit when used closer to the start of a patient’s journey. The fast turnaround time offered by the use of syndromic testing is particularly important in the context of emergency departments (EDs), where cohorts can be quickly isolated before they are discharged or enter the main hospital. Negative tests offer equal value, allowing patients who do not need to be isolated to also be identified.
References cited in the video have been provided as links in the see also section below.
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Syndromic Testing and Antimicrobial Stewardship
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Syndromic Testing and Antimicrobial Stewardship
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