Benefits, barriers and facilitators for out-of-hospital point of care testing: a qualitative study

Patient and public involvement

The study benefited from the input of several public contributors throughout the design and delivery of the wider study. The public contributors helped the research team understand their experiences with varied service provision, provided their perspectives on pre-hospital testing, and subsequently informed the topic guides for the interviews⁹. Additionally, the public contributors reviewed the results following data analysis.

Study design

This was a qualitative semi-structured interview study, underpinned by an exploratory-descriptive qualitative approach¹⁰.

Recruitment and consent

A diverse stakeholder group, who met the eligibility criteria in Table 1, were established to support the study. Stakeholders were identified and recruited through the existing professional networks of the research team. A combination of convenience and snowball sampling was used to recruit up to 20 participants with diverse backgrounds and experiences. A pragmatic approach was adopted, and a sample size of 20 was determined to be sufficiently large to allow a rich understanding and generate new knowledge in this area.

Potential participants were contacted by members of the research team by email with details of the study and an invitation to express an interest in participation. Where an interest in participation was indicated they were sent a participant information sheet, privacy notice, consent form and confidentiality agreement and were invited to take part in an online interview via Microsoft Teams. Participants had the opportunity to contact the study team to ask any questions before completing and returning the consent form. Patient and public participants were offered renumeration for their time via vouchers to the value of £25. Professional participants were offered renumeration for their time to their employing organisation.

Data collection

Semi-structured interviews were conducted by KK, a senior research fellow in paramedic science, using a topic guide developed by the research team and reviewed by public contributors⁹. The research aims were explained at the beginning of the interview. Interview questions explored use cases for POC tests, potential tests, benefits, facilitators, and barriers. The interviews took place via Microsoft Teams where the data was captured using a recording function with the participant’s permission. The recordings were transcribed and anonymised by an approved supplier with a data processing agreement in place.

Data analysis

Thematic analysis was employed using the framework method as the objective of the study was clear and known in advance^11,12. Transcripts were imported into Nvivo 14 software and an analytical framework was developed by two members of the research team (KK and JC) after the joint coding of three transcripts informing the creation of a framework method matrix for charting.

A combination of deductive and inductive coding was used. A stakeholder event held prior to this study had already developed the criteria for assessment of candidate POC tests, mapped the clinical pathways associated with the most promising tests and explored facilitators and barriers to the implementation of POC testing. This informed the deductive coding, and the initial codes can be found in Table 2. Following initial joint coding, JC completed the remainder of the analysis.

Ethics committee approval was received from the University of the West of England, Bristol, Faculty Research Ethics Committee on 2^nd June 2023 (UWE FREC Ref: HAS.23.04.101).

Enhancing patient care and system efficiency through POC testing

Potential to change patient pathway and achieve optimal treatment outcomes

All participants acknowledged that there was potential to alter the patient pathway, ensuring patients can be supported appropriately in the right place, first time. POC testing has the capacity to assist in ruling out conditions which would otherwise require ED care, thereby reducing avoidable ambulance conveyance and ED attendances. Additionally, it could ensure the safe management of patients within their homes. This aspect held particular significance for certain demographic groups, including the elderly and residents of nursing homes, for whom transportation could be distressing.

The outcomes of POC testing also had the potential to guide decisions in redirecting patients towards alternative care pathways, such as urgent care facilities, or accelerating the care pathway towards specialised centres such as those providing coronary intervention, rather than a more generic ED. However, pathway variation, often depending on the geographical location of the patient and local service provision, was felt to undermine the realisation of these potential benefits in practice.

Participants highlighted that the introduction of POC tests might not always alter the patient pathway, resulting in limited impact. For example, participants predicted challenges in gauging when a paramedic should perform a sepsis POC test based on the patient’s presentation; if a paramedic was concerned enough to conduct a sepsis POC test, how would a decision then be reached not to convey the patient based on a negative result. In a scenario involving major trauma, paramedics are juggling various critical factors, and conducting a POC test would likely be a secondary consideration.

Alongside a change in pathway, POC tests may lead to more optimal treatment outcomes for patients by enabling earlier diagnoses, expediting care, and potentially hastening recovery, particularly in cases like sepsis where rapid deterioration can occur. Furthermore, they could reduce the risk of missing conditions such as myocardial infarction and sepsis, even when patients appear relatively well. The outcomes of POC testing could also enhance the quality of care by providing guidance for specific treatments, such as antibiotics.

Decision support

Specific POC tests have the potential to impact the confidence of paramedics and support decision-making. Participants generally felt that if paramedics were provided with a tool, such as POC testing, that supports decision making and safe non-conveyance they would use it assuming that it is practical. Nonetheless, it was highlighted that a POC test serves as an additional tool and would not replace clinical decision making and judgment.

Resource availability and savings

Participants highlighted the financial benefits of POC testing, including reduced conveyance and ED attendance, however, patient safety was considered paramount.

