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Mohr NM, Young T, Vakkalanka JP, Carter KD, Shane DM, Ullrich F, Schuette AR, Mack LJ, DeJong K, Bell A, Pals M, Camargo CA, Zachrison KS, Boggs KM, Skibbe A, Ward MM. Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments. Acad Emerg Med 2024; 31:326-338. [PMID: 38112033 DOI: 10.1111/acem.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. METHODS Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. RESULTS In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. CONCLUSIONS Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.
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Affiliation(s)
- Nicholas M Mohr
- Departments of Emergency Medicine, Anesthesia, and Epidemiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Tracy Young
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - J Priyanka Vakkalanka
- Departments of Emergency Medicine and Epidemiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Dan M Shane
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Fred Ullrich
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | | | - Luke J Mack
- Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
- Avel eCARE, Sioux Falls, South Dakota, USA
| | | | | | - Mark Pals
- Avel eCARE, Sioux Falls, South Dakota, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adam Skibbe
- Department of Geography, University of Iowa College of Liberal Arts and Sciences, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
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Alter N, Arif H, Wright DD, Martinez B, Elkbuli A. Telehealth Utilization in Trauma Care: The Effects on Emergency Department Length of Stay and Associated Outcomes. Am Surg 2023; 89:4826-4834. [PMID: 37132648 DOI: 10.1177/00031348231173944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
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.
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Affiliation(s)
- Noah Alter
- NOVA Southeastern University, Dr Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Hassan Arif
- NOVA Southeastern University, Dr Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - D-Dre Wright
- John A. Burns School of Medicine, Honolulu, HI, USA
| | - Brian Martinez
- NOVA Southeastern University, Dr Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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Boyle T, Boggs K, Gao J, McMahon M, Bedenbaugh R, Schmidt L, Zachrison KS, Goralnick E, Biddinger P, Camargo CA. Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study. JMIR Public Health Surveill 2023; 9:e44164. [PMID: 37368481 DOI: 10.2196/44164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/20/2023] [Accepted: 05/03/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response. OBJECTIVE To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response. METHODS We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability. RESULTS Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns. CONCLUSIONS Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.
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Affiliation(s)
- Tehnaz Boyle
- Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Krislyn Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Jingya Gao
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Maureen McMahon
- Department of Emergency Management, Boston Medical Center, Boston, MA, United States
| | - Rachel Bedenbaugh
- Center for Disaster Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Lauren Schmidt
- Center for Disaster Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kori Sauser Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Paul Biddinger
- Center for Disaster Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
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Okobi E, Adigun AO, Ozobokeme OE, Emmanuel O, Akinsanya PA, Okunromade O, Okobi OE, Aiwuyo HO, Dick AI, Sadiq-Onilenla RA, Ogunlana FA. Examining Disparities in Ownership and Use of Digital Health Technology Between Rural and Urban Adults in the US: An Analysis of the 2019 Health Information National Trends Survey. Cureus 2023; 15:e38417. [PMID: 37273368 PMCID: PMC10233341 DOI: 10.7759/cureus.38417] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Although research shows that digital health tools (DHT) are increasingly integrated with healthcare in the United States, very few studies have investigated the rural-urban differences in DHT adoption at the national level. Individuals in rural communities experience disproportionately greater rates of chronic diseases and face unique challenges in accessing health care. Studies have shown that digital technology can improve access and support rural health by overcoming geographic barriers to care. OBJECTIVE To evaluate the rates of ownership and preferences for utilization of DHT as a measure of interest among rural adults compared to their urban counterparts in the United States using a National Inpatient Survey. METHODS Data was drawn from the 2019 (n= 5438) iteration of the Health Information National Trends Survey (HINTS 5 cycle 3). Chi-square tests and weighted multivariable logistic regressions were conducted to examine rural-urban differences regarding ownership, usage, and use of digital health tools to interact with health care systems while adjusting for health-related characteristics and sociodemographic factors. RESULTS The ownership rates of digital health technology (DHT) devices, including tablets, smart phones, health apps, and wearable devices, were comparable between rural and urban residents. For tablets, the ownership rates were 54.52% among rural residents and 60.24% among urban residents, with an adjusted odds ratio (OR) of 0.87 (95% confidence interval {CI}: 0.61, 1.24). The ownership rates of health apps were 51.41% and 53.35% among rural and urban residents, respectively, with an adjusted OR of 0.93 (95% CI: 0.62, 1.42). For smartphones, the ownership rates were 81.64% among rural residents and 84.10% among urban residents, with an adjusted OR of 0.81 (95% CI: 0.59, 1.11). Additionally, rural residents were equally likely to use DHT in managing their healthcare needs. Both groups were equally likely to have reported their smart device as helpful in discussions with their healthcare providers (OR 0.90; 95% CI 63 - 1.30; p = 0.572). Similarly, there were similar odds of reporting that DHT had helped them to track progress on a health-related goal (e.g., quitting smoking, losing weight, or increasing physical activity) (OR 1.17; 95% CI 0.75 - 1.83; p = 0.491), and to make medical decisions (OR 1.05; 95% CI 0.70 - 1.59; p = 0.797). However, they had lower rates of internet access and were less likely to use DHT for communicating with their healthcare providers. CONCLUSION We found that rural residents are equally likely as urban residents to own and use DHT to manage their health. However, they were less likely to communicate with their health providers using DHT. With increasing use of DHT in healthcare, future research that targets reasons for geographical digital access disparities is warranted.
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Affiliation(s)
- Emeka Okobi
- Dentistry, Ahmadu Bello University Teaching Hospital Zaria, Abuja, NGA
| | - Aisha O Adigun
- Division of Infectious Diseases, University of Louisville, Louisville, USA
| | | | | | | | - Omolola Okunromade
- Public Health/Community Health Behavior & Education, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Greater Savannah Area, USA
| | - Okelue E Okobi
- Family Medicine, Medficient Health Systems, Laurel, USA
- Family Medicine, Lakeside Medical Center, Belle Glade, USA
| | - Henry O Aiwuyo
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | | | | | - Foluke A Ogunlana
- Family Medicine/General Practice, National Health Service (NHS) Foundation Trust Derbyshire, Derby, GBR
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Avila FR, Carter RE, McLeod CJ, Bruce CJ, Guliyeva G, Torres-Guzman RA, Maita KC, Ho OA, TerKonda SP, Forte AJ. The Role of Telemedicine in Prehospital Traumatic Hand Injury Evaluation. Diagnostics (Basel) 2023; 13:diagnostics13061165. [PMID: 36980474 PMCID: PMC10047211 DOI: 10.3390/diagnostics13061165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/11/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Unnecessary ED visits and transfers to hand clinics raise treatment costs and patient burden at trauma centers. In the present COVID-19 pandemic, needless transfers can increase patients' risk of viral exposure. Therefore, this review analyzes different aspects of the remote diagnosis and triage of traumatic hand injuries. The most common file was photography, with the most common devices being cell phone cameras. Treatment, triage, diagnosis, cost, and time outcomes were assessed, showing concordance between teleconsultation and face-to-face patient evaluations. We conclude that photography and video consultations are feasible surrogates for ED visits in patients with traumatic hand injuries. These technologies should be leveraged to decrease treatment costs and potentially decrease the time to definitive treatment after initial evaluation.
