A Randomized Trial of Computer Kiosk–expedited Management of Cystitis in the Emergency Department

Abstract

Objectives: The objective was to assess the efficiency and safety of an interactive computer kiosk module for the management of uncomplicated urinary tract infections (UTI) in emergency departments (EDs).Methods: This was a prospective unblinded randomized trial. Women age 18 to 64 years seeking care for suspected UTI in three urban EDs were referred to a computer kiosk after triage. The kiosk evaluated women for uncomplicated UTI (based on patient report of at least one irritable voiding symptom within 7 days and absence of complicating features), and eligible patients were randomized to expedited management or usual ED care. Expedited management consisted of a brief clinician encounter to confirm computer kiosk responses and selection of one of four standard antibiotic regimens. Study outcomes included urine culture results, duration of ED visit, time to illness resolution, return visits, and satisfaction with care.Results: Seventeen percent (n = 103) of 624 participants with suspected UTI fulfilled uncomplicated criteria and were randomized. Sixty-nine percent of these women had a positive urine culture. 2,3 One approach to reduce crowding has been to reroute patients with low-acuity illnesses to primary care clinics. 4 However, this approach has not had a significant effect on the problem for a variety of reasons-one being limited access to primary care for underserved patient populations, such as those seeking care at safety net EDs. 5A computer kiosk module for expedited management of UTIs was found to be accurate, acceptable, and safe in an urgent care clinic setting.6 However, it is unclear whether the technology is suitable for the ED or whether these findings can be generalized to the ED, an often chaotic environment where care is more complicated and the patient population is particularly diverse. If successful in the ED, computer kioskexpedited management of low-acuity illnesses could be an important tool in efforts to improve efficiency of care, reduce ED wait times, and ease crowding.Our aim was to assess the efficiency and safety of kiosk management for women presenting to the ED with symptoms of UTI compared with usual (traditional)

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department

“…Huppert et al (5) found that only 26% of adolescent women presenting to the ED with urinary symptoms had a positive urine culture. Even in a selected group of women presenting to several EDs with a history of UTI, irritable-voiding symptoms, and absence of vaginitis and complicating factors, a group comprising only 17% of the women presenting with suspected UTIs, Stein et al (20) found that only 69% had a positive urine culture. Other etiologies of traditional UTI symptoms without vaginal symptoms would include infection with herpes simplex virus, other viruses, Mycoplasma genitalium, and Ureaplasma urealyticum, as well as noninfectious causes such as vaginal atrophy, urethral trauma during sexual intercourse or other physical activity, sensitivity to topical perianal products, nephrolithiasis, and psychogenic conditions (21).…”

Benefit or burden? A sociotechnical analysis of diagnostic computer kiosks in four California hospital emergency departments

“…This includes an acknowledgment that success and failure are socially negotiated e and often contested e categories (Berg, 2001). In the case of the kiosk, the researchers considered the study a success, and they published a report suggesting that the kiosk "accurately, efficiently, and safely expedited the management of women with uncomplicated UTI in a busy, urban ED" (Stein et al, 2011). ED staff, on the other hand, generally considered the kiosk to be a failure, and their "triage" of the kiosk resulted in the device's being "unplugged" at all but the home site by the end of the study.…”

“…Results of a randomized trial at three of the four EDs confirmed the accuracy of the kiosk algorithm's diagnosis and treatment recommendations, and demonstrated that it reduced wait time among women who received kiosk-assisted services (Stein et al, 2011). However, attempts to integrate the kiosks into routine practice encountered unexpected difficulties at all sites, including uneven recruitment patterns, staff resistance, and lower than anticipated patient eligibility for kiosk-assisted services.…”

“…According to the kiosk study's findings, women with suspected UTIs who received kiosk-assisted services had a median visit duration of 89 min, compared with 146 min among patients with suspected UTIs receiving usual care (Stein et al, 2011). Notably, however, this measured reduction in wait time did not account for ED staff efforts to manage the kiosk and its users, including both eligible and ineligible patients.…”

“…Patients who interacted with the kiosk were asked a series of questions with yes/ no and multiple-choice answers. See Stein et al (2011) for a more complete description of the algorithm, patient eligibility criteria, wording of questions, and screen design.…”