Impact of Rapid Molecular Respiratory Virus Testing on Real-Time Decision Making in a Pediatric Emergency Department
2017; Elsevier BV; Volume: 19; Issue: 3 Linguagem: Inglês
10.1016/j.jmoldx.2017.01.009
ISSN1943-7811
AutoresDaniel T. Rogan, Mohit S. Kochar, Samuel Yang, James Quinn,
Tópico(s)Viral gastroenteritis research and epidemiology
ResumoAcute respiratory illnesses (ARIs) are usually viral [influenza, respiratory syncytial virus (RSV)] and account for 25% of emergency department (ED) peak-season visits. Laboratory PCR testing is accurate albeit slow, whereas rapid antigen testing is inaccurate. We determined the impact of bedside PCR (molecular point-of-care test; mPOCT) on pediatric ARI management. This was a prospective cohort study of consecutive pediatric patients with ED-ordered respiratory PCR test, enrolled over 9 weeks during peak flu season. On ordering, ED physicians were interviewed to ascertain real-time plans if given immediate influenza/RSV PCR results for the current patient. Two groups were compared: actual management and management adjusted for mPOCT results. We compared ED length of stay (LOS), tests ordered, and antibiotic/antiviral ordering. One-hundred thirty-six respiratory PCR panels were ordered, 71 by admitting team, 61 for ED management. Of 61 ED-initiated tests, physicians indicated in 39 cases (64%) they would change patient management were bedside viral results available. Physicians would have decreased ED LOS by 33 minutes, ordered fewer tests (18%; P < 0.001) with average patient charge savings of $669, fewer antibiotics among discharged patients (17%; P = 0.043), and increased appropriate antiviral use (13%; P = 0.023). Rapid bedside ARI mPOCT PCR has the potential to decrease ED LOS, reduce diagnostic tests and patient charges, and increase appropriate use of antibiotics and antiviral agents. Acute respiratory illnesses (ARIs) are usually viral [influenza, respiratory syncytial virus (RSV)] and account for 25% of emergency department (ED) peak-season visits. Laboratory PCR testing is accurate albeit slow, whereas rapid antigen testing is inaccurate. We determined the impact of bedside PCR (molecular point-of-care test; mPOCT) on pediatric ARI management. This was a prospective cohort study of consecutive pediatric patients with ED-ordered respiratory PCR test, enrolled over 9 weeks during peak flu season. On ordering, ED physicians were interviewed to ascertain real-time plans if given immediate influenza/RSV PCR results for the current patient. Two groups were compared: actual management and management adjusted for mPOCT results. We compared ED length of stay (LOS), tests ordered, and antibiotic/antiviral ordering. One-hundred thirty-six respiratory PCR panels were ordered, 71 by admitting team, 61 for ED management. Of 61 ED-initiated tests, physicians indicated in 39 cases (64%) they would change patient management were bedside viral results available. Physicians would have decreased ED LOS by 33 minutes, ordered fewer tests (18%; P < 0.001) with average patient charge savings of $669, fewer antibiotics among discharged patients (17%; P = 0.043), and increased appropriate antiviral use (13%; P = 0.023). Rapid bedside ARI mPOCT PCR has the potential to decrease ED LOS, reduce diagnostic tests and patient charges, and increase appropriate use of antibiotics and antiviral agents. During the winter months, fever and respiratory infection symptoms make up to 25% of all emergency department (ED) visits.1Silka P.A. Geiderman J.M. Goldberg J.B. Kim L.P. Demand on ED resources during periods of widespread influenza activity.Am J Emerg Med. 2003; 21: 534-539Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Acute respiratory illness (ARI) is a leading cause of hospitalization for young children, contributing to 10.4% of all deaths in children younger than 5 years.2Black R.E. Morris S.S. Bryce J. Where and why are 10 million children dying every year?.Lancet. 2003; 361: 2226-2234Abstract Full Text Full Text PDF PubMed Scopus (1767) Google Scholar, 3Yorita K.L. Holman R.C. Sejvar J.J. Steiner C.A. Schonberger L.B. Infectious disease hospitalizations among infants in the United States.Pediatrics. 