EDTITRATE (Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency)

Telemedicine in the emergency department: an overview of systematic reviews

AIM

There is both favorable and controversial evidence on the application of telemedicine in the emergency department (ED), which has created uncertainty regarding the effectiveness of these systems. We performed a systematic review of the literature on systematic reviews to provide an overview of the benefits and challenges to the application of telemedicine systems for the ED.

SUBJECT AND METHODS

PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar databases were explored for systematic reviews of telemedicine applications for the ED. Each review was critically appraised by two authors for data items to be extracted and evaluated. The most highly recommended technology, feasibility, benefits, and challenges to the application of telemedicine systems were studied and reported.

RESULTS

We identified 18 studies of varying methodological quality and summarized their key findings. Form these 18 studies, 12 papers yielded a high risk of bias in their investigation. Nine papers concluded that real-time video conferencing was the best method of delivery, eight papers found cost reduction as an outcome of implementing these systems, and six studies found technical and infrastructure issues as a challenge when implementing telemedicine for EDs.

CONCLUSION

There is strong evidence suggesting that the use of telemedicine positively impacts patient care. However, there are many challenges in implementing telemedicine that may impede the process or even impact patient safety. In conclusion, despite the high potential of telemedicine systems, there is still a need for better quality of evidence in order to confirm their feasibility in the ED.

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.

Emergency physician perspectives on using telehealth with older adults during COVID-19: A qualitative study

OBJECTIVES

Emergency medicine physicians have played a pivotal role throughout the coronavirus disease 19 (COVID-19) pandemic through in-person and remote management and treatment. Our primary objectives were to understand emergency medicine physicians' experiences using telehealth throughout the pandemic, any facilitators/barriers to successful usage, lessons learned during implementation, and successful/abandoned strategies used to engage with older adults.

METHODS

Using a semi-structured interview guide, we conducted 30-min interviews. We used purposeful sampling to recruit emergency medicine physicians from all United States regions, rural-urban settings, and academic and community practices, who reported caring for patients 65 years or older in-person or virtually during the pandemic. Interviews were audio-recorded, transcribed, double-coded, and analyzed for emergent themes using framework analysis.

RESULTS

A total of 15 in-depth interviews were completed from September to November 2020. Physicians had a median age of 37 years, 7 were women, and 9 had experience with telehealth before the pandemic. We identified several themes: (1) there were various motivations for telehealth use; (2) telehealth was used primarily to supplement, not replace in-person care; (3) most platforms were easy to use; (4) patients and caregivers had high acceptability of telemedicine; and (5) older adults with sensory and cognitive impairments often relied on caregivers. Emergency medicine physicians played a critical role during primary care office closures during the first wave-dispelling misinformation about COVID-19, triaging patients to testing and treatment, and providing care that would otherwise have been deferred.

CONCLUSIONS

Our data show that telemedicine gained acceptability among emergency medicine physicians and provided options to patients who may have otherwise deferred care. These findings can inform future healthcare delivery for acute care needs or pandemic responses.

Telehealth use in emergency care during coronavirus disease 2019: a systematic review

OBJECTIVE

The coronavirus disease 2019 pandemic has presented emergency departments (EDs) with many challenges to address the acute care needs of patients. Many EDs have leveraged telehealth to innovatively respond to these challenges. This review describes the landscape of telehealth initiatives in emergency care that have been described during the coronavirus disease 2019 pandemic.

METHODS

We conducted a comprehensive, systematic review of the literature using PubMed, supplemented by a review of the gray literature (ie, non-peer reviewed), with input from subject matter experts to identify telehealth initiatives in emergency care during coronavirus disease 2019. We categorized types of telehealth use based on purpose and user characteristics.

RESULTS

We included 27 papers from our review of the medical literature and another 8 sources from gray literature review. The vast majority of studies (32/35) were descriptive in nature, with the additional inclusion of 2 cohort studies and one randomized clinical trial. There were 5 categories of ED telehealth use during the pandemic: (1) pre-ED evaluation and screening, (2) within ED (including as a means of limiting staff and patient exposure and facilitating consultation with specialists), (3) post-ED discharge monitoring and treatment, (4) educating trainees and health care workers, and (5) coordinating resources and patient care.

CONCLUSION

Telehealth has been used in a variety of manners during the coronavirus disease 2019 pandemic, enabling innovation in emergency care delivery. The findings from this study can be used by institutions to consider how telehealth may address challenges in emergency care during the coronavirus disease 2019 pandemic and beyond. Because few studies included cost data and given the variability in institutional resources, how organizations implement telehealth programs will likely vary. Future work should further explore barriers and facilitators of innovation, and the impact on care delivery and patient outcomes.

The Implementation of an Emergency Medicine Telehealth System During a Pandemic

Background

In March of 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19)—a disease caused by a novel coronavirus—a pandemic, and it continued to spread rapidly in the community. Our institution implemented an emergency medicine telehealth system that sought to expedite care of stable patients, decrease provider exposure to COVID-19, decrease overall usage rate of personal protective equipment, and provide a platform so that infected or quarantined physicians could continue to work. This effort was among the first to use telehealth to practice emergency medicine in the setting of a pandemic in the United States.

Discussion

Outside the main emergency departments at each of 2 sites of our academic institution, disaster tents were erected with patient care equipment and medications, as well as technology to allow for telehealth visits. The triage system was modified to appropriately select low-risk patients with symptoms suggestive of COVID-19 who could be seen in these disaster tents. Despite some issues that needed to be addressed, such as provider discomfort, limited medication availability, and connectivity problems, the model was successful overall.