The perception was that implementing POC testing to decrease conveyance rates could increase the availability of ambulances, leading to reduced wait times and alleviating congestion in EDs. Increased fleet availability would subsequently allow ambulances to attend to other patients more promptly, thereby enhancing patient safety. Non-conveyance would also reduce the number of ED and hospital beds required. Nonetheless, the challenge of hospital discharges would continue to persist.

Reducing stress or inconvenience for patients and families

Implementing POC testing out of hospital could potentially alleviate the emotional strain associated with ambulance conveyance and ED attendance, with greater comfort for both patients and their family members, particularly for those who are less mobile. If non-conveyance is the outcome, this would avoid patients having to wait in the ED. Participants reported that patients generally express higher contentment when allowed to stay in their own homes. Paramedic participants shared that the home environment tends to foster increased receptiveness to engage in conversations and shared decision making.

Participants also highlighted the quick reassurance a POC test could provide to patients, particularly if a decision not to convey the patient is made. Patient and public participants discussed the challenges of supporting a family member in the ED as opposed to in their own homes.

Navigating implementation challenges: balancing barriers and facilitators for successful implementation

Participants discussed numerous impediments and enablers associated with the implementation of POC tests in EMS, with a degree of overlap between factors serving as both facilitators and barriers.

Logistics

When discussing barriers and facilitators, logistics was frequently discussed. Participants emphasised several factors relating to POC tests in EMS, including user-friendliness, test consistency and replicability across different environments, storage, robustness, self-calibration to prevent burdening staff, compact size, power source accessibility, simple interpretability, minimal invasiveness, and rapid result generation. There was also support for a POC testing device that could offer multiple different tests.

Organisational barriers and risks

The out-of-hospital setting generally leans towards risk aversion due to the seriousness of the consequences, and this aspect was identified as a hindrance to implementation due to the limited potential for altering this established culture. Lack of support from managers with regards to decision making when using a POC test was highlighted.

Ambiguous results could potentially lead to unsafe patient discharges at the scene, particularly when non-diagnostic test outcomes are based on numerical scales or if they are detecting a biomarker that may change significantly within a short period of time, such as troponin. It was highlighted that paramedics should be educated when interpreting results to support their decision on conveyance.

The management of change was also anticipated to be a barrier during the implementation process. Different healthcare trusts currently face distinct challenges, such as escalating population numbers, regions lacking additional facilities, and a shortage of GPs (General Practitioners).

Financial impact

The introduction of POC tests could potentially have financial implications for ambulance services, including the cost of purchasing tests, component costs, and paramedic training. These changes might have advantages for providers beyond the ambulance service, but such benefits would need to be passed back to the ambulance service to incentivise and support adoption. Apprehension was voiced regarding the risk of duplicate testing if patients are transported to hospital, thereby increasing overall costs. Additionally, there is a prospect of resource allocation impact due to the time invested in calibrating the POC tests and ambulance staff dedicating more time to patient interactions when ED conveyance does not occur.

Coordination across the pathway

Coordination across the patient pathway was identified as an important facilitator in the implementation of POC tests, and provides a basis for improved communication between healthcare professionals. Being able to have clear communication with clinicians ahead of admission is important to enable preparation and any required infection control. It would also support the triage and streaming of patients within the ED. GPs reported that having results from POC tests would be useful. The sharing of records would support coordination across the pathway more generally, but particularly when considering POC tests.

Clear purpose

Establishing well-defined objectives for POC tests was considered integral to streamlining their implementation and potentially assisting ambulance staff in overcoming associated challenges. Their purpose must be clear, and paramedics must be able to interpret results effectively, using results to support decision making. Identifying key decision points influenced by a POC test would be a facilitator. Participants emphasised that POC testing serves as supplementary information to construct a broader clinical picture and evidence, without replacing clinical judgment. It was highlighted that patient overview could still be limited with just the POC test results. Various factors, including co-morbidities, individual patient characteristics, observations and other potential reasoning must be considered.

Building the foundations: key considerations for future research

Participants were aware of the study's aims and were subsequently prompted to reflect on the potential for future research. They emphasised the necessity for careful management of POC test implementation, highlighting the criticality of feasibility testing, particularly to ascertain the willingness of paramedics to use these tests. Participants stressed the importance of having a local study contact to facilitate study delivery; a lesson drawn from prior studies.

The significance and practical aspects of training were also addressed. Participants stressed the need for comprehensive training to instil confidence in users and ensure appropriate interpretation of results to ensure a meaningful contribution to decision-making. While the importance of training was acknowledged, preferences regarding its delivery method varied, with advantages and drawbacks of both face-to-face and online training being discussed. Additional support, for example from a senior clinician who could be consulted by telephone, would also help paramedics to feel confident in their decision-making.

Regarding the selection of appropriate tests, participants emphasised the importance of choosing tests that would provide substantial benefits to many patients and support non-conveyance decisions. Participants noted the rapid pace of commercial developments and advocated for a flexible trial design capable of accommodating alternative tests.

Additional considerations included ensuring the availability of evidence supporting an analysis of cost-effectiveness, implementing effective quality control measures, engaging technicians, incorporating the patient voice in dissemination, addressing broader pathways alongside POC test implementation, and regularly capturing the opinions of paramedics.