2008; 121: 244-252Crossref PubMed Scopus (142) Google Scholar ARI has a large spectrum of disease, ranging from mild upper respiratory tract problems to severe lower respiratory infections (eg, bronchiolitis and pneumonia) that can be associated with significant rates of morbidity and mortality. Although most ARIs are viral in cause with influenza (A and B) and respiratory syncytial virus (RSV) being most common, symptoms are often nonspecific, therefore making causative diagnosis based on clinical presentation unreliable.4Monto A.S. Gravenstein S. Elliott M. Colopy M. Schweinle J. Clinical signs and symptoms predicting influenza infection.Arch Intern Med. 2000; 160: 3243-3247Crossref PubMed Scopus (580) Google Scholar Furthermore, the Centers for Disease Control and Prevention currently recommend administration of antiviral agents within 48 hours of symptom onset for children younger than 2 years of age or young immunocompromised children who are at high risk of influenza-related complications.5Fiore A.E. Fry A. Shay D. Gubareva L. Bresee J.S. Uyeki T.M. Centers for Disease Control and Prevention (CDC)Antiviral agents for the treatment and chemoprophylaxis of influenza—recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Recomm Rep. 2011; 60: 1-24PubMed Google Scholar There is a need and desire to improve diagnosis and management in the ED setting.6Call S.A. Vollenweider M.A. Hornung C.A. Simel D.L. McKinney W. Does this patient have influenza?.JAMA. 2005; 293: 987-997Crossref PubMed Scopus (281) Google Scholar Current criterion standard laboratory tests based on traditional real-time PCR, which may require up to several hours for turnaround time, are too slow to affect ED management.7CDC, NCIRD: Guidance for Clinicians on the Use of RT-PCR and Other Molecular Assays for Diagnosis of Influenza Virus Infection, 2016. Atlanta, GA: US Department of Health and Human Services. Available at https://www.cdc.gov/flu/professionals/diagnosis/molecular-assays.htm, last accessed December 20, 2016.Google Scholar Without a confirmed viral diagnosis, ED physicians may resort to precautionary patient management strategies that result in antibiotic overuse and antiviral misuse, additional diagnostic testing, and unnecessary hospitalizations requiring isolation beds.8Dugas A.F. Valsamakis A. Atreya M.R. Thind K. Alarcon Manchego P. Faisal A. Gaydos C.A. Rothman R.E. Clinical diagnosis of influenza in the ED.Am J Emerg Med. 2015; 33: 770-775Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 9Sharma V. Dowd M. Slaughter A.J. Simon S.D. Effect of rapid diagnosis of influenza virus type a on the emergency department management of febrile infants and toddlers.Arch Pediatr Adolesc Med. 2002; 156: 41-43Crossref PubMed Scopus (113) Google Scholar These conservative measures promote antibiotic and antiviral resistance in the population and increase overall health system expenditures. In particular they contribute to prolonged ED wait times, length of stay (LOS), and overcrowding. Further, prior studies have shown that reducing testing turnaround times and initiating diagnostic testing earlier during ED triage reduces ED LOS.10Holland L.L. Smith L.L. Blick K.E. Reducing laboratory turnaround time outliers can reduce emergency department patient length of stay. An 11-hospital study.Am J Clin Pathol. 2005; 124: 672-674Crossref PubMed Scopus (86) Google Scholar, 11Chan T.C. Killeen J.P. Kelly D. Guss D.A. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait times, lengths of stay, and rate of left without being seen.Ann Emerg Med. 2005; 46: 491-497Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar Antigen tests can provide results between 30 and 150 minutes with near-patient testing capability, but they have unacceptable sensitivity as low as 10% for influenza and RSV in certain studies.12Ginocchio C.C. Zhang F. Manji R. Arora S. Bornfreund M. Falk L. Lotlikar M. Kowerska M. Becker G. Korologos D. de Geronimo M. Crawford J.M. Evaluation of multiple test methods for the detection of the novel 2009 influenza A (H1N1) during the New York City outbreak.J Clin Virol. 2009; 45: 191-195Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar, 13Casiano-Colon A.E. Hulbert B.B. Mayer T.K. Walsh E.E. Falsey A.R. Lack of sensitivity of rapid antigen tests for the diagnosis of respiratory syncytial virus infection in adults.J Clin Virol. 2003; 28: 169-174Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar As a result, studies have shown antigen testing has limited impact on ED patient management.14Iyer S.B. Gerber M.A. Pomerantz W.J. Mortensen J.E. Ruddy R.M. Effect of point-of-care influenza testing on management of febrile children.Acad Emerg Med. 2006; 13: 1259-1268Crossref PubMed Google Scholar Recent technologic advances in molecular diagnostics have enabled the development of fully automated PCR platforms with point-of-care (POC) capability to detect influenza A and B and RSV with >95% sensitivity and specificity and turnaround time as fast as 20 minutes.15Binnicker M.J. Espy M.J. Irish C.L. Vetter E.A. Direct detection of influenza A and B viruses in less than 20 minutes using a commercially available rapid PCR assay.J Clin Microbiol. 