Real-Time Electronic Patient Portal Use Among Emergency Department Patients.

Importance: Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients. Objectives: To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers. Design, Setting, and Participants: In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022. Exposure: Use of the patient portal during ED visit. Main Outcomes and Measures: The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use. Results: The study included 1 280 924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes. Conclusions and Relevance: These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.

Clinical and financial outcome impacts of comprehensive geriatric assessment in a level 1 geriatric emergency department.

BACKGROUND: The aging population has led to an increase in emergency department (ED) visits by older adults who have complex medical conditions and high social needs. The purpose of this study was to assess if comprehensive geriatric evaluation and management impacted service utilization and cost by older adults admitted to the ED. METHODS: This is a retrospective matched case-control study at a level 1 geriatric ED (GED) from January 1, 2018-March 31, 2020. Geriatric nurse specialists (GENIEs) provided comprehensive evaluations and management for GED patients. Propensity score matching was used to match patients receiving GENIE consultations to ED patients who did not receive a GENIE consult. Regression was used to assess the impact of the GENIE services on inpatient admissions, ED revisits and cost of inpatient and ED care from the payor perspective. RESULTS: GENIE consults were associated with a 13.0% reduction in absolute risk of admission through the ED at index (95% confidence interval [CI] -17.0%, -9.0%, p < 0.001) and a reduction in risk for total admissions at 30 and 90-days post discharge (-11.3%, 95% CI -15.6%, -7.1%, p-value < 0.001; and -10.0, 95% CI -13.8%, -6.0%; p < 0.001 respectively), both driven by reduced risk of admission at the index visit. GENIE consults were associated with a 4% increase in absolute risk of revisits to the ED within 30 days (95% CI 0.6%, 7.3%; p = 0.001). GENIE consults were associated with a decrease in cost of inpatient and ED care, with savings of $2344 within 30 days (95% CI $2247, $2441, p < 0.001) and savings of $2004 USD within 90 days (95% CI $1895, $2114, p < 0.001), driven by reduced costs at the index visit. CONCLUSIONS: GENIE consults were associated with decreased inpatient admissions through the ED, modestly increased ED revisits, and decreased cost of inpatient and ED care. The results of this study can be useful for EDs considering approaches to better serve older adults. They can also be of interest to payers as an area of potential cost savings.

Development and Validation of a Respiratory-Responsive Vocal Biomarker-Based Tool for Generalizable Detection of Respiratory Impairment: Independent Case-Control Studies in Multiple Respiratory Conditions Including Asthma, Chronic Obstructive Pulmonary Disease, and COVID-19.

BACKGROUND: Vocal biomarker-based machine learning approaches have shown promising results in the detection of various health conditions, including respiratory diseases, such as asthma. OBJECTIVE: This study aimed to determine whether a respiratory-responsive vocal biomarker (RRVB) model platform initially trained on an asthma and healthy volunteer (HV) data set can differentiate patients with active COVID-19 infection from asymptomatic HVs by assessing its sensitivity, specificity, and odds ratio (OR). METHODS: A logistic regression model using a weighted sum of voice acoustic features was previously trained and validated on a data set of approximately 1700 patients with a confirmed asthma diagnosis and a similar number of healthy controls. The same model has shown generalizability to patients with chronic obstructive pulmonary disease, interstitial lung disease, and cough. In this study, 497 participants (female: n=268, 53.9%; <65 years old: n=467, 94%; Marathi speakers: n=253, 50.9%; English speakers: n=223, 44.9%; Spanish speakers: n=25, 5%) were enrolled across 4 clinical sites in the United States and India and provided voice samples and symptom reports on their personal smartphones. The participants included patients who are symptomatic COVID-19 positive and negative as well as asymptomatic HVs. The RRVB model performance was assessed by comparing it with the clinical diagnosis of COVID-19 confirmed by reverse transcriptase-polymerase chain reaction. RESULTS: The ability of the RRVB model to differentiate patients with respiratory conditions from healthy controls was previously demonstrated on validation data in asthma, chronic obstructive pulmonary disease, interstitial lung disease, and cough, with ORs of 4.3, 9.1, 3.1, and 3.9, respectively. The same RRVB model in this study in COVID-19 performed with a sensitivity of 73.2%, specificity of 62.9%, and OR of 4.64 (P<.001). Patients who experienced respiratory symptoms were detected more frequently than those who did not experience respiratory symptoms and completely asymptomatic patients (sensitivity: 78.4% vs 67.4% vs 68%, respectively). CONCLUSIONS: The RRVB model has shown good generalizability across respiratory conditions, geographies, and languages. Results using data set of patients with COVID-19 demonstrate its meaningful potential to serve as a prescreening tool for identifying individuals at risk for COVID-19 infection in combination with temperature and symptom reports. Although not a COVID-19 test, these results suggest that the RRVB model can encourage targeted testing. Moreover, the generalizability of this model for detecting respiratory symptoms across different linguistic and geographic contexts suggests a potential path for the development and validation of voice-based tools for broader disease surveillance and monitoring applications in the future.

