Ian Smith, Head of Laboratory and Clinical Trials at Veritie Group, looks at point-of-care testing and virtual wards in Oxfordshire.
NHS England describes virtual wards (also known as hospital at home) as a service that allows patients to get hospital-level care safely at home in familiar surroundings, helping speed up their recovery while freeing up hospital beds.
As in hospital, people on a virtual ward are cared for by a multidisciplinary team who can provide a range of tests and treatments. This could include blood tests, prescribing medication or administering fluids.
Patients are reviewed daily by the clinical team and the “ward round” may involve a home visit or take place through video technology. Many virtual wards use technology like apps, wearables and other medical devices enabling clinical staff to easily check in and monitor a person.
The aim is to expand and improve care outside hospital, so that people can be better supported at home for their physical and mental health needs, including to avoid unnecessary admissions to hospital.
The NHS England Delivery Plan for Recovering Urgent and Emergency Care Services (January 2023) called for greater use of “virtual wards” and The Getting It Right First Time (GIRFT) and Virtual Ward programmes at NHS England have produced a guide outlining how the NHS can make better use of virtual wards.
The guide includes recommendations that virtual wards should provide equitable access to hospital-level diagnostics, such as endoscopy, radiology, or cardiology, and which may include bedside tests, such as point-of-care testing (POCT) for blood.
Virtual ward POCT in Oxfordshire
A variety of virtual ward services are delivered across Oxfordshire through collaboration of Oxford University Hospitals NHS Foundation Trust (OUHFT), Oxford Health NHS Foundation Trust (OHFT), and Principal Medical Ltd (PML), a GP-led service.
The POCT team at OUHFT has supported the development and delivery of POCT in community and ambulatory settings over the past 10 years.
Although largely coordinated through the Clinical Biochemistry department, the team is multidisciplinary and supports a wide variety of POCT across both OUHFT and OHFT. This includes supporting the Hospital-at-Home service featured in the BBC Panorama programme.
These services have evolved out of community ambulatory care services, which was used as a template. However, the mobile nature of the Hospital-at-Home service provides additional challenges.
Designing a POCT service to support virtual wards
With any POCT service there are several elements we need to consider in the design and implementation phase.
Understand the requirement: We need to consider the patient pathway, repertoire, environment and who will operate the device. If there are existing similar sites this will help and expedite the process. In the virtual ward scenario, a multidisciplinary team is providing a range of tests in patients’ homes.
Select device: We need to think about general suitability for how the device will be used. This is particularly the case with mobile services as robustness and portability are significant factors. A device that has already been verified and standardised across similar POCT sites is also desirable.
Site survey: Thought is required into how much information can be obtained without visiting the site. The device will also be stored in another location (hub) and transported to the patient location.
Delivery: Mechanisms for the delivery of instruments and consumables need to be considered. Temperature-sensitive consumables may require storing locally and broken instrumentation may require replacement. However, there may be existing routes and mechanisms already in place that can be utilised (e.g. pharmacy and specimen transport).
IT connectivity: This provides challenges in that the collaborative nature of these services may mean that multiple IT networks and patient records may be used within a given area and for the same patient group. Developing an understanding of the “local IT landscape” is helpful and may inform decision-making around how POCT requests and results are entered onto clinical systems. The ability to configure the device prior to deployment, or to be able to configure remotely, is also advantageous.
The four pillars of POCT
To successfully maintain a POCT service there are four key area areas to address.
1. Training: POCT training is challenging as it typically involves training large numbers of non-laboratory personnel in multiple locations. Cascade training is an important tool, but needs to be controlled within a well-established and traceable hierarchy. This has often been problematic to deliver for remote and mobile services. However, the development of business communication platforms during the pandemic has increased the options around remote training and increased availability and accessibility to training directly from the supplier, and this has become the preferred route in Oxford.
2. Supplies and maintenance: Supplying and maintaining equipment and consumables provides challenges when operating outside of the base facility. The Oxford laboratory acts as the distributor to the virtual wards with Oxford Health purchasing tests on a cost-per-cartridge basis. The service includes ordering, central stock management and acceptance testing. Additionally, the lab is the first-line technical support, and an instrument pool is maintained so that faulty equipment can be swapped out.
Deliveries to hubs utilise existing non-patient transport routes to POCT locations, as well as using pharmacy refrigeration for storing temperature-sensitive consumables.
