The Digital Rectal Exam and the Joint Commission

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Slide 1 : The law of unintended consequences: The Joint Commission regulations and the digital rectal examination. Ann Emerg Med 2008 Feb; 51:197. Adams BD et al.
Slide 2 : Background Since 1988, hospitals have been required to centrally maintain appropriate quality-control and test records for point-of-care testing. In 2003, the Joint Commission issued even more stringent regulations, including one for bedside testing of stool for occult blood. The new regulation requires physicians to manually document in a central log each patient’s demographic information, fecal occult blood (FOB) testing card number, reagent lot number, and FOB testing quality-control test results; alternatively, physicians can send a confirmatory FOB testing card to a central laboratory.
Slide 3 : The Research We compared the incidence of digital rectal examination and FOB testing at a single academic emergency department during a 3-month period in the year before and after the new policy was implemented. We reviewed the charts of 361 patients in the period before the new policy and 427 in the period after who presented with abdominal pain, gastrointestinal bleeding, chest pain, constipation, diarrhea, or syncope/presyncope. Compared with the period before the policy was implemented, in the period after, physicians performed 17% fewer digital rectal exams (41.3% vs. 24.6%) and 19% fewer FOB tests (38.5 vs. 19.8%). Overall compliance with the new policy was 3%.
Slide 4 : Comment This simple study demonstrates that overly arduous regulations, however well-intended, might have unintended effects on patient care. The study also shows that clinicians vote with their feet (or their fingers), as demonstrated by the remarkably low rate of compliance with the policy. This policy is far more likely to put an end to bedside digital rectal examination and FOB testing than to improve its accuracy.

 


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