The Implementation of an Emergency Medicine Telehealth System During a Pandemic.

BACKGROUND: In March of 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19)-a disease caused by a novel coronavirus-a pandemic, and it continued to spread rapidly in the community. Our institution implemented an emergency medicine telehealth system that sought to expedite care of stable patients, decrease provider exposure to COVID-19, decrease overall usage rate of personal protective equipment, and provide a platform so that infected or quarantined physicians could continue to work. This effort was among the first to use telehealth to practice emergency medicine in the setting of a pandemic in the United States. DISCUSSION: Outside the main emergency departments at each of 2 sites of our academic institution, disaster tents were erected with patient care equipment and medications, as well as technology to allow for telehealth visits. The triage system was modified to appropriately select low-risk patients with symptoms suggestive of COVID-19 who could be seen in these disaster tents. Despite some issues that needed to be addressed, such as provider discomfort, limited medication availability, and connectivity problems, the model was successful overall. CONCLUSIONS: Other emergency departments might find this proof of concept article useful. Telehealth will likely be used more broadly in the future, including emergency care. It is imperative that the health care system continues to adapt to respond appropriately to challenges such as pandemics.

Clinical Cybersecurity Training Through Novel High-Fidelity Simulations.

BACKGROUND: Cybersecurity risks in health care systems have traditionally been measured in data breaches of protected health information, but compromised medical devices and critical medical infrastructure present risks of disruptions to patient care. The ubiquitous prevalence of connected medical devices and systems may be associated with an increase in these risks. OBJECTIVE: This article details the development and execution of three novel high-fidelity clinical simulations designed to teach clinicians to recognize, treat, and prevent patient harm from vulnerable medical devices. METHODS: Clinical simulations were developed that incorporated patient-care scenarios featuring hacked medical devices based on previously researched security vulnerabilities. RESULTS: Clinicians did not recognize the etiology of simulated patient pathology as being the result of a compromised device. CONCLUSIONS: Simulation can be a useful tool in educating clinicians in this new, critically important patient-safety space.

National Survey of Emergency Physicians Concerning Home-Based Care Options as Alternatives to Emergency Department-Based Hospital Admissions.

BACKGROUND: Emergency departments (EDs) in the United States play a prominent role in hospital admissions, especially for the growing population of older adults. Home-based care, rather than hospital admission from the ED, provides an important alternative, especially for older adults who have a greater risk of adverse events, such as hospital-acquired infections, falls, and delirium. OBJECTIVE: The objective of the survey was to understand emergency physicians' (EPs) perspectives on home-based care alternatives to hospitalization from the ED. Specific goals included determining how often EPs ordered home-based care, what they perceive as the barriers and motivators for more extensive ordering of home-based care, and the specific conditions and response times most appropriate for such care. METHODS: A group of 1200 EPs nationwide were e-mailed a six-question survey. RESULTS: Participant response was 57%. Of these, 55% reported ordering home-based care from the ED within the past year as an alternative to hospital admission or observation, with most doing so less than once per month. The most common barrier was an "unsafe or unstable home environment" (73%). Home-based care as a "better setting to care for low-acuity chronic or acute disease exacerbation" was the top motivator (79%). Medical conditions EPs most commonly considered for home-based care were cellulitis, urinary tract infection, diabetes, and community-acquired pneumonia. CONCLUSIONS: Results suggest that EPs recognize there is a benefit to providing home-based care as an alternative to hospitalization, provided they felt the home was safe and a process was in place for dispositioning the patient to this setting. Better understanding of when and why EPs use home-based care pathways from the ED may provide suggestions for ways to promote wider adoption.