2015; 53: 2353-2354Crossref PubMed Scopus (68) Google Scholar, 16Babady N.E. The FilmArray® respiratory panel: an automated, broadly multiplexed molecular test for the rapid and accurate detection of respiratory pathogens.Expert Rev Mol Diagn. 2013; 13: 779-788Crossref PubMed Scopus (79) Google Scholar, 17Van Wesenbeeck L. Meeuws H. Van Immerseel A. Ispas G. Schmidt K. Houspie L. Van Ranst M. Stuyver L. Comparison of the FilmArray RP, Verigene RV+, and Prodesse ProFLU+/FAST+ multiplex platforms for detection of influenza viruses in clinical samples from the 2011-2012 influenza season in Belgium.J Clin Microbiol. 2013; 51: 2977-2985Crossref PubMed Scopus (38) Google Scholar, 18Williams K. Tian Y. Gibson J. Mace S. Mitchell P. Schecter-Perkins E. Yen-Lieberman B. Luo R. Chen L. Rapid and accurate polymerase chain reaction (PCR) diagnosis of influenza and RSV with the cobas® Liat® System in point of care settings.Open Forum Infect Dis. 2016; 3: 649Google Scholar These emerging rapid molecular POC tests (mPOCTs) are designed to be performed at the bedside by minimally trained personnel. Before the clinical availability of these tests with Food and Drug Administration (FDA) clearance for waived status under Clinical Laboratory Improvement Amendments (CLIA), we performed a study to determine the impact and potential value of rapid influenza and RSV PCR results on physician decision making in a pediatric ED during peak ARI season (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K153544; http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/Detail.cfm?ID=39763&NoClia=1, last accessed January 10, 2017). This was a prospective observational study with real-time interviews of physicians during active patient management in the ED, when a PCR test for respiratory viruses was ordered. The study occurred in the pediatric ED of an academic medical center during peak ARI season. It involved consecutive pediatric patients younger than 18 years of age who had a respiratory virus PCR panel by nasopharyngeal swab in the Pediatric Emergency Department at Stanford University Medical Center during the 9-week study period from January 10, 2016, to March 13, 2016. During the study period patients were identified by a real-time electronic notification system developed to identify patients in real time for clinical studies.19Weber S. Lowe H.J. Malunjkar S. Quinn J. Implementing a real-time complex event stream processing system to help identify potential participants in clinical and translational research studies.AMIA Annu Symp Proc. 2010; 2010: 472-476PubMed Google Scholar No post hoc convenience surveys were administered at any time. The electronic notification was set according to the order coming from the pediatric ED in a patient younger than 18 months for a respiratory virus PCR panel. This set up a real-time notification to the on-call research coordinator who then contacted the ordering attending ED physician to conduct a brief survey relating to patient management within minutes of the respiratory panel order being placed. Given the real-time nature of the electronic notifications and immediate subsequent interviews, interviews were possible at any time of day throughout the study period. At the time of the survey, while patients were still being actively managed in the ED, physicians were informed that the viral PCR as an mPOCT would have results within 20 minutes of a nasopharyngeal swab. Further, physicians were informed the test would present individually positive or negative viral presence results for RSV, influenza A, and influenza B (influenza A and B collectively referred to as influenza). This theoretical mPOCT was considered to have the same diagnostic accuracy as the commercially available standard respiratory panel PCR test used at the institution (Respiratory Virus Panel XT8; GenMark, Fremont, CA), albeit only testing for RSV and influenza A/B.15Binnicker M.J. Espy M.J. Irish C.L. Vetter E.A. Direct detection of influenza A and B viruses in less than 20 minutes using a commercially available rapid PCR assay.J Clin Microbiol. 