Diagnostic Testing in the Waiting Room
Initiating Diagnostic Studies on Patients With Abdominal Pain in the Waiting Room Decreases Time Spent in an Emergency Department Bed: A Randomized Controlled Trial.
Begaz et al. (2016) Annals of Emergency Medicine.
To determine if ordering diagnostic tests on patients from the waiting room, after a screening exam but before a full history and physical, could improve patient flow.
A single-center, unblinded, randomized, controlled trial comparing the addition of waiting room diagnostic testing (WRDT) to rapid medical evaluation (RME) alone. Inclusion criteria required all beds in the ED to be occupied, and the patients to have a chief complaint of abdominal pain and be triaged to an ESI of 3.
Exclusion criteria included pregnancy, age less than 18, or patient too unstable to return to the waiting room based on clinical judgment.
A nurse practitioner or attending physician stationed near the waiting room determined what if any tests for order if a patient was randomized to the intervention group, but performed the RME assessment on every patient. During off-peak hours, these providers had other clinical responsibilities. Staffing otherwise remained identical. Prior to the study, providers occasionally initiated diagnostic studies but there was no policy or protocol authorizing this. Urine pregnancy and EKG testing could be ordered for RME alone patients. WRDT patients could receive blood, urine, plain radiograph, CT scan, or ultrasonographic testing.
The primary outcome was time in an ED bed, with total ED time and left before completion of service (LBCoS) rates as secondary outcomes. LBCoS patients were excluded from the primary outcome analysis.
1659 patients were included in the study. Patients in the RME+WRDT spent 31 minutes less in an ED bed versus the RME-only group (95%CI 16 to 46 minutes, 245 vs. 277 minutes). Only 32% of all arrivals overall got an RME. 26 of 811 patients randomized to RME only had diagnostic testing ordered, but were nonetheless analyzed by intention-to-treat in the control group. Total ED time was also shorter by 42 minutes in the RME+WRDT intervention group (95%CI 22 to 63 minutes, 460 vs. 504 minutes). The intervention group 3.5% fewer patients LBCoS in the intervention group (95% 0.5% to 6.5%, 9% vs. 13%).
Of note, the intervention group had more types of diagnostic studies ordered than the control (2.6 vs 2.0 unique test categories, difference 0.6 with (95%CI 0.4 to 0.7).
Waiting room diagnostic testing improved patient flow through the ED, at the expense of increased diagnostic test utilization with possible risk of increase in over diagnosis, false positives, and resource utilization.