Overtesting and Overcare Contributes to ED Overcrowding

The more crowded it gets, the less time we spend with each patient. This may make it more likely that clinicians order more tests in an effort to make up for clinical assessments that are limited by time constraints. However, this testing leads to longer lengths of stay. Labs and radiology departments get backed up. While patients may say they have come to the emergency department for a test, a thorough history and physical with clear explanations is often as or more effective in satisfying the patient than rushing through an assessment and ordering unnecessary tests that take longer and may lead to iatrogenic harm. Emergency physicians who order more tests compared to their peers are less efficient; a lower number of patients are assessed and treated per shift without a difference in patient outcomes.²⁰

Physician-specific solutions to overtesting have been described, such as a five-step systematic approach to curb unnecessary diagnostic test ordering:

1. Decide what diagnosis is being investigated before ordering a test.
2. Determine the pretest probability of the condition in question.
3. Decide whether to rule the condition in or out.
4. Decide what will be done if the test result is positive or negative.
5. Ask whether ordering the test could harm the patient.²¹

It is important for emergency physicians to understand that patients do not have a disease but rather have a probability of a disease. Diagnostic tests are merely revisions of probabilities. The possible interpretations of a test should be considered before test ordering. If a test result leads to a revision in the probability of a disease, ask whether that will entail a change in subsequent management. If not, use of that test should be reconsidered.²²

Take the time to complete a thorough clinical assessment and provide clear, compassionate communication. Consider further investigations or referral only if they clearly improve emergency management.

Consistently minimizing overcare can be simpler than you realize and can alleviate overcrowding. Order oral medications or fluids rather than IV ones whenever possible. Consider discharging (or admitting) patients rather than keeping them in the emergency department overnight just for convenience. Removing patients from cardiac monitors can reduce alarm fatigue. Use space and resources efficiently; get patients out of ED stretchers when they are no longer indicated.

“More” or “invasive” care is not necessarily better care. Choose every intervention only after a careful risk and benefit analysis. Complete reassessments in a timely manner, before assessing new patients. Given two patients with equal acuity, attend to the patient who is likely to be moved through the emergency department more efficiently so that the bed they are occupying can be freed up for another patient. Avoid delaying uncomfortable or difficult decisions. Delegate non-ED physician tasks to nurses, porters, consultants, and other members of the team. Spending 30 minutes on a tendon laceration repair when there is a plastic surgeon on call or the repair can be delayed while there are 30 patients waiting to be seen is not an efficient use of your time. It is important to keep patient flow and situational awareness in mind constantly during the ED shift, reviewing flow-sensitive decision points before assessing the next noncritical patient.

Developing a strong sense of your mandate as an emergency physician—to diagnose acute illness rather than screen for chronic diseases and to model professional behavior to your team and colleagues—can go a long way to setting the stage for the necessary culture in your hospital that values efficient, excellent care.