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Cortel-LeBlanc MA, Lemay K, Woods S, Bakewell F, Liu R, Garber G. Medico-legal risk and use of medical directives in the emergency department. CAN J EMERG MED 2023; 25:589-597. [PMID: 37170059 DOI: 10.1007/s43678-023-00522-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/30/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE The medico-legal risk associated with application of medical directives in the emergency department (ED) is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases involving medical directives in the ED. METHODS We conducted a descriptive analysis of closed medico-legal cases [hospital complaints, regulatory authority (i.e., College) complaints, and civil legal actions] involving emergency physicians in Canadian EDs involving medical directives (alternate terms including "standing order", "nursing initiated", "nurse initiated", "nursing order", "triage initiated", "triage ordered", "directive", "ED protocol", and "ED's protocol"). We used data from closed cases involving the Canadian Medical Protective Association from January 2016 until December 2021. We abstracted descriptive factors of the cases and used a framework for contributing factors classification. RESULTS From 2016 until 2021, 43,332 cases were closed and 1957 involved emergency physicians for which there was medico-legal information available for analysis. In all, 28 involved emergency physicians and medical directives. Situational awareness, team communication, and issues with clinical decision-making were the most important factors contributing to harm and medico-legal risk. Peer experts were critical of physicians not reviewing all results available for patients when initiated through a directive, misinterpreting test results, a less than thorough initial assessment, and of failing to reassess patients or re-order investigations when indicated. CONCLUSION Our findings suggest that the medico-legal risk exposure from the use of medical directives in the ED is low. Emergency departments may consider implementing systems to support adherence to medical directive policies, ensure physicians are alerted when medical directives are completed in a timely fashion, and leverage tools to notify the healthcare team when results have not been reviewed.
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Affiliation(s)
- Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada.
- Department of Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Karen Lemay
- Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Sue Woods
- Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Francis Bakewell
- Department of Emergency Medicine, QEII Health Sciences Centre, Halifax, NS, Canada
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Richard Liu
- Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Gary Garber
- Canadian Medical Protective Association, Ottawa, ON, Canada
- Department of Medicine and the School of Public Health and Epidemiology, University of Ottawa, Ottawa, ON, Canada
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VanSpronsen AD, Zychla L, Turley E, Villatoro V, Yuan Y, Ohinmaa A. Causes of Inappropriate Laboratory Test Ordering from the Perspective of Medical Laboratory Technical Professionals: Implications for Research and Education. Lab Med 2023; 54:e18-e23. [PMID: 35801961 DOI: 10.1093/labmed/lmac076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Inappropriate laboratory test ordering is a significant and persistent problem. Many causes have been identified and studied. Medical laboratory professionals (MLPs) are technical staff within clinical laboratories who are uniquely positioned to comment on why inappropriate ordering occurs. We aimed to characterize existing MLP perceptions in this domain to reveal new or underemphasized interventional targets. METHODS We developed and disseminated a self-administered survey to MLPs in Canada, including open-ended responses to questions about the causes of inappropriate laboratory test ordering. RESULTS Four primary themes were identified from qualitative analysis: ordering-provider factors, communication factors, existing test-ordering processes, and patient factors. Although these factors can largely be found in previous literature, some are under-studied. CONCLUSION MLP insights into nonphysician triage ordering and poor result communication provide targets for further investigation. A heavy focus on individual clinician factors suggests that current understandings and interprofessional skills in the MLP population can be improved.
