CLINICIAN'S CAPSULE What is known about the topic? Bed boarding is one of the major contributors to emergency department overcrowding. What did this study ask? What are the characteristics of patients with prolonged boarding times, and what are the impacts on patient-oriented outcomes? What did this study find? Patients who were older, sicker, and had isolation and telemetry requirements experienced longer boarding times, and longer inpatient length of stay even after correcting for confounders. Why does this study matter to clinicians? Organization-wide interventions to improve efficiency and flow are required to mitigate the burden of bed boarding.

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Background A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients. Objective To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA). Methods Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate. Results A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield. Conclusion This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.