Emergency Medical Technicians lift a patient on a stretcher out of an ambulance

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Acutely ill and injured patients arriving by emergency medical services (EMS) present unique testing challenges, especially during the COVID-19 pandemic. This is compounded by the fact that no national standard exists for collecting samples and testing in the EMS prehospital setting. Teamwork between laboratory and emergency personnel is crucial to ensure that preanalytical measures taken during transport don’t lead to errors.

In a Clinical Chemistry Q&A, Octavia Peck Palmer, PhD, sought insight from Mario Plebani, MD, Sarah E. Wheeler, PhD, FACB, P. Daniel Patterson, PhD, MPH, Nichole Korpi-Steiner, PhD, DABCC, FACB, and Cameron Martin, MAppSc, on identifying and mitigating prehospital challenges during EMS transport, and on collaborative strategies to improve testing.

Lab-based tests don’t always translate well to EMS settings, explained Patterson. “The odds of an analytical error in this environment are high, due to the numerous obstacles to care paramedics, and emergency medical technicians must overcome these to deliver emergent care,” he said. Inadequate mixing of whole blood with anticoagulant, air bubbles in samples, and over- and underfilling samples in point-of-care (POC) devices are common preanalytical errors that take place during EMS transport, noted Korpi-Steiner. To reduce errors, her practice established a comprehensive quality management program that leveraged a multidisciplinary team of POC and emergency transport experts and a series of safeguard measures.

These safeguards include things like using devices’ operator and quality control lockout features, checking devices’ power level during daily quality control activities, using a “grab and go” transport bag with must-have equipment and supplies, and using temperature-regulated vehicles, added Korpi-Steiner.

Panelists also reviewed the differences between EMT and standard hospital-based POCT, and which EMT interventions have the greatest preanalytical impact on POCT and central laboratory testing. “Fluids and blood products are among the most common interventions and can influence POCT and central laboratory testing. However, less common medications can also be problematic,” said Wheeler. Hydroxocobalamin interactions in particular can interfere with many common lab and POCT tests. “However, it can be challenging to identify without a medication history to refer to in the electronic medical record,” she added.

Panelists also addressed the importance of clinical labs collaborating with EMS and emergency department (ED) staff to reduce prehospital errors. “Currently, the lack of knowledge on specific issues about laboratory testing in emergency transport does not allow to take quality, efficiency, effectiveness, and patient safety for granted,” cautioned Plebani. “The cooperation for better understanding patient needs and the type of interventions may allow laboratory professionals to provide expert advice for improving the quality and accuracy of laboratory tests both in the central laboratory and in POCT, as well as in ambulance and helicopter settings.”

Clinical labs reluctant to approach ED and EMS staff should be aware of the benefits of fostering these relationships, stressed Martin. “The first step is to begin a dialogue with EMS, spend time with them, see their workflow, and have them share their opinions on bottlenecks in the testing system.” Together, all parties can establish agreed-upon workflows that meet everyone’s needs without sacrificing testing quality.

Plebani called for better standards for testing in EMT transport. This is a neglected area, he said, requiring action on the part of federations of laboratory medicine and scientific societies.

Read more about improving EMS transport through collaborative relationships in the August issue of Clinical Chemistry.