2015; 53: 2353-2354Crossref PubMed Scopus (68) Google Scholar Physicians were asked hypothetically how their patient management would change if the mPOCT results were available imminently, including whether fewer diagnostic testing [urinalysis (UA), blood draw, or chest X-ray (CXR)] would have been pursued if a source of fever was identified (Supplemental Figure S1). Potential changes in antibiotic use and oseltamivir use and changes in disposition were also surveyed. Physicians' a priori proposed plans according to potential mPOCT results were retroactively aligned with test results from the hospital laboratory standard 14-virus PCR test; this allowed determination of individual theoretical management plans that the physician would have followed if test results had been known in the ED compared with actual ED management performed in the absence of test result information. Per standard practice at our institution, ED nasopharyngeal swabs for viral testing are transported to an off-site institutional facility for processing by fully trained laboratory staff. Viral DNA/RNA is extracted with the EZ1 Virus Mini Kit version 2.0 (Qiagen, Hilden, Germany), and virus is detected via Respiratory Virus Panel XT8 (GenMark). Total turnaround time is between 8 and 24 hours, factoring in transport and handling, assay time (7 hours), and allowance for batch testing (two to five times daily, seasonally depending on staffing and volume concerns). No changes in institutional standard of practice for ordering or processing respiratory virus panels were made during the conduction of this study. The primary outcome was the potential change in ED LOS. Patient-specific outcomes, including ED LOS, were compared as baseline (true encounter) versus test-dependent management (hypothetical management) according to the potential ED LOS from the assumption that the POC test would have the actual results of the institution standard PCR test that was performed. For cases when physicians may have changed management by altering the number of ancillary diagnostic studies performed, we compared the ED LOS for two groups: actual ED LOS versus ED LOS if mPOCT was available (adjusted LOS). Baseline ED LOS was calculated from triage time to selection of disposition, reflecting the evaluation time by the ED physician rather than logistics of leaving the ED according to the disposition. For the adjusted ED LOS group, we calculated the ED LOS for these cases according to the actual results and assuming the mPOCT would have the same sensitivity and specificity as the gold standard test. In cases when mPOCT availability would have resulted in changes in ED management (reduced number of ancillary tests), the triage-to-disposition time was changed to the triage-to-respiratory panel order time plus 20 minutes to allow time for the test to result. Secondary outcomes included admission status, patient charges for additional diagnostic evaluations for fever source (UA, blood draw, CXR), and both antibacterial and antiviral prescription incidence. Demographic and encounter-specific medical information was obtained by chart review and administrative databases, including actual charges for the assessed procedures that included standard UA screen (protocol for culture if positive), blood draw with culture and complete blood count, and two-view CXR. We determined that we would need to have 28 patients serving as their own comparison (ie, 28 in each group) to determine the effect on the primary outcome of ED LOS. This was calculated using an α of 0.05 and power of 80% to determine 10% decrease in ED LOS of 20 minutes (average 200 minutes) as an important decrease in ED LOS. The data were considered paired, and as such, continuous outcomes were measured with paired t-tests and dichotomous outcomes with McNemar's test as appropriate. Statistical analyses were performed using GraphPad Prism version 6 (GraphPad Inc., La Jolla, CA) and reported as P values and 95% CIs when appropriate. There were no extra tests or procedures and no change in the care for patients, and the institutional review board waived consent for patients who met inclusion criteria. Attending physicians who would be completing the surveys received in-service instruction and were required to receive and acknowledge an e-mail message detailing the study and their ability to refuse participation and contact the institutional review board with concerns before onset of the study. No physicians refused to participate. During the study period, 136 respiratory PCR panels were ordered by 25 unique attending physicians staffing the pediatric ED (Figure 1); of these, 132 panels were completed, with 4 being incomplete because of patient declination of nasopharyngeal swab or patient leaving the ED before sample collection. Seventy-one were ordered on behalf of the admitting pediatric team, whereas 61 panels were ordered for ED management. Of these 61 ED physician-initiated