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Affiliation(s)
- Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Rickey E Carter
- Department of Quantitative Health Sciences, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Christopher J McLeod
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Charles J Bruce
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Gunel Guliyeva
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | | | - Karla C Maita
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Olivia A Ho
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Sarvam P TerKonda
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
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Siu M, Dan J, Cohen J, Carey Y, Alouidor R, Kramer K, Kamine TH. Impact of Telemedicine on Extended Focused Assessment With Sonography for Trauma Performance and Workload by Critical Care Transport Personnel. Air Med J 2023; 42:105-109. [PMID: 36958873 DOI: 10.1016/j.amj.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/27/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION There are currently no reports on whether telementoring for extended focused assessment with sonography for trauma (eFAST) improves critical care transport providers' performance in prehospital settings. Our objective was to determine the impact of teleguidance on eFAST performance and quantify workload experience. METHODS Eight trauma injury modules were selected on simulated patients. Critical care transport (CCT) providers were tasked to complete one independent and one emergency physician-telementored eFAST. The time to completion and the percent of correct findings were obtained. Participants completed the NASA Task Load Index after each iteration to assess workload. RESULTS Eight independent and 8 telementored eFASTs were completed. The mean times to complete the independent and telementored eFAST were 5 minutes 16 seconds (95% confidence interval [CI], 3 minutes 32 seconds, 6 minutes 59 seconds) and 8 minutes 27 seconds (95% CI, 5 minutes 14 seconds, 11 minutes 39 seconds), respectively (P = .06). The percentage of correctly identified injuries for the independent versus the teleguided eFAST was 65% versus 92.5% (P = .01). The CCT providers experienced higher mental (P = .004), temporal (P = .01), and effort (P = .004) demands; greater frustration (P = .001); and subjective lower performance (P = .003) during independent trials. The emergency physician experienced higher mental (P = .001), temporal (P = .02), effort (P = .005), and frustration (P = .001) demands than the CCT members. CONCLUSION The teleguided eFAST yielded higher accuracy than the independent eFAST. The CCT providers relied on teleguidance of the remote physician when performing the eFAST. Teleguidance may improve the accuracy of ultrasounds performed by prehospital personnel in real-life scenarios.
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Affiliation(s)
- Margaret Siu
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA.
| | - Jeffrey Dan
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
| | - Jason Cohen
- Boston MedFlight, Bedford, MA; Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA
| | - Yamuna Carey
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA; Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
| | - Reginald Alouidor
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA; Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
| | - Kristina Kramer
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA; Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
| | - Tovy Haber Kamine
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA; Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA; Department of Healthcare Policy and Population Science, University of Massachusetts Chan Medical School, Worcester, MA
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Mohr NM, Okoro U, Harland KK, Fuller BM, Campbell K, Swanson MB, Wymore C, Faine B, Zepeski A, Parker EA, Mack L, Bell A, DeJong K, Mueller K, Chrischilles E, Carpenter CR, Wallace K, Jones MP, Ward MM. Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study. Ann Emerg Med 2023; 81:1-13. [PMID: 36253295 PMCID: PMC9780149 DOI: 10.1016/j.annemergmed.2022.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/07/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). METHODS Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. RESULTS A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). CONCLUSION Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.
| | - Uche Okoro
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
| | - Kalyn Campbell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Surgery, Hennepin County Medical Center, Minneapolis, MN
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Cole Wymore
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brett Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Pharmaceutical Practice, College of Pharmacy, University of Iowa, Iowa City, IA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Edith A Parker
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, IA
| | - Luke Mack
- Avel eCare, Sioux Falls, SD; Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD
| | | | | | - Keith Mueller
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | | | | | - Kelli Wallace
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
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Totten AM, Womack DM, Griffin JC, McDonagh MS, Davis-O'Reilly C, Blazina I, Grusing S, Elder N. Telehealth-guided provider-to-provider communication to improve rural health: A systematic review. J Telemed Telecare 2022:1357633X221139892. [PMID: 36567431 DOI: 10.1177/1357633x221139892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare. METHODS We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes. RESULTS Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples. DISCUSSION Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.
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Affiliation(s)
| | - Dana M Womack
- Oregon Health & Science University, Portland, OR, USA
| | | | | | | | - Ian Blazina
- Oregon Health & Science University, Portland, OR, USA
| | - Sara Grusing
- Oregon Health & Science University, Portland, OR, USA
| | - Nancy Elder
- Oregon Health & Science University, Portland, OR, USA
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Vakkalanka JP, Nataliansyah MM, Merchant KAS, Mack LJ, Parsons S, Mohr NM, Ward MM. Telepsychiatry services across an emergency department network: A mixed methods study of the implementation process. Am J Emerg Med 2022; 59:79-84. [PMID: 35810736 DOI: 10.1016/j.ajem.2022.06.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Due to limited community resources for mental health and long travel distances, emergency departments (EDs) serve as the safety net for many rural residents facing crisis mental health care. In 2019, The Leona M. and Harry B. Helmsley Charitable Trust funded a project to establish and implement an ED-based telepsychiatry service for patients with mental health issues in underserved areas. The purpose of this study was to evaluate the implementation of this novel ED-based telepsychiatry service. METHODS This was a mixed-methods study evaluating the new ED-based telepsychiatry consult service implemented in five EDs across three rural states that participated within a mature hub-and-spoke telemedicine network between June 2019 and December 2020. Quantitative evaluation in this study included characteristics of the telehealth encounters and the patient population for whom this service was used. For qualitative assessments, we identified key themes from interviews with key informants at the ED spokes to assess overall facilitators, barriers, and impact. Integrating the quantitative and qualitative findings, we explored emergent phenomena and identified insights to provide a comprehensive perspective of the implementation process. RESULTS There were 4130 encounters for 3932 patients from the EDs during the evaluation period. Approximately 54% of encounters involved female patients. The majority of patients seen were white (51%) or Native American (44%) reflecting the population of the communities where the EDs were located. Among the indications for the telepsychiatry consult, the most frequently identified were depression (28%), suicide/self-harm (17%), and schizophrenia (12%). Across sites, 99% of clinician-to-clinician consults were by phone, and 99% of clinical assessments/evaluations were by video. The distribution of encounters varied by the day of the week and the time of day. Facilitators for the service included increasing need, a supportive infrastructure, a straightforward process, familiarity with telemedicine, and a collaborative relationship. Barriers identified by respondents at the sites included the lack of clarity of process and technical limitations. The themes emerging from the impact of the telepsychiatry consultation in the ED included workforce improvement, care improvement, patient satisfaction, cost-benefit, facilitating COVID care, and access improvement. CONCLUSIONS Implementation of a telepsychiatry service in ED settings may be beneficial to the patient, local ED, and the underserved community. In this study, we found that implementing this service alleviated the burden of care during the COVID-19 pandemic, enhanced local site capability, and improved local ability to provide quality and effective care.