3. Quality: As previously stated, the device should be verified and standardisation with similar POCT sites is also desirable. Moving forward, this is an opportunity
for shared learning within a lab network. However, an additional, scaled-down evaluation (robustness test) should be performed where there is a novel testing environment. The Oxfordshire virtual ward services have developed out of and are closely linked to ambulatory medicine and the POCT requirements are similar.
Adoption of quality management for POCT, including EQA, improves the quality of the results but can be difficult in remote locations. Challenges remain around EQA distribution, including correct preparation and stability.
The monitoring of pre-analytical errors is an often-underutilised tool in quality management. With connectivity and appropriate data extraction, information can be obtained remotely, identifying areas for further training.
4. Connectivity: We know that the collaborative nature of these services means that multiple IT networks and patient records are often in place for a given patient group. In Oxfordshire, community facilities are on the same network as the acute trust, but patients are managed on three different administration systems. The patient demographic feed to the instrument relies on an event from the acute trust electronic patient record (EPR) and further interfacing is required with community systems.
Additional issues remain around staff identifiers (different for acute and community staff) and patient identifiers (there are limited wristband production in the community setting) in addition to the more obvious issues around connectivity “out in the field”. The availability of interface-drivers to connect devices to middleware has also proved problematic in some instances.
This has led to innovative solutions such as the adoption of indirect result pathways back to community via views of the laboratory IT system and acute trust EPR, generating bespoke staff barcodes for OHFT staff and connecting to multiple POCT middleware systems to increase the range of drivers available.
A local mobile connectivity solution has been developed and applied to Frailty Response vehicles. However, whilst we have been able to deliver connectivity in two rapid response vehicles, this was not a scalable solution and mobile devices are docked at the base location after visits.
Devices, repertoire and workload
Using a model developed around the requirements of ambulatory medicine, we have delivered a service with limited resource, focusing on utilising existing resources wherever possible.
Commencing with the acute Hospital-at-Home, the service has been successfully expanded to support mobile POCT across Oxfordshire.
Device selection and repertoire has been standardised. Up to this point mobile services have been limited to use of the Abbott i-Stat & Alinity systems (electrolytes/metabolites/blood gas using the Chem 8 and CG4 cartridges).
“The service has been successfully expanded to support mobile POCT across Oxfordshire”
As of July 2023, 14 Abbott i-Stat and Alinity devices have been deployed to six locations across Oxfordshire. Estimated annual workload is 12,000 tests with an approximately 50:50 split between Chem 8 and CG4 cartridges. However, Hospital-at-Home and other mobile services are requesting a greater repertoire of tests, particularly C-reactive protein (CRP) as this is part of the POCT repertoire available in the community hospital ambulatory wards.
The LumiraDx platform provides us with an option for CRP that is portable, easy to operate, connectable and robust. We have evaluated it in the laboratory and field.
The future
Moore’s Law is a reductive title for the idea, first postulated by American engineer Gordon Moore in the 1960s, that approximately every two years, technology doubles the total number of transistors that manufacturers can squeeze into an integrated circuit. In general terms, it implies that computing power increases exponentially over time. This leads us to a probability that more and more devices that we currently associate with the laboratory will be available in a POCT format, expanding the range of diagnostics available to mobile services such as virtual wards.
An example of this is Raman spectroscopy, a well-established technique used for chemical identification, which is now available in a POCT format. The Raman spectrum is a unique “fingerprint” of the molecules in the sample and can be used in conjunction with machine-learning algorithms to classify these patterns into groups, e.g. cancerous or not cancerous.
Summary
Oxfordshire’s virtual ward services have developed out of and are closely linked to ambulatory medicine and the POCT requirements appear similar. Starting with the acute Hospital-at-Home, the service has been successfully expanded to support mobile POCT across Oxfordshire.
Device selection and repertoire has been standardised around the Abbott i-Stat & Alinity systems, with the laboratory acting as the distributor of instruments and supplies (including EQA), facilitating connectivity, and testing, and coordinating the delivery of training through a combination of remote and cascade routes.
Challenges remain around connectivity and information management. This has been exacerbated by the cross-organisational nature of these services leading to the management of patients through multiple IT systems, and led to the development of indirect routes for result entry into the patient record.
Whilst we have been able to deliver connectivity in two rapid response vehicles, this was not a scalable solution and mobile devices are docked at the base location on return from visits.
The service continues to develop and we continue to search for new technologies and solutions.
Ian Smith led on POCT for OUHFT for over 10 years and worked with OHFT to develop community POCT services. He is now Head of Laboratory and Clinical Trials, Veritie Group, a new company, developing POCT applications using Raman spectroscopy.
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