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Closed loop communication to prevent delay in recombinant tissue plasminogen activator administration.

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Fugate JE, Wijdicks EFM, Mandrekar J, et al. Predictors of neurologic outcome in hypothermia after cardiac arrest. Ann Neurol
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down to the computed tomography scanner. The same personnel
will immediately tube the blood sample and call the laboratory
about the sample being transmitted. The laboratory will prioritize
the testing and will call back the neurologist with results before the
results are released to EMR, thereby saving precious time.
In conclusion, POC testing might be a reasonable option
in the future, with improvement in technology and standardization, especially for hospitals with large volumes of patients.
Potential Conflicts of Interest
Nothing to report.
DOI: 10.1002/ana.22469
Closed Loop Communication to Prevent Delay
in Recombinant Tissue Plasminogen Activator
Raghav Govindarajan, MD and Efrain Salgado, MD
We read with interest the article by Walter et al entitled ‘‘Pointof-care laboratory halves door-to-therapy decision time in acute
stroke.’’1 We have sometimes noted a delay in obtaining results
from our central laboratory. Emergency room (ER) personnel
who draw the blood sample often wait for samples from other
patients to be collected so they can tube all samples together.
Once the sample reaches the laboratory, technicians are either
not immediately available to process them or do not prioritize.
There may be a delay from the time the results are actually
released into the data pool to the time of posting in the electronic medical record (EMR).
The point-of-care (POC) laboratory was discussed as an
alternative, but the following drawbacks were noted:
• The accuracy of these systems has not been tested thoroughly. There are numerous prototypes on the market, but
there is no standardization.2,3 In the study by Walter et al, at
least 3 different analyzers were used. They found that there
were at least 13 patients in whom the POC values did not
match with standard results, with coagulation parameters
showing the greatest variability.1 Meier and Jones concluded
that POC testing errors are relatively common, their frequency amplified by incoherent regulation, and their likelihood of affecting patients’ care amplified by the rapid
availability of POC test results and the results’ immediate
therapeutic implications.4
• POC test costs are volume dependent under current reimbursement mechanisms for emergency department patient
care services and thus may not be cost-effective.5
• It has been proposed that POC testing might reduce emergency waiting times,6 but in the long run this is more likely
to stretch out the already burdened ER personnel and to
increase the chance of errors.
To overcome the delay, we devised closed loop communication in laboratory reporting. As soon as stroke alert is called, the ER
personnel draw blood samples even before the patient is wheeled
July 2011
Department of Neurology, Cleveland Clinic Florida, Weston, FL
Walter S, Kostopoulos P, Haass A, et al. Point-of-care laboratory
halves door-to-therapy decision time in acute stroke. Ann Neurol
Nichols JH. Quality in point-of-care testing. Expert Rev Mol Diagn
Plebani M. Does POCT reduce the risk of error in laboratory testing? Clin Chim Acta 2009;404:59–64.
Meier FA, Jones BA. Point-of-care testing error: sources and
amplifiers, taxonomy, prevention strategies, and detection monitors. Arch Pathol Lab Med 2005;129:1262–1267.
Tsai WW, Nash DB, Seamonds B, Weir GJ. Point-of-care versus
central laboratory testing: an economic analysis in an academic
medical center. Clin Ther 1994;16:898–910.
Lee-Lewandrowski E, Corboy D, Lewandrowski K, et al. Implementation of a point-of-care satellite laboratory in the emergency
department of an academic medical center. Impact on test turnaround time and patient emergency department length of stay.
Arch Pathol Lab Med 2003;127:456–460.
DOI: 10.1002/ana.22495
Silke Walter, MD and Klaus Fassbender, MD
We would like to thank Dr Govindarajan for his interesting comments regarding our article.
In his letter, he pointed out that in current practice laboratory examinations are often delayed by a failure to assign priority to stroke cases, both in the emergency room and in the
centralized laboratory, with the consequence that the narrow
therapeutic window expires for many stroke patients.
Instead of a point-of-care laboratory strategy such as we
proposed,1,2 Dr Govindarajan advocates a high-priority stroke
laboratory pathway that includes immediate tubing of the blood
samples, notification of the laboratory personnel, prioritized examination, and immediate transmission of the laboratory results
by phone. We agree that this pathway, which could be performed within the current setting, would substantially improve
stroke management. However, in this debate it should not be
overlooked that laboratory analysis times of the point-of-care
laboratory are significantly shorter than those of the centralized
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