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10
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Mohr NM, Schuette AR, Ullrich F, Mack LJ, DeJong K, Camargo CA, Zachrison KS, Boggs KM, Skibbe A, Bell A, Pals M, Shane DM, Carter KD, Merchant KA, Ward MM. An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study. J Comp Eff Res 2022; 11:703-716. [PMID: 35608080 DOI: 10.2217/cer-2022-0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa College of Medicine, Iowa City, IA 52242, USA.,Department of Anesthesia, Division of Critical Care, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Allison R Schuette
- Department of Emergency Medicine, University of Iowa College of Medicine, Iowa City, IA 52242, USA.,Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Fred Ullrich
- Department of Health Management & Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Luke J Mack
- Avera eCARE, Sioux Falls, SD 57104, USA.,Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD 57104, USA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Adam Skibbe
- Department of Geographical & Sustainability Sciences, University of Iowa College of Liberal Arts & Sciences, Iowa City, IA 52242, USA
| | | | - Mark Pals
- Avera eCARE, Sioux Falls, SD 57104, USA
| | - Dan M Shane
- Department of Health Management & Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Kimberly As Merchant
- Department of Health Management & Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Marcia M Ward
- Department of Health Management & Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
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11
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Patel SY, Huskamp HA, Barnett ML, Zubizarreta JR, Zachrison KS, Busch AB, Wilcock AD, Mehrotra A. Association Between Telepsychiatry Capability and Treatment of Patients With Mental Illness in the Emergency Department. Psychiatr Serv 2022; 73:403-410. [PMID: 34407629 PMCID: PMC8857309 DOI: 10.1176/appi.ps.202100145] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Because of limited access to psychiatrists, patients with acute mental illness in some emergency departments (EDs) may wait days for a consultation in the ED or as a medical-surgical admission. The study assessed whether telepsychiatry improves access to care and decreases ED wait times and hospital admissions. METHODS ED visits with a primary diagnosis of mental illness were identified from 2010-2018 Medicare claims. A total of 134 EDs across 22 states that implemented telepsychiatry between 2013 and 2016 were matched 1:1 with control EDs without telepsychiatry on several characteristics, including availability of in-person psychiatrist consultations. Outcomes included patients' likelihood of admission to a medical-surgical or psychiatric bed, mental illness spending, prolonged ED length of stay (LOS) (two or more midnights in the ED), 90-day mortality, and outpatient follow-up care. Using a difference-in-difference design, changes in outcomes between the 3 years before telepsychiatry adoption and the 2 years after were examined. RESULTS There were 172,708 ED mental illness visits across the 134 matched ED pairs in the study period. Telepsychiatry adoption was associated with increased admissions to a psychiatric bed (differential increase, 4.3 percentage points; p<0.001), decreased admissions to a medical-surgical bed (differential decrease, 2.0 percentage points; p<0.001), increased likelihood of a prolonged ED LOS (differential increase, 3.0 percentage points; p<0.001), and increased mental illness spending (differential increase, $292; p<0.01). CONCLUSIONS Telepsychiatry adoption was associated with a lower likelihood of admission to a medical-surgical bed but an increased likelihood of admission to a psychiatric bed and a prolonged ED LOS.
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Affiliation(s)
- Sadiq Y Patel
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
| | - Michael L Barnett
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
| | - José R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
| | - Kori S Zachrison
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
| | - Alisa B Busch
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
| | - Andrew D Wilcock
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston (Patel, Huskamp, Zubizarreta, Busch, Mehrotra); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston (Barnett); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Statistics, Harvard University, Cambridge (Zubizarreta); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Zachrison); McLean Hospital, Belmont, Massachusetts (Busch); Department of Family Medicine, University of Vermont College of Medicine, Burlington (Wilcock)
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12
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Sharifi Kia A, Rafizadeh M, Shahmoradi L. Telemedicine in the emergency department: an overview of systematic reviews. Z Gesundh Wiss 2022; 31:1-15. [PMID: 35103232 PMCID: PMC8791673 DOI: 10.1007/s10389-021-01684-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Ali Sharifi Kia
- Master of Science degree in Health Informatics, Department of Health Information Management, School of Health Management & Information Sciences, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mouna Rafizadeh
- Master of Science degree in Health Information Technology, Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Leila Shahmoradi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences (TUMS), No. 17, Farredanesh Alley, Ghods St, Enghelab Ave, Tehran, 14177-44361 Iran
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13
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Hayden EM, Davis C, Clark S, Joshi AU, Krupinski EA, Naik N, Ward MJ, Zachrison KS, Olsen E, Chang BP, Burner E, Yadav K, Greenwald PW, Chandra S. Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine. Acad Emerg Med 2021; 28:1452-1474. [PMID: 34245649 DOI: 10.1111/acem.14330] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Emily M. Hayden
- Department of Emergency Medicine Massachusetts General Hospital Boston MA USA
| | - Christopher Davis
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO USA
| | - Sunday Clark
- Department of Emergency Medicine Weill Cornell Medicine New York NY USA
| | - Aditi U. Joshi
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
| | | | - Neel Naik
- Department of Emergency Medicine Weill Cornell Medicine New York NY USA
| | - Michael J. Ward
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Kori S. Zachrison
- Department of Emergency Medicine Massachusetts General Hospital Boston MA USA
| | - Erica Olsen
- Department of Emergency Medicine Columbia UniversityCollege of Physicians and Surgeons New York NY USA
| | - Bernard P. Chang
- Department of Emergency Medicine Columbia UniversityCollege of Physicians and Surgeons New York NY USA
| | - Elizabeth Burner
- Department of Emergency Medicine Keck School of Medicine of University of Southern California Los Angeles CA USA