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Affiliation(s)
- Amanda D VanSpronsen
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Laura Zychla
- Research, Canadian Association for Medical Radiation Technologists, Ottawa, Ontario, Canada
| | - Elona Turley
- Coagulation Medicine, Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Valentin Villatoro
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Yan Yuan
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Monahan AC, Feldman SS, Fitzgerald TP. Reducing Crowding in Emergency Departments With Early Prediction of Hospital Admission of Adult Patients Using Biomarkers Collected at Triage: Retrospective Cohort Study. JMIR BIOINFORMATICS AND BIOTECHNOLOGY 2022; 3:e38845. [PMID: 38935936 PMCID: PMC11135233 DOI: 10.2196/38845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 06/29/2024]
Abstract
BACKGROUND Emergency department crowding continues to threaten patient safety and cause poor patient outcomes. Prior models designed to predict hospital admission have had biases. Predictive models that successfully estimate the probability of patient hospital admission would be useful in reducing or preventing emergency department "boarding" and hospital "exit block" and would reduce emergency department crowding by initiating earlier hospital admission and avoiding protracted bed procurement processes. OBJECTIVE To develop a model to predict imminent adult patient hospital admission from the emergency department early in the patient visit by utilizing existing clinical descriptors (ie, patient biomarkers) that are routinely collected at triage and captured in the hospital's electronic medical records. Biomarkers are advantageous for modeling due to their early and routine collection at triage; instantaneous availability; standardized definition, measurement, and interpretation; and their freedom from the confines of patient histories (ie, they are not affected by inaccurate patient reports on medical history, unavailable reports, or delayed report retrieval). METHODS This retrospective cohort study evaluated 1 year of consecutive data events among adult patients admitted to the emergency department and developed an algorithm that predicted which patients would require imminent hospital admission. Eight predictor variables were evaluated for their roles in the outcome of the patient emergency department visit. Logistic regression was used to model the study data. RESULTS The 8-predictor model included the following biomarkers: age, systolic blood pressure, diastolic blood pressure, heart rate, respiration rate, temperature, gender, and acuity level. The model used these biomarkers to identify emergency department patients who required hospital admission. Our model performed well, with good agreement between observed and predicted admissions, indicating a well-fitting and well-calibrated model that showed good ability to discriminate between patients who would and would not be admitted. CONCLUSIONS This prediction model based on primary data identified emergency department patients with an increased risk of hospital admission. This actionable information can be used to improve patient care and hospital operations, especially by reducing emergency department crowding by looking ahead to predict which patients are likely to be admitted following triage, thereby providing needed information to initiate the complex admission and bed assignment processes much earlier in the care continuum.
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Affiliation(s)
| | - Sue S Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tony P Fitzgerald
- School of Mathematical Sciences, University College Cork, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
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Singh D, Nagaraj S, Mashouri P, Drysdale E, Fischer J, Goldenberg A, Brudno M. Assessment of Machine Learning-Based Medical Directives to Expedite Care in Pediatric Emergency Medicine. JAMA Netw Open 2022; 5:e222599. [PMID: 35294539 PMCID: PMC8928004 DOI: 10.1001/jamanetworkopen.2022.2599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/06/2022] [Indexed: 12/26/2022] Open
Abstract
Importance Increased wait times and long lengths of stay in emergency departments (EDs) are associated with poor patient outcomes. Systems to improve ED efficiency would be useful. Specifically, minimizing the time to diagnosis by developing novel workflows that expedite test ordering can help accelerate clinical decision-making. Objective To explore the use of machine learning-based medical directives (MLMDs) to automate diagnostic testing at triage for patients with common pediatric ED diagnoses. Design, Setting, and Participants Machine learning models trained on retrospective electronic health record data were evaluated in a decision analytical model study conducted at the ED of the Hospital for Sick Children Toronto, Canada. Data were collected on all patients aged 0 to 18 years presenting to the ED from July 1, 2018, to June 30, 2019 (77 219 total patient visits). Exposure Machine learning models were trained to predict the need for urinary dipstick testing, electrocardiogram, abdominal ultrasonography, testicular ultrasonography, bilirubin level testing, and forearm radiographs. Main Outcomes and Measures Models were evaluated using area under the receiver operator curve, true-positive rate, false-positive rate, and positive predictive values. Model decision thresholds were determined to limit the total number of false-positive results and achieve high positive predictive values. The time difference between patient triage completion and test ordering was assessed for each use of MLMD. Error rates were analyzed to assess model bias. In addition, model explainability was determined using Shapley Additive Explanations values. Results There was a total of 42 238 boys (54.7%) included in model development; mean (SD) age of the children was 5.4 (4.8) years. Models obtained high area under the receiver operator curve (0.89-0.99) and positive predictive values (0.77-0.94) across each of the use cases. The proposed implementation of MLMDs would streamline care for 22.3% of all patient visits and make test results available earlier by 165 minutes (weighted mean) per affected patient. Model explainability for each MLMD demonstrated clinically relevant features having the most influence on model predictions. Models also performed with minimal to no sex bias. Conclusions and Relevance The findings of this study suggest the potential for clinical automation using MLMDs. When integrated into clinical workflows, MLMDs may have the potential to autonomously order common ED tests early in a patient's visit with explainability provided to patients and clinicians.
