TY - JOUR
AU - Feldman, Brett, J
AB - point-of-care testing, health disparities, street medicine Over 550 000 Americans are homeless each night in the United States (1,). Homelessness is associated with higher rates of disability and disease, reduced access to preventative care and treatment, and poorer prognoses (2,). Homeless individuals represent substantial proportions of emergency room patients, particularly in urban areas (3,). Once hospitalized, homeless individuals incur longer lengths of stay and greater medical costs relative to those who are not homeless (4). To combat these statistics, street medicine programs, which provide care directly to the homeless in their own environment, are increasingly arising in American cities. Keck School of Medicine of USC and the LAC+USC Medical Center have partnered in developing a street medicine consultation service to care for unsheltered homeless patients in Los Angeles. Patients are identified during hospital admission, and when these patients endorse significant barriers to accessing traditional clinics, street medicine provides primary care when discharged from the hospital. Care is delivered to the patient in the field where the patient feels most comfortable, whether this is in a tent, under a bridge, behind a dumpster, or literally on the street. Laboratory diagnostics are critical to the practice of primary care. Heart failure is just one of many conditions primary care providers regularly manage for which regular laboratory evaluation is essential. Homeless adults are at a particularly increased risk for cardiovascular diseases, with heart disease being the leading cause of death for the unsheltered homeless in Los Angeles County (5). Expected practices include therapeutics such as angiotensin-converting enzyme inhibitors or receptor blockers, aldosterone antagonists, digoxin, and loop diuretics. Regular monitoring of serum creatinine and electrolytes, especially potassium, is critical to safely administer these therapeutics. With unsheltered patients experiencing homelessness, laboratory monitoring is even more critical, as these patients inconsistently access food and water. However, getting to a laboratory can be an enormous challenge. Leaving an encampment site for clinic visits or laboratory testing is largely impractical for many people experiencing homelessness. Without a friend to watch their belongings, the risk of theft of what little they have is high. Taking public transportation and waiting in a waiting room means other competing priorities, such as obtaining their only reliable meal for the day, will be the cost of seeking care. Unfortunately, the collection of blood or urine samples on the street, and subsequent transport to a laboratory for analysis, introduces challenges with specimen stability and analytical quality of results. Stabilizing procedures such as centrifugation of blood tubes and refrigeration of urine samples may not be possible. Furthermore, the cumulative collection, transport, and turnaround time involved with laboratory analysis limits real-time management. For these reasons, the Street Medicine program saw point-of-care testing (POCT) as essential to its delivery model. Point-of-care measurements, if performed with the proper regulatory and quality considerations, mitigate sample stability limitations, and provide real-time test results. The Street Medicine program personnel consulted and teamed with the medical center laboratory’s POCT division, comprised of pathologists, clinical chemists, and certified clinical laboratory scientists, to understand and implement the policies and procedures needed for quality, safety, and CLIA compliance. The Street Medicine program subsequently obtained its own CLIA Certificate of Waiver. The team consists of 3 physicians, 2 physician assistants, and 1 nurse who are trained as test operators. Technical and compliance duties are overseen by the nurse. The Street Medicine team identified the desired menu of diagnostics needed for its practice (Table 1). The POCT team then aided in determining which analytical POCT devices could best serve these needs. Important criteria for device selection included ease of use in the street medicine environment, e.g., durable, could fit in a transport bag, and could operate wirelessly on battery. The team’s vehicle is equipped with a temperature-controlled cooler for reagents that require refrigeration. Because our street medicine patient population consists of patients who have previously visited our hospital, the patients are already registered in the electronic health record system, and test results are documented in their medical charts when the test operator returns to the hospital network via a POCT