| | - Kabir Yadav
- Department of Emergency Medicine Harbor–UCLA Medical Center Torrance CA USA
| | | | - Shruti Chandra
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
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14
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Tsou C, Robinson S, Boyd J, Jamieson A, Blakeman R, Yeung J, McDonnell J, Waters S, Bosich K, Hendrie D. Effectiveness of Telehealth in Rural and Remote Emergency Departments: Systematic Review. J Med Internet Res 2021; 23:e30632. [PMID: 34842537 PMCID: PMC8665379 DOI: 10.2196/30632] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/24/2021] [Accepted: 09/12/2021] [Indexed: 01/18/2023] Open
Abstract
Background Emergency telehealth has been used to improve access of patients residing in rural and remote areas to specialist care in the hope of mitigating the significant health disparities that they experience. Patient disposition decisions in rural and remote emergency departments (EDs) can be complex and largely dependent on the expertise and experience available at local (receiving-end) hospitals. Although there has been some synthesis of evidence of the effectiveness of emergency telehealth in clinical practice in rural and remote EDs for nonacute presentations, there has been limited evaluation of the influence of contextual factors such as clinical area and acuity of presentation on these findings. Objective The aims of this systematic review are to examine the outcome measures used in studying the effectiveness of telehealth in rural and remote EDs and to analyze the clinical context in which these outcome measures were used and interpreted. Methods The search strategy used Medical Subject Headings and equivalent lists of subject descriptors to find articles covering 4 key domains: telehealth or telemedicine, EDs, effectiveness, and rural and remote. Studies were selected using the Population, Intervention, Comparator, Outcomes of Interest, and Study Design framework. This search strategy was applied to MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, and EconLit, as well as the Centre for Reviews and Dissemination databases (eg, National Health Service Economic Evaluation Database) for the search period from January 1, 1990, to May 23, 2020. Qualitative synthesis was performed on the outcome measures used in the included studies, in particular the clinical contexts within which they were interpreted. Results A total of 21 full-text articles were included for qualitative analysis. Telehealth use in rural and remote EDs demonstrated effectiveness in achieving improved or equivalent clinical effectiveness, appropriate care processes, and—depending on the context—improvement in speed of care, as well as favorable service use patterns. The definition of effectiveness varied across the clinical areas and contexts of the studies, and different measures have been used to affirm the safety and clinical effectiveness of telehealth in rural and remote EDs. The acuity of patient presentation emerged as a dominant consideration in the interpretation of interlinking time-sensitive clinical effectiveness and patient disposition measures such as transfer and discharge rates, local hospital admission, length of stay, and ED length of stay. These, together with clinical area and acuity of presentation, are the outcome determination criteria that emerged from this review. Conclusions Emergency telehealth studies typically use multiple outcome measures to determine the effectiveness of the services. The outcome determination criteria that emerged from this analysis are useful when defining the favorable direction for each outcome measure of interest. The findings of this review have implications for emergency telehealth service design and policies. Trial Registration PROSPERO CRD42019145903; https://tinyurl.com/ndmkr8ry
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Affiliation(s)
- Christina Tsou
- School of Population Health, Curtin Univeristy, Bentley, Australia.,Innovation & Development, WA Country Health Service, Perth, Australia
| | - Suzanne Robinson
- School of Population Health, Curtin Univeristy, Bentley, Australia
| | - James Boyd
- Digital Health, La Trobe University, Bundoora, Australia
| | - Andrew Jamieson
- Innovation & Development, WA Country Health Service, Perth, Australia
| | - Robert Blakeman
- Consumer and Community Health Research Network, Nedlands, Australia.,Consumer and Mental Health WA, Cloverdale, Australia
| | - Justin Yeung
- Command Centre, WA Country Health Service, Perth, Australia
| | | | - Stephanie Waters
- Innovation & Development, WA Country Health Service, Perth, Australia
| | - Kylie Bosich
- Command Centre, WA Country Health Service, Perth, Australia
| | - Delia Hendrie
- School of Population Health, Curtin Univeristy, Bentley, Australia
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15
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Wright N, Scherdt M, Aebersold ML, McCullagh MC, Medvec BR, Ellimoottil C, Patel MR, Shapiro S, Friese CR. Rural Michigan Farmers' Health Concerns and Experiences: A Focus Group Study. J Prim Care Community Health 2021; 12:21501327211053519. [PMID: 34704487 PMCID: PMC8554574 DOI: 10.1177/21501327211053519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objectives: Rural residents comprise approximately 15% of the United States population. They face challenges in accessing and using a health care system that is not structured to meet their unique needs. It is important to understand rural residents’ perceptions of health and experiences interacting with the health care system to identify gaps in care. Methods: Our team conducted focus groups with members of the Michigan Farm Bureau during their 2019 Annual Meeting. Topics explored included resources to manage health, barriers to virtual health care services, and desired changes to localized healthcare delivery. Surveys were used to capture demographic and internet access information. Conclusion: Analysis included data from 2 focus groups (n = 14). Participants represented a wide age range and a variety of Michigan counties. The majority were full-time farm owners with most—93% (n = 13)—reporting they had access to the internet in their homes and 86% (n = 12) reporting that their cellphones had internet capabilities. Participants identified challenges and opportunities in 4 categories: formal health care; health and well-being supports; health insurance experiences; and virtual health care. Conclusion: The findings from this study provide a useful framework for developing interventions to address the specific needs of rural farming residents. Despite the expressed challenges in access and use of health care services and resources, participants remained hopeful that innovative approaches, such as virtual health platforms, can address existing gaps in care. The study findings should inform the design and evaluation of interventions to address rural health disparities.
