A Novel Emergency Department-Based Telemedicine Program: How Do Older Patients Fare?

Differences in antibiotic prescriptions between direct-to-consumer telehealth and telehealth in the emergency department

BACKGROUND

Telemedicine, which allows physicians to assess and treat patients via real-time audiovisual conferencing, is a rapidly growing modality for providing medical care. Antibiotic stewardship is one important measure of care quality, and research on antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine has yielded mixed results. We compared antibiotic prescription rates for acute respiratory infections in two groups treated by telemedicine: (1) patients treated via a direct-to-consumer telemedicine application and (2) patients treated via telemedicine while physically inside the emergency department.

METHODS

We included direct-to-consumer telemedicine and emergency department telemedicine visits for patients 18 years and older with physician-coded International Classification of Diseases, Tenth Revision acute respiratory infection diagnoses between November 2016 and December 2018. Patients in both groups were seen by the same emergency department faculty working dedicated telemedicine shifts. We compared antibiotic prescribing rates for direct-to-consumer telemedicine and emergency department telemedicine visits before and after adjustment for age, sex, and diagnosis.

RESULTS

We identified a total of 468 acute respiratory infection visits: 191 direct-to-consumer telemedicine visits and 277 emergency department telemedicine visits. Overall, antibiotics were prescribed for 47% of visits (59% of direct-to-consumer telemedicine visits vs 39% of emergency department telemedicine visits; odds ratio 2.23; 95% confidence interval 1.53-3.25; P < 0.001). The difference in antibiotic prescribing rates remained significant after adjustment for age, sex, and diagnosis (odds ratio 2.49; 95% confidence interval 1.65-3.77; P < 0.001).

CONCLUSION

Patients seen by the same group of physicians for acute respiratory infection were significantly more likely to be prescribed antibiotics by direct-to-consumer telemedicine care compared with telemedicine care in the emergency department. This work suggests that contextual factors rather than evaluation over video may contribute to differences in antibiotic stewardship for direct-to-consumer telemedicine encounters.

Telehealth Utilization in Trauma Care: The Effects on Emergency Department Length of Stay and Associated Outcomes

INTRODUCTION

Since the onset of the Covid-19 Pandemic, Telehealth utilization has grown rapidly; however, little is known about its efficacy in specific areas of healthcare, including trauma care in the emergency department. We aim to evaluate telehealth utilization in the care of adult trauma patients within United States emergency departments and associated outcomes over the past decade.

METHODS

PubMed, Google Scholar, EMBASE, ProQuest, and Cochrane were searched for relevant articles published from database conception to Dec 12th, 2022. Our review includes studies that assessed the utilization of telehealth practices within a United States emergency department for the treatment of adult (age ≥ 18) trauma patients. Evaluated outcomes included emergency department length of stay, transfer rates, cost incurred to patients and telehealthimplementing hospitals, patient satisfaction, and rates of left without being seen.

RESULTS

A total of 11 studies, evaluating 59,319 adult trauma patients, were included in this review. Telehealth practices resulted in comparable or reduced emergency department length of stay for trauma patients admitted to the emergency department. Costs incurred to the patient and rates of leaving without being seen were significantly reduced following telehealth implementation. There was no difference in transfer rates or patient satisfaction for telehealth practices compared to in-person treatment.

CONCLUSION

Emergency department telehealth utilization significantly reduced trauma patient care-related costs, emergency department length of stay, and rates of leaving without being seen. No significant differences were found in patient transfer rates, patient satisfaction rates, or mortality rates following emergency department telehealth utilization.

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes

BACKGROUND

Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management.

OBJECTIVE

Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries.

METHODS

We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center.

RESULTS

A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia.

CONCLUSIONS

Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

Telemedicine Use by Older Adults in a COVID-19 Epicenter

Background

In early 2020, New York City was the epicenter of the Coronavirus disease 2019 (COVID-19) pandemic in the United States. Older adults were at especially high risk. Telemedicine (TM) was used to shift care from overburdened emergency departments (EDs) to provide health care to a community in lockdown. TM options presented unique challenges to our diverse older adult population, including visual, hearing, cognitive, and language limitations.

Objective

Our objective was to evaluate the use of TM during the peak of the pandemic in New York City.

Methods

We conducted a retrospective chart review of patients 65 years and older evaluated remotely via TM during our pandemic surge. Chart extraction was performed by six emergency physicians. Outcomes included demographics, technical limitations, rates of ED referral, and 30-day mortality.

Results

During the study period, a total of 140 encounters were reviewed. The mean age was 73 years. Overall, 20% of patients in the cohort were emergently referred to the ED. Use of TM by this age cohort increased 20-fold as compared with a similar time frame pre-pandemic. ED referral was highest in those over 75 (45.9% > 75 years). Forty-three percent used family to assist. Thirty-day mortality was 7%.

Conclusion

TM use by older adults grew substantially at our institution during our initial COVID-19 surge. The same-day emergent referral rate and mortality rate reflect the high acuity represented in this cohort and points to the need for telehealth providers that are trained in triage and emergency medicine with a knowledge of local resource availability.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Use of telehealth for HIV care in Italy: Are doctors and patients on the same page? A cross-sectional study

BACKGROUND

The COVID-19 pandemic has changed outpatient clinical practice, which has led to the need defining digital healthcare modalities to provide telehealth services. The aim of our study was to explore opinions about HIV management via telehealth in a representative, southern central Italian cohort of individuals with HIV (PLWH) and doctors involved in the treatment process.

METHODS

We enrolled 80 PLWH who have never used telehealth tools and 60 doctors, who administered an anonymous self-report questionnaire to investigate their opinions about telehealth service use.

RESULTS

Most of the doctors and patients indicated that they would use telehealth services; however, 88.3% of the doctors and 40% of the PLWH did not want to substitute personal visits with telehealth services. Unlike PLWH, physicians seemed to agree with most of the possible risks of telehealth, such as patients' isolation from the hospital system (71.7%), interaction difficulty (46.7%) and lower quality of patient assessment (63.3%). The doctors focused on the qualitative aspects of telehealth services reducing patients' exposure to stigma (61.7%), improving quality of patient care (41.7%), and improving privacy (58.3%). By contrast, patients focused on the quantitative aspects of telehealth services improving timely access to care (44%), time saving (63%) and improving interaction with doctor (43%).

CONCLUSIONS

Both PLWH (especially older patients and those with longer experience of disease management) and doctors welcome the use of telehealth services but disagree using it to substitute medical consultation in person focusing on different possible benefits and risks of telehealth depending on the needs expressed. Thus, our results suggest the need to initiate and expand communication about telehealth between doctors and patients.

Telehealth dashboard: leverage reporting functionality to increase awareness of high-acuity emergency department patients across an enterprise practice

BACKGROUND

Emergency Medicine Telehealth (TeleEM) represents an opportunity to work directly with referral centres, rural facilities and underserved areas to mitigate unnecessary testing, optimise resource utilisation and facilitate patient transfers across health systems. To optimise the impact of a TeleEM programme, a tool is needed to remotely monitor patient activity in multiple emergency department facilities, concurrently.

METHODS

After identifying data sources for activation criteria put forth by the TeleEM operations group, rules were constructed within the electronic health record to facilitate data checks and ultimately produce a yes/no response if the category's conditions were met. Responses were organised into a table, with functionality allowing end users to drill into the different sites to see patient-specific information for patients meeting activation criteria.

CONCLUSIONS

The TeleEM dashboard allows for proactive engagement by the TeleEM physician and strengthens the team-based approach of critically ill.