Optimization of Pregnancy Testing in the University of Virginia Emergency Department

Internal quality improvement data from the University of Virginia Emergency Department (UVA ED) identified frequent ordering of serum quantitative human chorionic gonadotropin testing (hCG) without clear indications for ectopic pregnancy or miscarriage. Despite rapid bedside processing, point-of-care (POCT) urine testing had the longest order-to-result time, likely reflecting inefficiencies in urine collection. Serum qualitative hCG was the most efficient and cost-effective ($85), followed by POCT urine ($207), and serum quantitative hCG ($279). In response, staff education and modifications to electronic health record (EHR) order sets were implemented to promote serum qualitative hCG. This study evaluated the impact of these interventions on pregnancy test ordering patterns, efficiency, and cost.

This retrospective analysis examined pregnancy tests in the UVA ED over two periods: July 1, 2024 to June 30, 2025 (pre-intervention, n = 7704), and September 1 to November 30, 2025 (post-intervention, n = 2473). Primary outcomes included order-to-result time, cost, and appropriateness of serum quantitative hCG use based on primary chief complaint (abdominal pain, vaginal bleeding, miscarriage) and/or ultrasound use. Cost data were obtained from the UVA Health Master Price List.

Serum quantitative hCG orders lacking appropriate indication decreased from 42.3% to 28.6% following intervention (Δ13.7 percentage points (pp), p < 0.001). Use of serum qualitative hCG testing increased from 8.0% to 54.5% of total pregnancy tests (Δ46.5 pp, p < 0.001), while POCT urine testing decreased from 72.0% to 35.2% (Δ36.8 pp, p < 0.001) and serum quantitative hCG testing decreased from 20.0% to 10.3% (Δ9.7 pp, p < 0.001). Order-to-result times for serum hCG testing remained at 80 minutes, whereas POCT urine testing improved from 92 to 78 minutes (Δ14 minutes, p < 0.001). Using a weighted average based on test utilization, mean cost per test decreased from $211.64 to $147.93, yielding $63.71 in patient-facing savings per test (30.1% reduction).

Departmental education and changes to EHR order sets were associated with increased use of serum qualitative hCG testing and reduced unnecessary quantitative testing, with downstream cost savings. Additionally, POCT urine turnaround times decreased, suggesting improved workflow efficiency with greater use of serum-based testing.