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16
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Wood T, Freeman S, Banner D, Martin-Khan M, Hanlon N, Flood F. Exploring user perspectives of factors associated with use of teletrauma in rural areas. Australas Emerg Care 2021; 25:106-114. [PMID: 33972192 DOI: 10.1016/j.auec.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Despite the existence of universal health care for Canadians, health inequalities persist and those residing in rural regions experience disparities when accessing appropriate services. To enhance access, a teletrauma program was implemented in a rural northern region in western Canada, connecting rural clinicians to urban emergency physicians and trauma specialists during emergency cases. OBJECTIVE To explore reasons why teletrauma is used in rural contexts from the perspectives of service users and stakeholders. METHODS 14 semi-structured interviews were conducted with stakeholders, clinicians (physicians, specialists), management, and researchers. Interpretive description methodology guided the study and analysis, and findings were organized thematically. RESULTS Teletrauma was used to connect clinicians, manage complex cases when weather or distance delayed transfer, and to enable appropriate and timely treatment locally. Teletrauma was more likely to be activated when clinicians were uncomfortable with clinical management, when relationships were established, and when technology was familiar and easy to use. CONCLUSIONS Teletrauma is more than just the technology that is deployed. The establishment of relationships between teletrauma users was vital to the success of teletrauma. To design effective, integrated, and sustainable services, rural clinicians must remain at the center of teletrauma models.
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Affiliation(s)
- Timothy Wood
- University of Northern British Columbia, School of Nursing, Canada
| | - Shannon Freeman
- University of Northern British Columbia, School of Nursing, Canada.
| | - Davina Banner
- University of Northern British Columbia, School of Nursing, Canada
| | | | - Neil Hanlon
- University of Northern British Columbia, School of Geography, Canada
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17
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Mohr NM, Harland KK, Okoro UE, Fuller BM, Campbell K, Swanson MB, Simpson SQ, Parker EA, Mack LJ, Bell A, DeJong K, Faine B, Zepeski A, Mueller K, Chrischilles E, Carpenter CR, Jones MP, Ward MM. TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study). J Comp Eff Res 2021; 10:77-91. [PMID: 33470848 DOI: 10.2217/cer-2020-0141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Uche E Okoro
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA.,Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Kalyn Campbell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Surgery, Hennepin County Medical Center, Minneapolis, MN 55415, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Stephen Q Simpson
- Department of Pulmonary, Critical Care, & Sleep Medicine, University of Kansas, Kansas City, KS 66160, USA.,Biomedical Advanced Research & Development Authority, US Department of Health & Human Services, Washington, DC 20201, USA
| | - Edith A Parker
- Department of Community & Behavioral Health, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Luke J Mack
- Avera eCARE, Sioux Falls, SD 57104, USA.,Department of Family Medicine, University of South Dakota School of Medicine, Sioux Falls, SD 57105, USA
| | | | | | - Brett Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Pharmacy Practice & Science, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA.,Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Department of Health Management & Policy, Iowa City, IA 52242, USA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Department of Health Management & Policy, Iowa City, IA 52242, USA
| | - Keith Mueller
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Elizabeth Chrischilles
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA 52242, USA
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Heppner S, Mohr NM, Carter KD, Ullrich F, Merchant KAS, Ward MM. HRSA's evidence-based tele-emergency network grant program: Multi-site prospective cohort analysis across six rural emergency department telemedicine networks. PLoS One 2021; 16:e0243211. [PMID: 33434197 PMCID: PMC7802919 DOI: 10.1371/journal.pone.0243211] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 11/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) funded the Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) to serve the dual purpose of providing telehealth services in rural emergency departments (teleED) and systematically collecting data to inform the telehealth evidence base. This provided a unique opportunity to examine trends across multiple teleED networks and examine heterogeneity in processes and outcomes. Method and findings Six health systems received funding from HRSA under the EB TNGP to implement teleED services and they did so to 65 hospitals (91% rural) in 11 states. Three of the grantees provided teleED services to a general patient population while the remaining three grantees provided teleED services to specialized patient populations (i.e., stroke, behavioral health, critically ill children). Over a 26-month period (November 1, 2015 –December 31, 2017), each grantee submitted patient-level data for all their teleED encounters on a uniform set of measures to the data coordinating center. The six grantees reported a total of 4,324 teleED visits and 99.86% were technically successful. The teleED patients were predominantly adult, White, not Latinx, and covered by Medicare or private insurance. Across grantees, 7% of teleED patients needed resuscitation services, 58% were rated as emergent, and 30% were rated as urgent. Across grantees, 44.2% of teleED patients were transferred to another inpatient facility, 26.0% had a routine discharge, and 24.5% were admitted to the local inpatient facility. For the three grantees who served a general patient population, the most frequent presenting complaints for which teleED was activated were chest pain (25.7%), injury or trauma (17.1%), stroke symptoms (9.9%), mental/behavioral health (9.8%), and cardiac arrest (9.5%). The teleED consultation began before the local clinician exam in 37.8% of patients for the grantees who served a general patient population, but in only 1.9% of patients for the grantees who provided specialized services. Conclusions Grantees used teleED services for a representative rural population with urgent or emergent symptoms largely resulting in transfer to a distant hospital or inpatient admission locally. TeleED was often available as the first point of contact before a local provider examination. This finding points to the important role of teleED in improving access for rural ED patients.
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Affiliation(s)
- Sarah Heppner
- Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, United States of America
- * E-mail:
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
- Department of Anesthesia Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Knute D. Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Fred Ullrich
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Kimberly A. S. Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Marcia M. Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
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Fairchild R, Ferng-Kuo SF, Rahmouni H, Hardesty D. An Observational Study of Telemental Care Delivery and the Context for Involuntary Commitment for Mental Health Patients in a Group of Rural Emergency Departments. Telemed Rep 2020; 1:22-35. [PMID: 33283206 PMCID: PMC7714264 DOI: 10.1089/tmr.2020.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 06/12/2023]
Abstract
Background: Rates for all-cause U.S. emergency department (ED) visits to rural critical access hospitals (CAHs) have increased by 50% since 2005. During the same time period, total number of U.S. hospital admissions for a mental health (MH) crisis has increased by 12.2%, with rural counties demonstrating the largest suicide rate increases overall. Introduction: Increasing number of rural patients are reporting need for MH care in the region's four rural EDs. Characteristics of ED telemental health services were evaluated, including MH diagnostic category, voluntary vs. involuntary commitment (IC), forensic vs. nonforensic presentation, ED throughput, disposition, and payor reimbursement. Materials and Methods: Observational 2.5-year program evaluation of telemental health care delivery for children (n = 114) and adults (n = 417) who were evaluated by a rural ED physician and received an MH diagnosis. Participants (N = 531) were treated by a licensed psychiatrist through telemental care delivery from September 2017 to April 2020. Results: Noncommitted ED MH patients (86%; n = 455) were distributed across three major diagnostic groups: (1) depression, anxiety, or other mental illness (35%); (2) substance abuse (33%); or (3) suicide risk (32%), with 47% admitted inpatients (IPs), 47% referred outpatient (OPs), and 6% admitted to CAH. Fourteen percent (n = 76/531) of ED MH patients were subsequently IC, with 67% of those assessed as needing IP care. Forty-nine percent (n = 37) of IC patients presented in police custody. Most common diagnosis for IC patients was suicidal ideation/attempt (χ2 [2, N = 452] = 12.884, p = 0.002). Admitted patients experienced significantly longer length of stay than those with OP referral (p = 0.001). Mean total payor reimbursements for ED MH care were significantly lower than actual ED costs (p < 0.001). Discussion: Innovative approaches to telemental care for IC and non-IC patients need to be piloted and comparatively evaluated in rural CAHs. Conclusion: As the gateway to critically needed MH care, rural CAHs and public services pivotal to care access (e.g., law enforcement) need additional resources and support.