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Affiliation(s)
- Devin Singh
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sujay Nagaraj
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Pouria Mashouri
- DATA Team, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Erik Drysdale
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jason Fischer
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anna Goldenberg
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario Canada
- Canadian Institute for Advanced Research, Toronto, Ontario Canada
| | - Michael Brudno
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- DATA Team, Techna Institute, University Health Network, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario Canada
- Canadian Institute for Advanced Research, Toronto, Ontario Canada
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Rajan JJ, Rodzevik T. Sepsis Awareness to Enhance Early Identification of Sepsis in Emergency Departments. J Contin Educ Nurs 2021; 52:39-42. [PMID: 33373006 DOI: 10.3928/00220124-20201215-10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/15/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Early identification of sepsis continues to be a challenge for nurses in the acute care setting. Often, a gap exists between existing policies for sepsis identification and structured education to support these policies. METHOD Using quantitative methodology and descriptive correlational design, this project explored the differences between emergency department nurses who received education on the early identification and treatment of sepsis and emergency department nurses who did not receive this education. RESULTS Descriptive statistics and independent t test were used to analyze and compare data between the control and implementation group. The p value was .018, which was statistically significant. The mean time to identify sepsis was decreased by 33 minutes. CONCLUSION Using a sepsis standing order set combined with education helped to identify and elevate the care of sepsis patients. Resources such as the Surviving Sepsis Campaign screening tool to identify sepsis helped emergency department nurses to identify sepsis in a timely manner. [J Contin Educ Nurs. 2021;52(1):39-42.].
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Sember M, Donley C, Eggleston M. Implementation of a Provider in Triage and Its Effect on Left without Being Seen Rate at a Community Trauma Center. Open Access Emerg Med 2021; 13:137-141. [PMID: 33824606 PMCID: PMC8018550 DOI: 10.2147/oaem.s296001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/09/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Emergency department (ED) overcrowding is a nationally recognized problem and multiple strategies have been proposed and implemented with varying levels of success. It has caused patients to present to the ED but leave without being seen (LWBS). These patients suffer delayed diagnosis, delayed treatment, and ultimately increased morbidity and mortality. In efforts to decrease the number of patients who leave without being seen, one proposed solution is to place a provider in triage to evaluate these patients at the initial point of contact. Methods A retrospective chart review was conducted on patient’s presenting to the Emergency Department from October through January for the years 2013 through 2017. A list of all patient dispositions for each study month was analyzed and compared for the 4 consecutive years with the implementation of an Advanced Practice Provider (APP) in triage. Results A total of 2162 patients dispositioned as LWBS during the entire study period of October 2013 through January 2017 were enrolled in the analysis. After implementation of a provider in triage, there was a 39% overall decrease (95% CI 0.005) in patients who left the ED before completion of treatment. There was a 69% reduction (95% CI 0.005) in patients who left before seeing the provider in triage. After seeing the provider, we saw an 83% reduction (95% CI<0.001) in LWBS. Overall, our initial LWBS rate was found to be 5%, and after implementation of a provider in triage that rate decreased to 1%. Discussion The addition of a provider in triage decreased our LWBS rate from 5% to 1%. The addition of a provider in triage also helped identify sick patients in the waiting room and helped facilitate more rapid assessment of ED patients on arrival.
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Affiliation(s)
- Maria Sember
- Department of Emergency Medicine, Mercy Health Youngstown Hospital, Youngstown, OH, USA
| | - Chad Donley
- Department of Emergency Medicine, Mercy Health Youngstown Hospital, Youngstown, OH, USA
| | - Matthew Eggleston
- Department of Emergency Medicine, Mercy Health Youngstown Hospital, Youngstown, OH, USA
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Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician. J Emerg Med 2021; 60:570-575. [PMID: 33419653 DOI: 10.1016/j.jemermed.2020.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/01/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND In an effort to decrease length of stay (LOS) and reduce overcrowding, many emergency departments (ED) have implemented triage nurse-ordered testing. STUDY OBJECTIVES To review the medical literature to determine the utility of triage nurse-ordered testing and to offer evidence-based recommendations to emergency physicians. METHODS A systematic search of the PubMed literature was performed for publication in English from inception to November 30, 2019 using a combination of the following keywords: "triage," "nurse," "protocol," and "emergency." The articles were screened for relevance and the selected studies were subjected to detailed review by all of the authors and assigned a grade of evidence based on focus, research design, and methodology. Recommendations were drawn from the findings. RESULTS The initial search yielded a total of 982 potentially relevant studies; 13 articles were ultimately selected for inclusion. Of these, 10 studies assessed ED LOS, with one study assessing time to diagnosis. The three remaining studies compared triage nurse-ordered testing with physician testing in the ED setting. CONCLUSIONS Triage nurses have reasonably similar accuracy as physicians in ordering limb x-ray studies and moderate accuracy for laboratory testing. However, we did not identify a clinically meaningful decrease in ED LOS from the use of nursing triage orders.