tests, the treating physician at the time of patient management stated that in 39 cases (64%) they would consider changing their patient management strategy if the influenza or RSV results were immediately available. Patients for whom management would be altered with immediately available test results were predominantly younger than 5 years (Table 1). In particular, physicians would have altered their management by forgoing further testing (UA, blood draw, or CXR) if positive virus presence was confirmed by mPOCT, changing therapeutic decisions, or altering disposition. Table 2 summarizes the potential management changes had the results been immediately available. The effect of these changes would have decreased the mean ED LOS by 33 minutes (95% CI, 12–54 minutes) in this group, with mean baseline ED LOS of 212 minutes versus mean adjusted ED LOS of 179 minutes.Table 1Demographic Characteristics of Patients for Whom Management Decisions Are Affected by Test Results (n = 39)CharacteristicValueAge, mean ± SD, years3.8 ± 4.2Age group, % <3 months10.3 3 to <6 months12.8 6 to <12 months12.8 1 to <5 years30.8 5 to <10 years23.1 10 to <18 years10.3Female sex, %35.9Race, % White12.8 Asian/Pacific Islander30.8 Hispanic48.7 Black5.1 Other2.6ED presentation Febrile (temperature ≥38.0°C), %61.5 Tachycardia∗Age-related vitals., %92.3 Tachypnea∗Age-related vitals., %33.3Admitted, %41.0Admission includes general floor, isolation, intensive care unit; no patients were admitted for observation (<24 hours) or to a clinical decision unit.ED, emergency department.∗ Age-related vitals. Open table in a new tab Table 2Survey Responses: Physicians Indicate Their Management Plans according to Different Test ResultsManagement decisionRSV, % (95% CI)Influenza, % (95% CI)Summative, % (95% CI)Pos. (+) (n = 40)Neg. (−) (n = 40)P1Pos. (+) (n = 40)Neg. (−) (n = 40)P2Any (+) (n = 80)Any (−) (n = 80)P3All results (n = 160)ED diagnostics Chest X-ray28 (13–42)53 (36–69)0.00135 (20–50)53 (36–69)0.00731 (21–42)53 (41–64)<0.00142 (34–50) UA screen23 (9–36)35 (20–50)0.02315 (3–27)40 (24–56)0.00119 (10–27)38 (27–48)<0.00128 (21–35) Blood draw30 (15–45)50 (34–66)0.00328 (13–42)53 (36–69)0.00129 (19–39)51 (40–62) 0.99985 (77–93)89 (82–96)0.18187 (82–92) Discharge to admit8 (−1 to 16)5 (−2 to 12)0.5703 (−3 to 8)5 (−2 to 12)0.3245 (0–10)5 (0–10)>0.9995 (2–8) Admit to discharge5 (−2 to 12)5 (−2 to 12)>0.9990 (0–0)5 (−2 to 12)0.1603 (−1 to 6)5 (0–10)0.4184 (1–7) Total change13 (2–23)10 (0–20)0.7113 (−3 to 8)10 (0–20)0.0838 (2–13)10 (3–17)0.5319 (4–13)Antimicrobial use Antibiotics18 (5–30)15 (3–27)0.74418 (5–30)25 (11–39)0.26218 (9–26)20 (11–29)0.62019 (13–25) Oseltamivir85 (73–97)10 (0–20)<0.001Values for P1 and P2 indicate comparison of management plans between positive and negative results of RSV and influenza, respectively; P3 compares management plans between a positive result from either RSV or influenza and a negative result from either test. Forty surveys were completed with indication that the treating physician would alter management according to test results; one patient did not have nasal swab completed for respiratory virus PCR testing, but survey results were retained, given it represents physician plans without regard to final panel results. Each survey allowed physicians to propose possible management plans for each of four scenarios (positive or negative, RSV, or influenza) for a total of n = 160 plans proposed from survey.ED, emergency department; RSV, respiratory syncytial virus; UA, urinalysis. Open table in a new tab Admission includes general floor, isolation, intensive care unit; no patients were admitted for observation ( 40% had either RSV or influenza infections, covering 69% of the tested population.Table 3Respiratory Virus Detection by Institution Standard PCR Test during Study Period (n = 132)Detection resultsPrevalenceRSV (+), %28.0Influenza (+), %13.6 Influenza A (+), %2.3 Influenza B (+), %11.4Both RSV (+) and influenza (+), %1.5Virus (+), other than RSV or influenza31.1Number of viruses (+) on panel 0, %28.8 1, %56.1 2, %13.6 3, %0.8 4, %0.8 ≥5, %0.0All values were calculated as fraction of entire tested sample (n = 132). Subtypes of influenza A were not reported here.