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Affiliation(s)
- Roseanne Fairchild
- Department of Research, Richard Lugar Center for Rural Health, Union Hospital, Terre Haute, Indiana, USA
| | - Shiaw-Fen Ferng-Kuo
- Department of Applied Health Sciences, Indiana State University, Terre Haute, Indiana, USA
| | - Hicham Rahmouni
- Department of Research, Richard Lugar Center for Rural Health, Union Hospital, Terre Haute, Indiana, USA
| | - Daniel Hardesty
- Department of Research, Richard Lugar Center for Rural Health, Union Hospital, Terre Haute, Indiana, USA
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20
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Boğan M, Altınsoy HB, Karadağ M. Smartphone evaluation of postero-anterior chest x-rays: An inter-observer study. Am J Emerg Med 2021; 46:515-9. [PMID: 33172746 DOI: 10.1016/j.ajem.2020.10.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/30/2020] [Accepted: 10/31/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Posterior-anterior chest x-ray (PA-CXR) is among the most commonly used imaging methods in the diagnosis both in the emergency departments (ED) and the other clinics. The aim of the present study was to evaluate the diagnostic reliability of PA-CXRs sent via a smartphone. METHODS This study was conducted as an inter-observer study. PA-CXRs were photographed with a smartphone and they were sent to two separate participants (emergency medicine specialists one with 4 years experience and another with 3) via the WhatsApp application. And the participants evaluated to these images on their mobile phone. RESULTS A poor concordance was determined in a ratio of 3/8 and good concordance was detected in a ratio of 3/8 between the two participants (p < 0.05). It was observed that only the mediastinum assessments could be an alternative to the gold standard (p < 0.01). CONCLUSION We may conclude that the assessments done via a smartphone (photographing and sharing) may not be reliable.
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21
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Fairchild RM, Ferng-Kuo SF, Rahmouni H, Hardesty D. Telehealth Increases Access to Care for Children Dealing with Suicidality, Depression, and Anxiety in Rural Emergency Departments. Telemed J E Health 2020; 26:1353-1362. [DOI: 10.1089/tmj.2019.0253] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Shiaw-Fen Ferng-Kuo
- Department of Applied Health Sciences, Indiana State University, Terre Haute, Indiana, USA
| | - Hicham Rahmouni
- Richard Lugar Center for Rural Health, Union Hospital, Terre Haute, Indiana, USA
| | - Daniel Hardesty
- Richard Lugar Center for Rural Health, Union Hospital, Terre Haute, Indiana, USA
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22
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Abstract
Overcrowding in emergency rooms (ERs) is a common yet nagging problem. It not only is costly for hospitals but also compromises care quality and patient experience. Our paper provides solid evidence that telemedicine can significantly improve ER care delivery, especially in the presence of demand and supply fluctuations. We believe such findings are critical for ERs, due to the special setting of unscheduled arrivals leading to high unpredictability of patient traffic. Additional evidence suggests that the efficiency gained from telemedicine does not come at the expense of lower care quality or higher medical expenditure, which points to telemedicine as a feasible solution to the ER overcrowding problem. For healthcare practitioners, our paper highlights the general applicability of telemedicine through the “hub and spoke” architecture. Besides increasing patients’ access to more immediate care from specialists who were not available otherwise, telemedicine enables flexible resource allocation for any hospitals, regardless of where hospitals are located. Our research also provides ground for policymakers to incentivize hospitals to adopt telemedicine in ER, which we believe is critical given the relatively low adoption rate, the lack of direct evidence on its effectiveness, and the current inflexibility of reimbursement policies regarding the application of ER telemedicine.
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Affiliation(s)
- Shujing Sun
- Simon Business School, University of Rochester, Rochester, New York 14627
| | - Susan F. Lu
- Krannert School of Management, Purdue University, West Lafayette, Indiana 47907
| | - Huaxia Rui
- Simon Business School, University of Rochester, Rochester, New York 14627
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23
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Jiang HY, MacLean A, Yoon J, Hughes S, Kim MJ, Anantha RV, Widder SL. Evaluation of trauma resources in rural northern Alberta identifies opportunities for improvement. Can J Surg 2020; 63:E383-E390. [PMID: 32856887 DOI: 10.1503/cjs.007119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background The care of rural trauma patients in northern Alberta can be extremely challenging because of the vast geographic area, the limited access to health care facilities and the lack of adequate resources to manage severe injuries. Identifying gaps in equipment and personnel in rural centres can provide opportunities for improving the care of injured patients in these environments. We conducted a survey based on Canadian Accreditation Council quality indicators to evaluate trauma infrastructure and human resources in rural centres across northern Alberta. Methods A standardized survey was developed to assess the availability of trauma-specific equipment and personnel across the prehospital and emergency department (ED) settings. The survey was distributed to 50 peripheral hospitals biannually from January 2017 to September 2018. Two-tailed paired t tests were used to evaluate changes in survey responses; a p value of less than 0.05 was considered statistically significant. Results The survey response rate was 100%. By the end of the study period, there were significant improvements in the number of providers (p = 0.04), nurses (p = 0.01) and dedicated trauma resuscitation bays (p = 0.04) in the ED for managing injured patients. There were also significant increases in the availability of equipment, including advanced airway management tools (p = 0.02), rapid infusion devices (p = 0.02) and warmers (p = 0.04). Access to x-ray equipment (p = 0.03) and computed tomography (CT) scanners (p = 0.04) as well as equipment to support telehealth and teleconferencing (p = 0.04) increased during the study period. Access to, and supply of, blood products also increased significantly (p = 0.02) during the study period. Conclusion Our study demonstrates that the trauma resources of rural health care centres may be evaluated in a standardized fashion centres, and the results point to opportunities to remedy gaps in equipment and personnel. Our methods may be applied to any trauma network that serves geographically large areas with a sparse distribution of health care facilities, to provide critical information for the optimization of resources in rural trauma.