data management interface. We also favored devices known to have strong analytical correlation to our hospital–laboratory based methods, as the patients may have baseline values from initial hospital visits. Further, selection of POCT devices already in use elsewhere within the hospital meant that the operators were already familiar with the devices, and that they could use standard operating procedures and training and competency materials already maintained by the POCT team as a starting point. Electronic devices maintain the same user login and QC lock-out settings used within the hospital setting. CLIA-waived devices are preferred due to their ease of use and the degree of oversight required. Notably, street medicine programs like ours could benefit from increasingly available CLIA-waived devices for blood chemistries. Table 1 Point-of-care tests for street medicine. Urine dipstick (macroscopic urinalysis) Urine hCG (pregnancy) Whole blood creatinine Whole blood electrolytes Whole blood glucose Whole blood hemoglobin Urine dipstick (macroscopic urinalysis) Urine hCG (pregnancy) Whole blood creatinine Whole blood electrolytes Whole blood glucose Whole blood hemoglobin Open in new tab Table 1 Point-of-care tests for street medicine. Urine dipstick (macroscopic urinalysis) Urine hCG (pregnancy) Whole blood creatinine Whole blood electrolytes Whole blood glucose Whole blood hemoglobin Urine dipstick (macroscopic urinalysis) Urine hCG (pregnancy) Whole blood creatinine Whole blood electrolytes Whole blood glucose Whole blood hemoglobin Open in new tab In conclusion, POCT can play an integral part in providing quality care to homeless patients. Collaboration between health providers and the clinical laboratory can ensure that a robust POCT program is put into place for this purpose. Currently, our Street Medicine program is actively using glucose meters and is refining processes and procedures to introduce the other tests listed in Table 1. In the future, our Street Medicine program seeks to expand its patient population and plans to continue to monitor the needs and utilization of POCT in the field. Nonstandard Abbreviations: POCT, point-of-care testing. Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 4 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; (c) final approval of the published article; and (d) agreement to be accountable for all aspects of the article thus ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved. Authors’ Disclosures or Potential Conflicts of Interest: Upon manuscript submission, all authors completed the author disclosure form. Disclosures and/or potential conflicts of interest: Employment or Leadership: A.B. Chambliss, The Journal of Applied Laboratory Medicine, AACC. Consultant or Advisory Role: None declared. Stock Ownership: None declared. Honoraria: None declared. Research Funding: None declared. Expert Testimony: None declared. Patents: None declared. REFERENCES 1 Henry M , Mahathey A , Morrill T , Robinson A , Shivji A , Watt R. The 2018 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-in Time Estimates of Homelessness. US Department of Housing and Urban Development; 2018 . https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf (Accessed May 2020). 2 Bowen E , Savino R , Irish A. Homelessness and health disparities: a health equity lens. In: Larkin H , Aykanian A , Streeter C , editors. Homelessness prevention and intervention in social work . Chamonix : Springer ; 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3 Feldman BJ , Calogero CG , Elsayed KS , Abbasi OZ , Enyart J , Friel TJ , et al. Prevalence of homelessness in the emergency department setting . West JEM 2017 ; 18 : 366 – 72 . Google Scholar OpenURL Placeholder Text WorldCat 4 Hwang SW , Weaver J , Aubry T , Hoch JS. Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services . Med Care 2011 ; 49 : 350 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Los Angeles County Department of Public Health. Center for Health Impact Evaluations, Recent Trends in Mortality Rates and Causes of Death Among People Experiencing Homelessness in Los Angeles County, 2019 . http://publichealth.lacounty.gov/chie/reports/HomelessMortality_CHIEBrief_Final.pdf (Accessed May 2020). © American Association for Clinical Chemistry 2021. All rights reserved. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Point-of-Care Testing to Support a Street Medicine Program in Caring for the Homeless
JF - The Journal of Applied Laboratory Medicine
DO - 10.1093/jalm/jfaa142
DA - 2021-01-12
UR - https://www.deepdyve.com/lp/oxford-university-press/point-of-care-testing-to-support-a-street-medicine-program-in-caring-aSlhIHoxUp
SP - 330
EP - 332
VL - 6
IS - 1
DP - DeepDyve
ER -