Introduction/Objective: Triage nursing protocols have the advantages of facilitating patient care, improving patient satisfactions, and increasing the consistency of care. However, such protocols have never been tested in a randomized controlled study. Our objective was to validate computerized diagnostic ordering guidelines comparing patient satisfaction, cost and agreement with actual emergency physician ordering.

Methods: The study was conducted at an urban, inner-city teaching hospital with an annual census of 43,000. Using previously validated clinical decision rules and practice guidelines, we developed interactive computerized clinical consensus-based protocols for diagnostic test ordering of patients presenting to the Emergency Department. Based on the patients' presenting complaints, simulated test ordering of laboratory, radiological, EKG, and pulse oximetry was documented by the triage nurses. Once discharged or admitted, patient's actual orders were compared to simulated orders. Ordering physicians and computer-using nurses were blinded to the process.

Results: The protocols were validated on 357 patients (ages 1 month to 89 years) and 26-28 (93%) of physicians at our ED. All shifts and days of the week were sampled randomly. Inter-rater agreement by Coheres Kappa was 61% and statistically significant for all radiographs, EKGs, urine, and laboratory tests ordered. The rates of over-ordering for the computerized protocols were 8% (SD+4%). The guidelines corrected gender-biased, test-ordering for men by an average of $25 per patient.

Discussion: Implementation of computerized clinical practice and diagnostic ordering guidelines by nurses results in a high rate of inter-observer agreement, low rates of over-ordering, decreased cost, and Identically high patient satisfaction when compared with standard physician ordering.