CORRESPONDENCE
Expediting Emergency Throughput: Kiosk-assisted Care and Telephone Treatment Protocols To the Editor: 1
I read with great interest the excellent study by Stein et al., showing that a novel use of kiosk-assisted management of women with uncomplicated cystitis can lead to a reduction in emergency department (ED) length of stay. Better still, their sizable time savings was accomplished without compromise to patient safety or satisfaction. The authors are to be commended for introducing to emergency medicine an assessment tool that may well help accelerate patient throughput, a welcome improvement in these days of increasing ED congestion and crowding. Published telephone treatment protocols for cystitis provided the framework for the investigators’ eligibility criteria. And this makes sense. Low-risk ambulatory medical conditions that are diagnosed principally by history without dependence on physical examination and laboratory analysis—that is, the conditions that health maintenance organization call center nurses treat over the phone—are the very ones that lend themselves to kioskassisted care. The interactive ED kiosk and the specially trained call center nurse provide a similar kind of patient assessment. Both guide the symptomatic patient through a structured, step-by-step interview to ascertain eligibility for expedited management. Both rely on the strength of their exclusion criteria to weed out patients with overlapping symptoms but different diagnoses (e.g., vaginitis) as well as those with more complicated versions of urinary tract infection (UTI; e.g., early pyelonephritis). Both then transfer their assessment to a prescribing physician who, if in agreement with the plan for expedited care, can select the most appropriate treatment. It is understandable that a groundbreaking study like this would err on the side of cautious safety by adopting more conservative inclusion criteria. But now that their proof-of-concept is established, the authors could expand the breadth of their eligibility net. Consider those over 64 years of age, who in this study were not even referred for kiosk care. In 2010 our call center nurses and physicians treated over the telephone 54,226 women with presumed cystitis, 6,452 (11.9%) of whom were at least 65 years old.2 In a retrospective study of the effectiveness and safety of this approach among 4,177 women aged 16 to 97 years, The authors have no commercial, financial, and other relationships that might create any potential conflict of interest.
ª 2012 by the Society for Academic Emergency Medicine
we found that those over the age of 70 years did quite well, almost as well, in fact, as their younger counterparts. Postmenopausal women are known to have an increased incidence of UTI.3 Our study found that expedited care put them at no greater risk for adverse outcomes and was associated with a comparable recurrence rate with that found with office-based management.4 Kiosk care could also expand to include other conditions that have been safely managed over the telephone. We have in play several telephone treatment protocols that easily could be adapted for kiosk-assisted care, including those for expedited management of the common cold, simple bronchitis, uncomplicated sinusitis, and seasonal influenza.5 I hope this study by Stein et al. provides the impetus for future research in kiosk-assisted care. And once the kiosk ‘‘conversation’’ is uploadable to the electronic health record, this new tool will find even greater uptake among the emergency medicine community. doi: 10.1111/j.1553-2712.2012.01308.x
David R. Vinson, MD (
[email protected]) Emergency Department Kaiser Permanente Roseville Medical Center Roseville, CA Supervising Editor: Jeffery Kline, MD. References 1. Stein JC, Navab B, Frazee B, et al. A randomized trial of computer kiosk-expedited management of cystitis in the emergency department. Acad Emerg Med. 2011; 18:1053–9. 2. Vinson DR, Quesenberry CP Jr. The safety of telephone management of presumed cystitis in women. Arch Intern Med. 2004; 164:1026–9. 3. Foxman B. Urinary tract infection in postmenopausal women. Curr Infect Dis Rep. 1999; 1:367–70. 4. Vinson DR, Quesenberry CP Jr. Telephone management of presumed cystitis in women: factors associated with recurrence. J Clin Outcomes Manage. 2007; 14:41–6. 5. Chaudhry R, Stroebel RJ, McLeod TG, et al. Nursebased telephone protocol versus usual care for management of URI and acute sinusitis: a controlled trial. Manag Care Interface. 2006; 19:26–31.
ISSN 1069–6563 PII ISSN 1069–6563583
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