Indistinguishable NDM-producing Escherichia coli isolated from recreational waters, sewage, and a clinical specimen in Ireland, 2016 to 2017.

In this study, New Delhi metallo-beta-lactamase (NDM)-producing Enterobacteriaceae were identified in Irish recreational waters and sewage. Indistinguishable NDM-producing Escherichia coli by pulsed-field gel electrophoresis were isolated from sewage, a fresh water stream and a human source. NDM-producing Klebsiella pneumoniae isolated from sewage and seawater in the same area were closely related to each other and to a human isolate. This raises concerns regarding the potential for sewage discharges to contribute to the spread of carbapenemase-producing Enterobacteriaceae.

Survey and Chart Review to Estimate Medicare Cost Savings for Home Health as an Alternative to Hospital Admission Following Emergency Department Treatment.

BACKGROUND: Almost 70% of hospital admissions for Medicare beneficiaries originate in the emergency department (ED). Research suggests that some of these patients' needs may be better met through home-based care options after evaluation and treatment in the ED. OBJECTIVE: We sought to estimate Medicare cost savings resulting from using the Home Health benefit to provide treatment, when appropriate, as an alternative to inpatient admission from the ED. METHODS: This is a prospective study of patients admitted from the ED. A survey tool was used to query both emergency physicians (EPs) and patient medical record data to identify potential candidates and treatments for home-based care alternatives. Patient preferences were also surveyed. Cost savings were estimated by developing a model of Medicare Home Health to serve as a counterpart to the actual hospital-based care. RESULTS: EPs identified 40% of the admitted patients included in the study as candidates for home-based care. The top three major diagnostic categories included diseases and disorders of the respiratory system, digestive system, and skin. Services included intravenous hydration, intravenous antibiotics, and laboratory testing. The average estimated cost savings between the Medicare inpatient reimbursement and the Home Health counterpart was approximately $4000. Of the candidate patients surveyed, 79% indicated a preference for home-based care after treatment in the ED. CONCLUSIONS: Some Medicare beneficiaries could be referred to Home Health from the ED with a concomitant reduction in Medicare expenditures. Additional studies are needed to compare outcomes, develop the logistical pathways, and analyze infrastructure costs and incentives to enable Medicare Home Health options from the ED.

Inpatient Readmissions and Emergency Department Visits within 30 Days of a Hospital Admission.

INTRODUCTION: Inpatient hospital readmissions have become a focus for healthcare reform and cost-containment efforts. Initiatives targeting unanticipated readmissions have included care coordination for specific high readmission diseases and patients and health coaching during the post-discharge transition period. However, little research has focused on emergency department (ED) visits following an inpatient admission. The objective of this study was to assess 30-day ED utilization and all-cause readmissions following a hospital admission. METHODS: This was a retrospective study using inpatient and ED utilization data from two hospitals with a shared patient population in 2011. We assessed the 30-day ED visit rate and 30-day readmission rate and compared patient characteristics among individuals with 30-day inpatient readmissions, 30-day ED discharges, and no 30-day visits. RESULTS: There were 13,449 patients who met the criteria of an index visit. Overall, 2,453 (18.2%) patients had an ED visit within 30 days of an inpatient stay. However, only 55.6% (n=1,363) of these patients were admitted at one of these 30-day visits, resulting in a 30-day all-cause readmission rate of 10.1%. CONCLUSION: Approximately one in five patients presented to the ED within 30 days of an inpatient hospitalization and over half of these patients were readmitted. Readmission measures that incorporate ED visits following an inpatient stay might better inform interventions to reduce avoidable readmissions.

Identifying frequent users of emergency department resources.

