The cost of time: A randomised, controlled trial to assess the economic impact of upfront, point-of-care blood tests in the Emergency Centre

Introduction Time and cost constraints abound in the Emergency Centre (EC). These resource-constraints are further magnified in low- and middle-income countries (LMIC). Almost half of all patients presenting to the EC require laboratory tests. Unfortunately, access to laboratory services in LMIC is commonly inadequate. Point-of-Care (POC) tests may assist to avert this shortcoming. The aims of this study were to evaluate the cost effectiveness of upfront POC blood tests performed prior to doctor assessment compared to the standard EC workflow.Methods A secondary analysis was performed on data from a prospective, randomised, controlled trial where patients with abdominal/chest symptoms or generalised body pain/weakness followed either the normal EC workflow pathway or one of two enhanced workflow pathways with POC tests (i-STAT with and without a complete blood count (CBC)) prior to doctor evaluation. The incremental cost effectiveness ratio (ICER) was used to perform the cost effectiveness analysis.Results :There were 248 patients enrolled in the study. The use of the two upfront, POC test pathways significantly exceeded the primary outcome measure of a 20% reduction in treatment time. In the i-STAT + CBC group, the 31 min. time-saving translated into cost-saving of US$14.96 per patient (IECR 0.27) whereas the 21 min. time-saving in the i-STAT only group only had an additional net cost of US$3.11 per patient (IECR 0.90).Conclusion Upfront, POC blood tests can be utilised in the resource-constrained EC to manage patients more efficiently by saving time. This time-saving can, in fact, be more cost effective than traditional EC workflow making it an economically viable option for implementation in LMIC

A prehospital randomised controlled trial in South Africa: Challenges and lessons learnt

The incidence of cardiovascular disease and STEMI is on the rise in sub-Saharan Africa. Timely treatment is essential to reduce mortality. Internationally, prehospital 12 lead ECG telemetry has been proposed to reduce time to reperfusion. Its value in South Africa has not been established. The aim of this study was to determine the effect of prehospital 12 lead ECG telemetry on the PCI-times of STEMI patients in South Africa. A multicentre randomised controlled trial was attempted among adult patients with prehospital 12 lead ECG evidence of STEMI. Due to poor enrolment and small sample sizes, meaningful analyses could not be made. The challenges and lessons learnt from this attempt at Africa's first prehospital RCT are discussed. Challenges associated with conducting this RCT related to the healthcare landscape, resources, training of paramedics, rollout and randomisation, technology, consent and research culture. High quality evidence to guide prehospital emergency care practice is lacking both in Africa and the rest of the world. This is likely due to the difficulties with performing prehospital clinical trials. Every trial will be unique to the test intervention and setting of each study, but by considering some of the challenges and lessons learnt in the attempt at this trial, future studies might experience less difficulty. This may lead to a stronger evidence-base for prehospital emergency care