+, positive test results; −, negative test results; RSV, respiratory syncytial virus. Open table in a new tab All values were calculated as fraction of entire tested sample (n = 132). Subtypes of influenza A were not reported here. +, positive test results; −, negative test results; RSV, respiratory syncytial virus. Secondary outcomes for this study included patient charge savings, ancillary test use, disposition, antibiotic use, and oseltamivir use (Table 4). Substantial charge savings were seen in 12 of 39 patients with affected management plans, with $669 saved per patient with fewer tests (95% CI, $421–$918). Diagnostic testing fell by 12% to 18% when PCR test results were available earlier, although disposition was essentially unchanged. Physicians would have prescribed 17% fewer antibiotics for discharged patients if they would have had the results immediately available and would have been more likely to prescribe oseltamivir to patients testing positive and to withhold it in patients testing negative (13% net increase in appropriate oseltamivir prescriptions).Table 4Changes in Secondary Outcomes if Survey Responses Reflected Changes in ED ManagementSecondary outcomeMean change (95% CI)Patients affected, nED charge savings Among all patients, $−205.97 (−83.72 to −328.23)39 Patients with changes only, $−669.42 (−420.95 to −917.88)12ED diagnostics use changes Chest X-ray, net %−12.8 (−23.8 to −1.8)7/39 UA screen, net %−18.0 (−30.6 to −5.3)5/39 Blood draw, net %−12.8 (−23.8 to −1.8)5/39 Any change, net %−30.8 (−45.9 to −15.6)12/39Admission status changes No change, %94.9 (87.9–102.1)37/39 Discharge to admit, %0.0 (0.0–0.0)0/39 Admit to discharge, %5.1 (−2.1 to 12.4)2/39 Total changes, %5.1 (−2.1 to 12.4)2/39Antibiotic use changes All patients, net %−15.4 (−31.2 to 0.5)10/39Added antibiotics, %5.1 (−2.1 to 12.4)2/39Reduced antibiotics, %20.5 (7.3–33.8)8/39 Discharged patients only, net %−17.4 (−34.2 to −0.6)4/23Added antibiotics, %0.0 (0.0–0.0)0/23Reduced antibiotics, %17.4 (0.6−34.2)4/23Oseltamivir use changes All patients, net %7.7 (−6.0 to 21.4)7/39Added oseltamivir, %12.8 (1.8–23.8)5/39Reduced oseltamivir, %5.1 (−2.1 to 12.4)2/39 Discharged patients only, net %2.6 (−9.2 to 14.3)5/23Added oseltamivir, %13.0 (−1.8 to 28.0)3/23Reduced oseltamivir, %8.7 (−3.8 to 21.2)2/23Appropriate oseltamivir use Pretest, total %76.9 (63.1–90.8)30/39Prescribed (influenza positive), %30.0 (−4.6 to 64.6)3/10Not prescribed (influenza negative), %93.1 (83.3–102.9)27/29 Posttest, total %84.6 (72.8–96.5)33/39Prescribed (influenza positive), %60.0 (23.1–96.9)6/10Not prescribed (influenza negative), %93.1 (93.3–102.9)27/29 Net change, %7.7 (1.8–23.8)3/39Charge savings were calculated from per-test patient charged for chest X-ray, UA screen, and blood draw; patients with changes are those with changes in the number of diagnostic studies performed. For diagnostic studies, all (n = 12) affected patients had reductions in studies ordered; none of the patients would have had a management change that increased the number of diagnostic studies. Admission includes general floor, isolation, and intensive care; no enrolled patients were admitted for observation (<24 hours) or to a clinical decision unit. Discharged status from pretest disposition (n = 23), not posttest theoretical disposition (n = 22 discharged). Appropriate oseltamivir usage defined as oseltamivir prescription for influenza-positive patients or no oseltamivir prescription for influenza-negative patients.ED, emergency department; UA, urinalysis. Open table in a new tab Charge savings were calculated from per-test patient charged for chest X-ray, UA screen, and blood draw; patients with changes are those with changes in the number of diagnostic studies performed. For diagnostic studies, all (n = 12) affected patients had reductions in studies ordered; none of the patients would have had a management change that increased the number of diagnostic studies. Admission includes general floor, isolation, and intensive care; no enrolled patients were admitted for observation (<24 hours) or to a clinical decision unit. Discharged status from pretest disposition (n = 23), not posttest theoretical disposition (n = 22 discharged). Appropriate oseltamivir usage defined as oseltamivir prescription for influenza-positive patients or no oseltamivir prescription for influenza-negative patients. ED, emergency department; UA, urinalysis. In this study we found that a rapid turnaround of influenza and RSV PCR test results, by mPOCT, would have affected most cases when a pediatric ED physician ordered nasopharyngeal swabs for respiratory viral PCR panels during the management of patients. In these cases mPOCT has the potential to improve ED LOS, decrease ordering of other tests, and improve the use of antibiotic and antiviral agents in these patients. The mPOCT would have had little if any impact on disposition of admitted patients. Commercially
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