The purpose of the randomized study, conducted by researchers from the University of California at San Francisco (UCSF), was to determine the efficacy and safety of using computer kiosks in emergency departments (EDs) to expedite workflow and shorten waiting times for patients. Three EDs in California participated in the trial, following a successful pilot of the kiosk strategy at an urgent care center, involving women with uncomplicated urinary tract infections (UTIs).
Women who presented at the EDs with UTI symptoms were asked to provide a urine sample, then go to the kiosks and fill out online questionnaires. In the process, the computer randomized the patients who met criteria for uncomplicated UTI into either a control or study group. Patients who were selected for the study group immediately received an antibiotic prescription and instructions and were sent home. The control group of patients had to remain in the waiting room after using the kiosk until an emergency physician could see them.
Of the participants, 17% met the criteria for uncomplicated UTI and were randomized to either group, and 69% of these women had a positive urine culture for UTI. The median amount of time spent in the ED was 89 minutes for the study group (who received expedited care), and 146 minutes for the control patients (who had to wait to see an ED doctor). Both groups had a similar time to illness resolution, number of return visits, and satisfaction with care.
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The conclusion of the study, which was published last year in Academic Emergency Medicine, was: "An interactive computer kiosk accurately, efficiently, and safely expedited the management of women with uncomplicated UTI in a busy, urban ED. Expanding the use of this technology to other conditions could help to improve ED patient flow."
Recently, the California Healthcare Foundation (CHCF), which funded the study, posted a follow-up report on the foundation's website. Authored by Ralph Gonzales, MD, one of the study coauthors, and Sara Ackerman, PhD, a medical anthropologist, the report described several problems in the implementation of the kiosks.
For one thing, it turned out that the proportion of patients with suspected UTIs who were referred to the kiosks ranged from 20% to 84% at different sites.
One reason for the differences was that some triage nurses resisted referring eligible patients to the kiosks. The nurses felt that the kiosks disrupted their workflow; also, the majority of patients they referred did not receive expedited care, either because they did not have uncomplicated UTIs or because they were randomized to the control group. As a result, these nurses didn't see the point of the experiment. In addition, the machines themselves were prone to breakdowns, which made the nurses' task harder.
John Stein, MD, lead author of the Academic Emergency Medicine paper and an associate professor of emergency medicine at UCSF, doesn't believe that any of this detracts from the value of the study's conclusions. In an interview with InformationWeek Healthcare he said, "we were successful in proving the kiosks' utility. We were able to show dramatically increased efficiency in care" without sacrificing quality. Moreover, he pointed out, the results of the study have prompted two of the EDs to consider reinstating the kiosks "for regular daily care."
Despite the nurses' complaints, he maintained that the kiosks did not impede the overall ED workflow. Noting that the UTI patients were a small percentage of ED visitors, he said that during the study period "the overall rates of time to discharge and time to admission were unchanged."
The main problem with the kiosk implementation, Stein stated, was that it forced the nurses "to do something different." As for their perception that some patients were irritated if their care were not expedited, he noted that in the patient satisfaction surveys there was no difference between patients who received fast-track care and those who didn't.
Nevertheless, he added, more study in a typical ED workflow is clearly warranted because the trial was conducted in an artificial research environment. As for whether kiosks can actually shorten overall ED wait times, he said, "All we did was to show that kiosks had the potential to improve efficiency without decreasing the quality of care."
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