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Affiliation(s)
- Henry Y Jiang
- From the Department of Surgery, University of Alberta Hospital, University of Alberta, Alta. (Jiang, MacLean, Yoon, Hughes, Kim, Anantha, Widder); and Alberta Trauma Services Edmonton Zone, Alberta Health Services, Edmonton, Alta. (Hughes, Kim, Anantha, Widder)
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24
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Zhu X, Merchant KAS, Mohr NM, Wittrock AJ, Bell AL, Ward MM. Real-Time Learning Through Telemedicine Enhances Professional Training in Rural Emergency Departments. Telemed J E Health 2020; 27:441-447. [PMID: 32552479 DOI: 10.1089/tmj.2020.0042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The low volume and the intermittent nature of serious emergencies presenting to rural emergency departments (EDs) make it difficult to plan and deliver pertinent professional training. Telemedicine provides multiple avenues for training rural ED clinicians. This study examines how telemedicine contributes to professional training in rural EDs through both structured and unstructured approaches. Methods: This qualitative study examined training experiences in 18 hospitals located in 6 Midwest states in the United States, which participated in a single hub-and-spoke telemedicine network. Twenty-eight interviews were conducted with 7 physicians, 10 advanced practice providers, and 11 nurses. Standard, inductive qualitative analysis was used to identify key themes related to experiences with telemedicine-based training and its impact on rural ED practice. Results: For structured formal training, rural ED clinicians used asynchronous sessions more often than live sessions. It was reported that the formal training program may not have been fully utilized due to time and workload constraints. Rural clinicians strongly valued unstructured real-time training during telemedicine consultations. It was perceived consistently across professional groups that real-time training occurred frequently and its spontaneous nature was beneficial. Hub providers offering suggestions respectfully and explaining the rationale behind recommendations facilitated real-time learning. Rural providers and nurses perceived several effects of real-time training, including keeping rural practice up to date, instilling confidence, and improving performance. Discussion: Our research shows that telemedicine provided rural ED providers and nurses both formal training and real-time training opportunities. Real-time training occurred frequently, complemented formal training, and was perceived to have many advantages.
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Affiliation(s)
- Xi Zhu
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA.,Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, Iowa, USA.,Division of Critical Care, Department of Anesthesia, College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | | | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
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25
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Lapointe L, Lavallee-Bourget MH, Pichard-Jolicoeur A, Turgeon-Pelchat C, Fleet R. Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review. Can J Rural Med 2020; 25:31-40. [PMID: 31854340 DOI: 10.4103/cjrm.cjrm_8_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients. Materials and Methods A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies. Results The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients. Conclusions The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.
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Affiliation(s)
- Luc Lapointe
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Marie-Helene Lavallee-Bourget
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Alexia Pichard-Jolicoeur
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Catherine Turgeon-Pelchat
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Richard Fleet
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis; Department of Family and Emergency Medicine, Laval University; Centre De Recherche Sur Les Soins Et Services De Première Ligne Université Laval, Québec, Canada
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26
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Heaton HA, Russi CS, Monroe RJ, Thompson KM, Koch KA. Telehealth dashboard: leverage reporting functionality to increase awareness of high-acuity emergency department patients across an enterprise practice. BMJ Health Care Inform 2020; 26:bmjhci-2019-100093. [PMID: 31843765 PMCID: PMC7252997 DOI: 10.1136/bmjhci-2019-100093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/08/2019] [Accepted: 12/03/2019] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Heather A Heaton
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Karen A Koch
- Department of Nursing Informatics, Mayo Clinic, Rochester, Minnesota, USA
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27
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Chauhan V, Galwankar S, Arquilla B, Garg M, Somma SD, El-Menyar A, Krishnan V, Gerber J, Holland R, Stawicki SP. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock 2020; 13:20-24. [PMID: 32308272 PMCID: PMC7161346 DOI: 10.4103/jets.jets_32_20] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/11/2020] [Accepted: 03/06/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Vivek Chauhan
- Department of Medicine, IGMC, Shimla, Himachal Pradesh, India. E-mail:
| | - Sagar Galwankar
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Bonnie Arquilla
- Department of Emergency Medicine, SUNY Downstate Medical Center, New York City, NY, USA
| | - Manish Garg
- Department of Emergency Medicine, Weill Cornell Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
| | - Salvatore Di Somma
- Department of Medical-Surgery Sciences and Translational Medicine, Sant'Andrea Hospital, University La Sapienza Rome, Rome, Italy
| | - Ayman El-Menyar
- Department of Clinical Medicine, Weill Cornell Medical College, Ar-Rayyan, Qatar
| | - Vimal Krishnan
- Department of Emergency Medicine, KMC Manipal, Manipal, Karnataka, India
| | - Joel Gerber
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Reuben Holland
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Fountain Hill, Pennsylvania, USA
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28
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Miller AC, Ward MM, Ullrich F, Merchant KAS, Swanson MB, Mohr NM. Emergency Department Telemedicine Consults are Associated with Faster Time-to-Electrocardiogram and Time-to-Fibrinolysis for Myocardial Infarction Patients. Telemed J E Health 2020; 26:1440-1448. [PMID: 32109200 DOI: 10.1089/tmj.2019.0273] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Introduction: Acute myocardial infarction (AMI) is a time-sensitive condition. Meeting guideline-recommended time metrics for these patients can be challenging in rural emergency departments (EDs). Telemedicine has been shown to improve the quality and timeliness of emergency care in rural areas. The objective of this study was to evaluate the impact of telemedicine on the timeliness of emergency AMI care for patients presenting to rural EDs with chest pain. Methods: A prospective cohort study, conducted in six telemedicine networks, identified ED patients presenting with chest pain from November 2015 through December 2017. Primary exposure was telemedicine consultation during the ED visit. The primary outcome was time-to-electrocardiogram (ECG). For eligible AMI patients, secondary outcomes included: (1) fibrinolysis administered and (2) time-to-fibrinolysis. Analyses for multivariable models were conducted by using logistic regression, clustered at the hospital level. Results: Overall, 1,220 patients presenting with chest pain were included in the study cohort (27.1% received telemedicine). Time-to-ECG was, on average, 0.39 times (95% confidence interval [CI] -0.26 to -0.52) faster for telemedicine cases. Among eligible patients, telemedicine was associated with higher odds of fibrinolysis administration (adjusted odds ratio 7.17, 95% CI 2.48-20.49). In a sensitivity analysis excluding patients with cardiac arrest, time-to-fibrinolysis administration did not differ when telemedicine was used. Discussion: In telemedicine networks, telemedicine consultation during the ED visit was associated with improved timeliness of ECG evaluation and increased use of fibrinolytic reperfusion therapy for rural AMI patients. Future work should focus on the impact of telemedicine consultation on patient-centered outcomes.