BACKGROUND: There is growing focus on frequent users of acute care resources. If these patients can be identified, interventions can be established to offer more consistent management plans to decrease inappropriate utilization. OBJECTIVE: To compare a hospital-specific approach with a region-wide approach to identify frequent Emergency Department (ED) users. METHODS: A retrospective multi-center cohort study of hospital ED visits from all 18 nonmilitary, acute care hospitals serving the San Diego region (population 3.2 million) between 2008 and 2010 using data submitted to the California Office of Statewide Health Planning and Development. Frequent users and super users were defined as having 6 to 20 and 21 or more visits, respectively, during any consecutive 12 months in the study period. Comparisons between community-wide and hospital-specific methods were made. RESULTS: There were 925,719 individual patients seen in an ED, resulting in 2,016,537 total visits. There were 28,569 patients identified as frequent users and 1661 identified as super users, using a community-wide approach. Individual hospitals could identify 15.6% to 62.4% of all frequent users, and from 0.3% to 15.2% of all the super users who visited their facility. Overall, the hospital-specific approach identified 20,314 frequent users and 571 super users, failing to identify 28.9% of frequent users and 65.6% of super users visiting San Diego County EDs that would otherwise have been identified using a community-wide approach. CONCLUSIONS: A community-wide identification method resulted in greater numbers of individuals being identified as frequent and super ED users than when utilizing individual hospital data.

Impact of wireless electronic medical record system on the quality of patient documentation by emergency field responders during a disaster mass-casualty exercise.

INTRODUCTION: The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing. OBJECTIVE: This study examines the role of wireless, electronic, medical records and communications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise. METHODS: A controlled, side-to-side comparison of the quality of the field responder patient documentation between responders utilizing National Institutes of Health-funded, wireless, electronic, field, medical record system prototype ("Wireless Internet Information System for medicAl Response to Disasters" or WIISARD) versus those utilizing conventional, paper-based methods during a mass-casualty field exercise. Medical data, including basic victim identification information, acuity status, triage information using Simple Triage and Rapid Treatment (START), decontamination status, and disposition, were collected for simulated patients from all paper and electronic logs used during the exercise. The data were compared for quality of documentation and record completeness comparing WIISARD-enabled field responders and those using conventional paper methods. Statistical analysis was performed with Fisher's Exact Testing of Proportions with differences and 95% confidence intervals reported. RESULTS: One hundred simulated disaster victim volunteers participated in the exercise, 50 assigned to WIISARD and 50 to the conventional pathway. Of those victims who completed the exercise and were transported to area hospitals, medical documentation of victim START components and triage acuity were significantly better for WIISARD compared to controls (overall acuity was documented for 100% vs 89.5%, respectively, difference = 10.5% [95%CI = 0.5-24.1%]). Similarly, tracking of decontamination status also was higher for the WIISARD group (decontamination status documented for 59.0% vs 0%, respectively, difference = 9.0% [95%CI = 40.9-72.0%]). Documentation of disposition and destination of victims was not different statistically (92.3% vs. 89.5%, respectively, difference = 2.8% [95%CI = -11.3-17.3%]). CONCLUSIONS: In a simulated, mass-casualty field exercise, documentation and tracking of victim status including acuity was significantly improved when using a wireless, field electronic medical record system compared to the use of conventional paper methods.

Effect of mandated nurse-patient ratios on patient wait time and care time in the emergency department.

OBJECTIVES: The objective was to evaluate the effect of mandated nurse-patient ratios (NPRs) on emergency department (ED) patient flow. METHODS: Two institutions implemented an electronic tracking system embedded within the electronic medical record (EMR) of two EDs (an academic urban, teaching medical center-Hospital A; and a suburban community hospital-Hospital B), with a combined census of 60,000/year, to monitor real-time NPRs and patient acuity, such that compliance with state-mandated ratios could be prospectively monitored. Data were queried for a 1-year period after implementation and included patient wait times (WTs), ED care time (EDCT), patient acuity, ED census, and NPR status for each nurse, patient, and the ED overall. Median WT and EDCT with interquartile ranges (IQRs) were analyzed to determine the effect of NPR status of each patient, nurse, and the ED overall. To control for factors that could affect the "within the mandated ratio" and the "outside of the mandated ratio" status, including patient volume and acuity, log-linear regression models were used controlling for specified factors for each hospital facility and combined. RESULTS: There were a total of 30,404 (50.9%) patients who waited in the waiting room prior to being placed in an ED bed (53.8% at Hospital A and 46.4% at Hospital B). Patients who waited at Hospital A waited a median duration of 55 minutes (IQR = 15-128 minutes), compared with 32 minutes (IQR = 12-67 minutes) at Hospital B with a combined median WT of 44 minutes (IQR = 13-101 minutes). In the log-linear regression analysis, WTs were 17% (95% confidence interval [CI] = 10% to 25%, p < 0.001) longer at Hospital A and 13% (95% CI = 3% to 24%, p = 0.008) longer at Hospital B (combined 16% [95% CI = 10% to 22%, p < 0.001] longer at both sites) when the ED overall was out-of-ratio compared to in-ratio. There were a total of 45,660 patients discharged from both EDs during the study period, from which EDCT data were collected (26,894 in Hospital A and 18,766 in Hospital B). Median EDCT was 184 minutes (IQR = 97-311 minutes) at Hospital A, compared to 120 minutes (IQR = 63-208 minutes) at Hospital B, for a combined median EDCT of 153 minutes (IQR = 81-269 minutes). In the log-linear regression analysis, the EDCT for patients whose nurse was out-of-ratio were 34% (95% CI = 30% to 38%, p < 0.001) longer at Hospital A and 42% (95% CI = 37% to 48%, p < 0.001) longer at Hospital B (combined 37% [95% CI = 34% to 41%, p < 0.001] longer at both sites) when compared to patients whose nurse was in-ratio. CONCLUSIONS: In these two EDs, throughput measures of WT and EDCT were shorter when the ED nurse staffing were within state-mandated levels, after controlling for ED census and patient acuity.