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Reynolds MS, Dunaway A, Stevens C, Shoemaker D, Buckingham D, Spencer SP. Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department. J Emerg Nurs 2020; 46:768-778. [PMID: 32981747 DOI: 10.1016/j.jen.2020.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Infants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival. METHODS The team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts. RESULTS Through use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes. DISCUSSION The use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.
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Bahl A, Jamali AM, Ramesh G. Impact of Early Urine Specimen Collection on Emergency Department Time to Disposition: A Randomized Controlled Trial. Cureus 2020; 12:e10495. [PMID: 33083194 PMCID: PMC7567408 DOI: 10.7759/cureus.10495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Diagnostic testing in the ED increases the length of stay (LOS). Urinalysis testing is highlighted specifically as a source of delays. We aim to determine whether a triage-initiated urine specimen collection process decreases ED time to disposition (TTD) in ambulatory patients with abdominal pain. Methods This prospective, randomized controlled study was implemented at a Suburban Level One trauma ED with greater than 120,000 annual visits. A convenience sample of patients was recruited. Adult, non-ambulance patients presenting with abdominal pain were eligible. Participants were randomized into experimental and control groups. Patients in the control group provided a urine sample after physician evaluation, if ordered by the provider. Patients in the experimental group were prompted to provide a urine sample in the triage restrooms immediately after screening at the greeter desk. The UA sample was transported to the treatment area and sent to the laboratory after physician evaluation. Results A total of 125 control patients and 124 experimental patients were enrolled. Forty-two patients were excluded because they were unable to provide a urine sample. Patients who had a urinalysis ordered were included in statistical analysis. Final data set included 65 patients in the experimental group and 96 patients in the control group. No significant difference (p=0.5072) in disposition time between subjects in the experimental group (n=65, mean=5:17 [hours:min]) and subjects in the control group (n=96, mean=5:30) was found. Conclusions The triage protocol for urine specimen collection did not significantly reduce ED TTD. Further research in overcrowded EDs with long patient waiting room times may benefit from implementing a triage protocol for urine specimen collection.
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Affiliation(s)
- Amit Bahl
- Emergency Medicine, Beaumont Hospital, Royal Oak, USA
| | - Ameen M Jamali
- Emergency Medicine, Medical Center Health System, Odessa, USA
| | - Gautam Ramesh
- Emergency Medicine, Michigan State University College of Human Medicine, Lansing, USA
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Sharma S, Rafferty AM, Boiko O. The role and contribution of nurses to patient flow management in acute hospitals: A systematic review of mixed methods studies. Int J Nurs Stud 2020; 110:103709. [PMID: 32745787 DOI: 10.1016/j.ijnurstu.2020.103709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 06/16/2020] [Accepted: 06/25/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Increased overcrowding in the emergency department is a potential threat to the quality and safety of patient care. Innovative ways are needed to explore overcrowding, the variables affecting patient flow and interventions necessary for future flow improvement. AIMS AND OBJECTIVES The aim of this review is to explore nurses' role(s) and their contribution to maintaining patient flow in acute hospitals through emergency departments. METHODOLOGY A systematic review of mixed studies (qualitative, quantitative and mixed-method) using narrative synthesis was undertaken. Five major databases-PubMed, CINHAL, BNI, ASSIA and SCOPUS-were searched to identify appropriate primary and secondary studies. Selected studies were critically appraised with a modified CASP tool. Data extraction and analysis was undertaken using narrative synthesis. RESULTS In total, 34 articles (31 primary studies and three systematic reviews) met the inclusion criteria. This systematic review is informed by studies from several countries, including the UK, US, Australia, Canada, and the Netherlands. The qualitative arm of this review explored both the role and function of nurses, as well as their experiences and perspectives of the patient flow process, while the quantitative arm investigated nurses' contribution to patient flow in terms of length of stay (LOS), triage time, and other associated performance data. FINDINGS Nurses' contribution to patient flow spanned their operational, strategic, and expanded roles. Strategic and expanded nursing roles offered the possibility of reducing LOS, triage time, and ED crowding in addition to improving the experience of patients and staff. Nurses in operational roles deployed experiential knowledge pertaining to several invisible aspects of patient flow challenges thereby facilitating decision-making for strategic flow improvement. The experiential knowledge and skills of these nursing roles are central to the success of flow-related interventions. However, the effects of emotional labour (e.g. conflicts, frustrations) of patient flow processes on nurses are significant and may have unaccounted for transaction costs and consequences that need acknowledging in order to be addressed by managers and policy makers. CONCLUSIONS AND RECOMMENDATIONS Policy-makers and senior managers need to capitalise on nurses' experiential knowledge and skills to enhance the strategic design and development of flow management in acute hospitals. Recommendations from this review have potential to deploy those skills and knowledge in flow improvement.