Conclusions

Other emergency departments might find this proof of concept article useful. Telehealth will likely be used more broadly in the future, including emergency care. It is imperative that the health care system continues to adapt to respond appropriately to challenges such as pandemics.

Attitudes of the Public to Receiving Medical Care during Emergencies through Remote Physician-Patient Communications

Providing health services through remote communications for sub-acute health issues during emergencies may help reduce the burden of the health care system and increase availability of care. This study aimed to investigate the attitudes of the public towards receiving medical services and providing medical information through remote communication in times of emergencies. During the pandemic outbreak of the novel coronavirus (COVID-19), pandemic outbreak, 507 participants answered a structured online survey, rating their mean willingness to receive medical care and provide medical information, on a four-point Likert scale. Furthermore, demographic characteristics, social media use, and trust in data protection was collected. The mean willingness to receive medical services was 3.1 ± 0.6 and the mean willingness to provide medical information was 3.0 ± 0.7, with a strong significant correlation between the two (r = 0.76). The multiple regression model identified higher trust in data protection, level of education, and social media use as statistically significant predictors for a higher willingness to receive medical information while the first two predicted willingness to provide information. The findings suggest an overall positive attitude to receive medical care through remote communications.

Emergency Department Operations: An Overview

Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.

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.

Use of Telemedicine to Screen Patients in the Emergency Department: Matched Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine

BACKGROUND

Early efforts to incorporate telemedicine into Emergency Medicine focused on connecting remote treatment clinics to larger emergency departments (EDs) and providing remote consultation services to EDs with limited resources. Owing to continued ED overcrowding, some EDs have used telemedicine to increase the number of providers during surges of patient visits and offer scheduled "home" face-to-face, on-screen encounters. In this study, we used remote on-screen telemedicine providers in the "screening-in-triage" role.

OBJECTIVE

This study aimed to compare the efficiency and patient safety of in-person screening and telescreening.

METHODS

This cohort study, matched for days and proximate hours, compared the performance of real-time remote telescreening and in-person screening at a single urban academic ED over 22 weeks in the spring and summer of 2016. The study involved 337 standard screening hours and 315 telescreening hours. The primary outcome measure was patients screened per hour. Additional outcomes were rates of patients who left without being seen, rates of analgesia ordered by the screener, and proportion of patients with chest pain receiving or prescribed a standard set of tests and medications.

RESULTS

In-person screeners evaluated 1933 patients over 337 hours (5.7 patients per hour), whereas telescreeners evaluated 1497 patients over 315 hours (4.9 patients per hour; difference=0.8; 95% CI 0.5-1.2). Split analysis revealed that for the final 3 weeks of the evaluation, the patient-per-hour rate differential was neither clinically relevant nor statistically discernable (difference=0.2; 95% CI -0.7 to 1.2). There were fewer patients who left without being seen during in-person screening than during telescreening (2.6% vs 3.8%; difference=-1.2; 95% CI -2.4 to 0.0). However, compared to prior year-, date-, and time-matched data on weekdays from 1 am to 3 am, a period previously void of provider screening, telescreening decreased the rate of patients LWBS from 25.1% to 4.5% (difference=20.7%; 95% CI 10.1-31.2). Analgesia was ordered more frequently by telescreeners than by in-person screeners (51.2% vs 31.6%; difference=19.6%; 95% CI 12.1-27.1). There was no difference in standard care received by patients with chest pain between telescreening and in-person screening (29.4% vs 22.4%; difference=7.0%; 95% CI -3.4 to 17.4).

CONCLUSIONS

Although the efficiency of telescreening, as measured by the rate of patients seen per hour, was lower early in the study period, telescreening achieved the same level of efficiency as in-person screening by the end of the pilot study. Adding telescreening during 1-3 am on weekdays dramatically decreased the number of patients who left without being seen compared to historic data. Telescreening was an effective and safe way for this ED to expand the hours in which patients were screened by a health care provider in triage.

The durability of operational improvements with rotational patient assignment

INTRODUCTION

Previous work has suggested that Emergency Department rotational patient assignment (a system in which patients are algorithmically assigned to physicians) is associated with immediate (first-year) improvements in operational metrics. We sought to determine if these improvements persisted over a longer follow-up period.

METHODS

Single-site, retrospective analysis focused on years 2-4 post-implementation (follow-up) of a rotational patient assignment system. We compared operational data for these years with previously published data from the last year of physician self-assignment and the first year of rotational patient assignment. We report data for patient characteristics, departmental characteristics and facility characteristics, as well as outcomes of length of stay (LOS), arrival to provider time (APT), and rate of patients who left before being seen (LBBS).

RESULTS

There were 140,673 patient visits during the five year period; 138,501 (98.7%) were eligible for analysis. LOS, APT, and LBBS during follow-up remained improved vs. physician self-assignment, with improvements similar to those noted in the first year of implementation. Compared with the last year of physician self-assignment, approximate yearly average improvements during follow-up were a decrease in median LOS of 18min (8% improvement), a decrease in median APT of 21min (54% improvement), and a decrease in LBBS of 0.69% (72% improvement).

CONCLUSION

In a single facility study, rotational patient assignment was associated with sustained operational improvements several years after implementation. These findings provide further evidence that rotational patient assignment is a viable strategy in front-end process redesign.