Impact of an express admit unit on emergency department length of stay.

BACKGROUND: Express admit units (EAUs) have been proposed as a way to expedite patient flow through the Emergency Department (ED). OBJECTIVES: We sought to determine the effect of opening a five-bed EAU unit for temporary placement of admitted patients on our ED length of stay (LOS) and waiting room times (WT). METHOD: This was a before-and-after interventional study of the 3-month period immediately before (pre-EAU) and after opening (post-EAU) of the EAU. We compared ED LOS and WT for patients admitted and discharged from the ED for both time periods, controlling for daily census and patient acuity. RESULTS: During the post-EAU period, 386 patients (26.2% of total admits) were admitted through the EAU. Overall LOS decreased from 8:21 (interquartile range [IQR] 6:02-11:20) to 7:41 (IQR 5:22-10:16) for all admitted patients (p < 0.001), and from 3:41 (IQR 2:05-5:58) to 3:35 (IQR 2:00-5:55) for the discharged patients (p = 0.025). After controlling for census and acuity, the LOS decreased an average of 10% (95% confidence interval [CI] 6%-14%; p < 0.001) for admitted patients and 4% (95% CI 2%-7%; p = 0.001) for discharged patients. These changes represented a decreased LOS of about 50 and 9 min, respectively. There were no significant differences in WT (0:44; IQR 0:09-2:07 vs. 0:50; IQR 0:11-2:20 for admitted patients and 0:41; IQR 0:09-1:50 vs. 0:41; IQR 0:10-1:47 for discharged patients). However, after controlling for census and acuity, WT decreased 9% (95% CI 1%-16%; p = 0.022) for discharged patients, which represented a decrease of about 4 min. CONCLUSIONS: With an EAU, there was a modest improvement in ED LOS despite an overall increase in daily ED volume.

Improving service quality by understanding emergency department flow: a White Paper and position statement prepared for the American Academy of Emergency Medicine.

Emergency Department (ED) crowding is a common problem in the United States and around the world. Process reengineering methods can be used to understand factors that contribute to crowding and provide tools to help alleviate crowding by improving service quality and patient flow. In this article, we describe the ED as a service business and then discuss specific methods to improve the ED quality and flow. Methods discussed include demand management, critical pathways, process-mapping, Emergency Severity Index triage, bedside registration, Lean and Six Sigma management methods, statistical forecasting, queuing systems, discrete event simulation modeling and balanced scorecards. The purpose of this review is to serve as a background for emergency physicians and managers interested in applying process reengineering methods to improving ED flow, reducing waiting times, and maximizing patient satisfaction. Finally, we present a position statement on behalf of the American Academy of Emergency Medicine addressing these issues.

Impact of an internet-based emergency department appointment system to access primary care at safety net community clinics.