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Affiliation(s)
- Shrawan Sharma
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom; London North West University Healthcare NHS Trust Harrow, HA1 3UJ London, England, United Kingdom.
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom
| | - Olga Boiko
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom
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Goldstein LN, Wells M, Vincent-Lambert C. The cost-effectiveness of upfront point-of-care testing in the emergency department: a secondary analysis of a randomised, controlled trial. Scand J Trauma Resusc Emerg Med 2019; 27:110. [PMID: 31829227 PMCID: PMC6907262 DOI: 10.1186/s13049-019-0687-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/20/2019] [Indexed: 11/25/2022] Open
Abstract
Background Time-saving is constantly sought after in the Emergency Department (ED), and Point-of-Care (POC) testing has been shown to be an effective time-saving intervention. However, when direct costs are compared, these tests commonly appear to be cost-prohibitive. Economic viability may become apparent when the time-saving is translated into financial benefits from staffing, time- and cost-saving. The purpose of this study was to evaluate the cost-effectiveness of diagnostic investigations utilised prior to medical contact for ED patients with common medical complaints. Methods This was a secondary analysis of data from a prospective, randomised, controlled trial in order to assess the cost-effectiveness of upfront, POC testing. Eleven combinations of POC equivalents of commonly-used special investigations (blood tests (i-STAT and complete blood count (CBC)), electrocardiograms (ECGs) and x-rays (LODOX® (Low Dose X-ray)) were evaluated compared to the standard ED pathway with traditional diagnostic tests. The economic viability of each permutation was assessed using the Incremental Cost Effectiveness Ratio and Cost-Effectiveness Acceptability Curves. Expenses related to the POC test implementation were compared to the control group while taking staffing costs and time-saving into account. Results There were 897 medical patients randomised to receive various combinations of POC tests. The most cost-effective combination was the i-STAT+CBC permutation which, based on the time saving, would ultimately save money if implemented. All LODOX®-containing permutations were costlier but still saved time. Non-LODOX® permutations were virtually 100% cost-effective if an additional cost of US$50 per patient was considered acceptable. Higher staffing costs would make using POC testing even more economical. Conclusions In certain combinations, upfront, POC testing is more cost-effective than standard diagnostic testing for common ED undifferentiated medical presentations – the most economical POC test combination being the i-STAT + CBC. Upfront POC testing in the ED has the potential to not only save time but also to save money. Trial registration ClinicalTrials.gov: NCT03102216.
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Affiliation(s)
- Lara Nicole Goldstein
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa.
| | - Mike Wells
- Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Craig Vincent-Lambert
- Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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The cost of time: A randomised, controlled trial to assess the economic impact of upfront, point-of-care blood tests in the Emergency Centre. Afr J Emerg Med 2019; 9:57-63. [PMID: 31193827 PMCID: PMC6543082 DOI: 10.1016/j.afjem.2019.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/07/2018] [Accepted: 01/16/2019] [Indexed: 12/02/2022] Open
Abstract
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.
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Lacroix MC, Borgès Da Silva R. [Standing Orders and Quality of Care at Triage in Emergency Services: Integrative Review]. SANTE PUBLIQUE 2018; 30:83-93. [PMID: 29589695 DOI: 10.3917/spub.181.0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Overcrowding of emergency services is a widespread problem in western countries. This situation results in negative patient outcomes and influences the quality of care. Standing orders are a possible way to improve the quality and performance of the health system. The aim of this article is to identify, based on a review of the literature, the effects of standing orders initiated by triage nurses in emergency services on the quality of care. METHODS The quality of care dimensions of the Institute of Medicine (2001) were used as a frame of reference. The integrative review was performed on a selection of articles from Cochrane, CINALH, EMBASE, Medline, PubMed and Google Scholar. A total of 23 articles were selected and analysed. RESULTS The integrative review documented the effects of standing orders initiated by triage nurses on the six dimensions of quality of care: effectiveness, patient-centeredness, efficiency, timeliness, safety and equity. Standing orders are able to improve the efficiency of care by reducing, among other things, the time to treatment and diagnostic tests. They also reduce the length of stay of patients in emergency services. CONCLUSION Standing orders initiated by triage nurses in emergency services can have positive effects on the quality of care provided to the patient. Further research with more robust study designs is needed.
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