A hornets’ nest in Trenton over plans to replace the hospital lab

It’s been a hornets’ nest for the past two months.

Quinte Health Care’s plan to shut down its lab at Trenton Memorial Hospital and replace it with “Point of Care Testing” (POCT) has raised the ire of local doctors, politicians and community members in this town of about 20,000 residents.

QHC plans to close Trenton’s lab in late September.

Doctors say the closure of the lab is the beginning of the end for Trenton’s emergency room – leaving the town with a glorified “first-aid post.” The hospital denies this, arguing the Picton and North Hastings sites maintain ERs with only POCT.

With cuts to nursing staff also part of the plan, the doctors question how emergency room nurses will have the time to safely operate POCT equipment.

POCT has remained controversial far beyond the confines of Trenton.

At stake is the accuracy of test results conducted most often by nurses using smaller more portable equipment than exists in hospital labs. While licensed medical laboratory technologists are supposed to be part of the quality control process, they are not always on site when testing takes place.

The hospital claims it is making these changes to save money, although the International Journal of Laboratory Hematology warns that “it may be that the cost per test of the POCT instrument is more expensive than sending the sample to the main laboratory.” Of particular concern to the Trenton Hospital, the journal notes “there is reduced efficiency in low volume activity and higher quality control costs.”

The hospital claims closing the lab will save $400,000, although a full costing has not been made public, raising questions on both the cost and delay in sending tests that cannot be performed by POCT to the central lab in Belleville.

While QHC has gone to great lengths to suggest this is the wave of the future, claiming there is no difference in the outcome, independent scientific literature on POCT is less clear on at least the latter point.

In the United States POCT has been found to be a lot less than the “foolproof” system its promoters claim it to be.

The Health Care Financing Administration noted that quality problems were identified in more than 50 per cent of “Certificate of Waiver” labs it included in its nation-wide study.

Problems stemmed from obsolete, incorrect, or a complete lack of instruction along with a failure to perform quality control required by the equipment manufacturer.

Reports in Pathology News also suggest that while POCT can be a valuable tool, limitations do exist and “constitute a pitfall for the unwary.” They specifically note that while even simple portable Glucose POCT devices may be satisfactory for the monitoring of glycemic disorders, they are not “sufficiently precise to establish the initial diagnosis of the condition.”

QHC maintains POCT is already successful in Picton, but the head of ER disagrees. Dr. Amber Stewart, who is Quinte’s Division Head for ERs in both Trenton and Picton, says there have been problems with POCT at the Quinte site in Prince Edward County and that she has previously made the hospital aware of those problems.

While there has been no decision, recommendations at Muskoka Algonquin Health Care have been made to restore full lab service overnight after recently experimenting with POCT during that shift. Could it be Quinte is not the only location in Ontario to see problems with relying exclusively on POCT?

Facing a nursing shortage, Quinte will likely need to do some training in lab testing for the nurses who will have to juggle POCT with other duties and higher workloads. Ontario requires tests conducted by POCT to be fully audited, meaning nurses will have to sign off on the tests they perform. They also require that operators of this equipment be certified and re-certified over time and records be kept.

“Because the operators do not have a laboratory background there is likely a lack of knowledge and understanding of the principles of laboratory assays and good laboratory practices to ensure the reliability of the test results,” the 2007 Ontario guidelines state.

Therefore only “certified” operators will be allowed to use this equipment.

The 2007 provincial guidelines also include assigning responsibility to the hospital’s Medical Advisory Committee to select and evaluate POCT devices and systems “with consideration of analytical accuracy (trueness), precision, detection limits and ease of implementation.”

All proposals to implement POCT devices or systems must be considered and approved by the Medical Advisory Committee or “equivalent.”

In what has to be one of the more bizarre moments of this debate, The Trentonian reports Quinte CEO Mary Clare Egberts took aim at the local doctors during a public meeting. “The Sunshine list will be out soon and my salary will come under attack,” she reportedly said. “It’s interesting that no one ever asks what a physician makes and I think it would be probably something that the community might want to start to ask… that’s my provocative comment for this morning.”

Doctors are complaining they were only consulted on the decision to close the Trenton lab and replace it with POCT after it was made.

POCT is not new – many devices have been around for 30 years. It has picked up steam in recent years as technology has improved and health care providers are seeing value in the additional speed such devices can deliver. But is it a substitute for a full service lab?

The very language of the provincial POCT guidelines would suggest not. In fact, external quality assessments are done by comparing POCT performance with the results generated by a central laboratory.

Nor would the province be talking about detection limits and trueness if the two were equivalent.

The question is, will Trenton find POCT good enough?