STUDY OBJECTIVE: We evaluate the effect of an Internet-based, electronic referral system (termed IMPACT-ED for Improving Medical home and Primary care Access to the Community clinics Through the ED) on access and follow-up at primary care community clinics for safety net emergency department (ED) patients. METHODS: We conducted a nonblinded interventional trial at an urban, safety net, hospital ED with a census of 39,000 annually. IMPACT-ED identified patients who had no source of regular care and lived in a 15-ZIP-code low-income area served by 3 community clinics. Emergency physicians received an automated notification through the electronic medical record to access an imbedded software program for scheduling follow-up clinic appointments. Patients who would benefit from a follow-up clinic visit within 2 weeks as determined by the emergency physician received a computer-generated appointment time and clinic map with bus routes as part of their discharge instructions, and the clinics received an electronic notification of the appointment. We compared frequency of follow-up for a 6-month period before implementation when patients received written instructions to call the clinic on their own (pre-IMPACT) and 6 months after implementation (post-IMPACT). Statistical analysis was conducted with chi(2) testing, and corresponding 95% confidence intervals are presented. RESULTS: There were 326 patients who received an appointment (post-IMPACT), of whom 81 followed up at the clinic as directed (24.8%), compared with 399 patients who received a referral (pre-IMPACT), of whom 4 followed up as directed (1.0%), for an absolute improvement of 23.8% (95% confidence interval 19.1% to 28.6%). CONCLUSION: Although most patients still failed to follow up at the community clinics as directed, the use of an Internet-based scheduling program linking a safety net ED with local community clinics significantly improved the frequency of follow-up for patients without primary care.

The impact of a pneumatic tube and computerized physician order management on laboratory turnaround time.

STUDY OBJECTIVE: We assess the effect of sequential modifications in laboratory processing, including pneumatic tube transport and fully computerized order management, on laboratory turnaround time in the emergency department (ED). METHODS: This was an observational analysis of a comprehensive computerized database derived from ED, laboratory, and hospital information systems. The setting was an academic urban ED with annual census of 38,000. Participants and interventions included all patients who had laboratory testing (serum sodium level, troponin level, or CBC count) during three 1-month study periods: before pneumatic tube and computerized order management (prepneumatic tube), after pneumatic tube but before computerized order management (postpneumatic tube), and after both pneumatic tube and computerized order management (postpneumatic tube/computerized order management). The primary outcome measure was median laboratory turnaround time, reported with interquartile ranges. Additional measures included ED census and number of laboratory tests ordered during each study period. RESULTS: The monthly ED census was 3,021, 3,428, and 3,066 for the prepneumatic tube, postpneumatic tube, and postpneumatic tube/computerized order management periods. There was a significant decrease in turnaround time with each period and each test over time. For serum sodium testing, the median laboratory turnaround time decreased from 55.9 to 46.7 to 37.2 minutes for prepneumatic tube, postpneumatic tube, and postpneumatic tube/computerized order management periods. For CBC-count testing, median times decreased from 55.6 to 42.2 to 36.3 minutes, respectively. For troponin I testing, median times decreased from 52.8 to 41.8 to 30.6 minutes, respectively. CONCLUSION: Changes in laboratory specimen management, including the use of a pneumatic tube and computerized order management, resulted in a progressive decrease in laboratory turnaround time in the study ED.

Can urine dipstick be used as a surrogate for serum creatinine in emergency department patients who undergo contrast studies?

Contrast-induced nephropathy (CIN) is a complication associated with contrasted computed tomography (CT). Elevated creatinine (Cr) is often used to screen for CIN. This study evaluates dipstick urinalysis (Udip) detection of Cr > 1.5 mg/dL. If sufficiently sensitive, Udip results could then be incorporated into future rapid screening protocols for patients undergoing contrast studies. This retrospective record review evaluated all Emergency Department patients over 2 years with documented Udip and serum creatinine results. Patient demographics and pertinent past medical history were also collected. Data were collected on 2421 patient visits, with 241 having Cr > 1.5 mg/dL (9.9%). There were 923 patient visits with a negative Udip (38.1%). Sensitivity and negative predictive value for abnormal Udip in detecting elevated creatinine were 85.5% and 96.2% (p < 0.01), respectively. Thirty-five patient visits (among 26 patients) had negative urine dip and Cr > 1.5 mg/dL, but each reported at least one of the following at triage: prior renal disease, hypertension, diabetes, congestive heart failure, or age > 60 years. Udip is a sensitive screening test, but alone is not accurate enough to predict patients at potential risk for CIN (Cr > 1.5 mg/dL). However, combining Udip results with risk factor screening may allow a rapid method for predicting which patients may safely undergo contrast CT scanning in the ED, but this needs prospective evaluation.