A Systematic Review of Emergency Department Point-of-Care Cardiac Markers and Efficiency Measures

Effects of point-of-care testing for serum markers of cardiac necrosis on the process and outcomes of patient care in the emergency department (ED) have yet to be fully elucidated. We conducted this systematic review to summarize the current state of knowledge and to identify focus areas for future work. The following databases were searched through June 2008: MEDLINE, the Cochrane Central Register of Controlled Trials, Science Citation Index Expanded, the Cumulative Index of Nursing and Allied Health Literature, and EMBASE Drugs and Pharmacology. Three authors (A.S., J.H., and J.L.) separately examined the full-text of the articles retrieved by the search and met to determine consensus on inclusion of studies for this systematic review. Inclusion criteria were clinical study (including cohort studies with both retrospective and prospective designs and excluding case reports and reviews), patients with suspicion of acute coronary syndromes, studies written in the English language, point-of-care testing (at or near the site of patient care) with a rapid assay for cardiac biomarkers, ED setting, and reporting at least 1 primary end point. Primary end points were test turnaround time, time to treatment, patient satisfaction, time to disposition, ED or hospital length of stay, and mortality or in-hospital procedures. Of the 167 articles examined in full-text form, 13 articles met inclusion criteria. Most exclusions were due to the study reporting only on the analytic performance of the test and not including one of the primary end points. Among the included studies, a compelling statistical decrease in test turnaround time (generally defined as blood collection to result reporting) was demonstrated in 11 of the 13 studies with implementation of point-of-care testing. There was no reported evidence of improvement in clinical outcome. Decreases in time to treatment or disposition and ED or hospital length of stay were generally favorable but were variable. A formal meta-analysis was not possible owing to study heterogeneity and differing outcome definitions. Turnaround time can be statistically reduced by the use of point-of-care cardiac biomarkers in the ED. Improvements in efficiency measures, such as throughput, are variable but can be attained. Point-of-care testing may become commonplace when systems studies determine how best to improve ED throughput with application of this newer technology.