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Affiliation(s)
| | - Marcia M Ward
- Department of Health Management and Policy, Division of Critical Care, College of Public Health University of Iowa, Iowa City, Iowa, USA
| | - Fred Ullrich
- Department of Health Management and Policy, Division of Critical Care, College of Public Health University of Iowa, Iowa City, Iowa, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, Division of Critical Care, College of Public Health University of Iowa, Iowa City, Iowa, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, Iowa City, Iowa, USA.,Department of Epidemiology, Division of Critical Care, College of Public Health University of Iowa, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, Iowa City, Iowa, USA.,Department of Anesthesia Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
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29
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Mohr NM, Wu C, Ward MJ, McNaughton CD, Richardson K, Kaboli PJ. Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study. BMC Health Serv Res 2020; 20:110. [PMID: 32050947 PMCID: PMC7014752 DOI: 10.1186/s12913-020-4956-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers. METHODS This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence. RESULTS Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%). CONCLUSIONS VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.
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Affiliation(s)
- Nicholas M. Mohr
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa USA
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa USA
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Mohr NM, Campbell KD, Swanson MB, Ullrich F, Merchant KA, Ward MM. Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments. J Telemed Telecare 2020; 27:518-526. [PMID: 31903840 DOI: 10.1177/1357633x19896667] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Sepsis is a life-threatening emergency. Together, early recognition and intervention decreases mortality. Protocol-based resuscitation in the emergency department (ED) has improved survival in sepsis patients, but guideline-adherent care is less common in low-volume EDs. This study examined the association between provider-to-provider telemedicine and adherence with sepsis bundle components in rural community hospitals. METHODS This is a prospective cohort study of adults presenting with sepsis or septic shock in community EDs participating in rural telemedicine networks. The primary outcome was adherence to four sepsis bundle requirements: lactate measurement within 3 hours, blood culture before antibiotics, broad-spectrum antibiotics, and adequate fluid resuscitation. Multivariable generalized estimating equations estimated the association between telemedicine and adherence. RESULTS In this cohort (n = 655), 5.6% of subjects received ED telemedicine consults. The telemedicine group was more likely to be male and have a higher severity of illness. After adjusting for severity and chief complaint, total sepsis bundle adherence was higher in the telemedicine group compared with the non-telemedicine group (aOR 17.27 [95%CI 6.64-44.90], p < 0.001). Telemedicine consultation was associated with higher adherence with three of the individual bundle components: lactate, antibiotics, and fluid resuscitation. DISCUSSION Telemedicine patients were more likely to receive initial blood lactate measurement, timely broad-spectrum antibiotics, and adequate fluid resuscitation. In rural, community EDs, telemedicine may improve sepsis care and potentially reduce disparities in sepsis outcomes at low-volume facilities. Future work should identify specific components of telemedicine-augmented care that improve performance with sepsis quality indicators.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA.,Department of Anesthesia Division of Critical Care, College of Medicine, University of Iowa, Iowa City, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, USA
| | - Kalyn D Campbell
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, USA
| | - Fred Ullrich
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Kimberly A Merchant
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
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Vakkalanka JP, Harland KK, Wittrock A, Schmidt M, Mack L, Nipe M, Himadi E, Ward MM, Mohr NM. Telemedicine is associated with rapid transfer and fewer involuntary holds among patients presenting with suicidal ideation in rural hospitals: a propensity matched cohort study. J Epidemiol Community Health 2019; 73:1033-1039. [PMID: 31492762 PMCID: PMC7027382 DOI: 10.1136/jech-2019-212623] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/05/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the impact of telemedicine in clinical management and patient outcomes of patients presenting to rural critical access hospital emergency departments (EDs) with suicidal ideation or attempt. METHODS Retrospective propensity-matched cohort study of patients treated for suicidal attempt and ideation in 13 rural critical access hospital EDs participating in a telemedicine network. Patients for whom telemedicine was used were matched 1:1 to those who did not have telemedicine as an exposure (n=139 TM+, n=139 TM-) using optimal matching of propensity scores based on administrative data. Our primary outcome was ED length-of-stay (LOS), and secondary outcomes included admission proportion, use of chemical or physical restraint, 30 day ED return, involuntary detention orders, treatment/follow-up plan and 6-month mortality. Analyses for multivariable models were conducted using conditional linear and logistic regression clustered on matched pairs with purposeful selection of covariates. RESULTS Mean ED LOS was not associated with telemedicine consultation among all patients, but was associated with a 29.3% decrease in transferred patients (95% CI 11.1 to 47.5). The adjusted odds of hospital admission (either local or through transfer) was 2.35 (95% CI 1.10 to 5.00) times greater among TM+ patients compared with TM- patients. Involuntary hold placement was lower in those exposed to telemedicine (adjusted odds ratio (aOR): 0.48; 95% CI 0.23 to 0.97). We did not observe significant differences in other outcomes. CONCLUSION The role of telemedicine in influencing access, quality and efficiency of care in underserved rural hospitals is critically important as these networks become more prevalent in rural healthcare environments.
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Affiliation(s)
- Jayamalathi Priyanka Vakkalanka
- Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Karisa K Harland
- Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | | | | | - Luke Mack
- Avera eCARE, Sioux Falls, South Dakota, USA
| | | | - Elaine Himadi
- Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Marcia M Ward
- Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Natafgi N, Mohr NM, Wittrock A, Bell A, Ward MM. The Association Between Telemedicine and Emergency Department (ED) Disposition: A Stepped Wedge Design of an ED-Based Telemedicine Program in Critical Access Hospitals. J Rural Health 2019; 36:360-370. [PMID: 31013552 DOI: 10.1111/jrh.12370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 02/17/2019] [Accepted: 03/11/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To study the relationship between the availability and activation of emergency department-based telemedicine (teleED) and patient disposition in Critical Access Hospitals (CAHs). METHODS A non randomized stepped wedge design examined 133,396 ED visits in 15 CAHs that subscribe to a single teleED provider. Data were available for at least 12 months prior to teleED implementation and at least 12 months of post-implementation. Primary analyses were conducted using multinomial logistic regression models with teleED availability (indicator of post-teleED implementation period) and activation (indicator of utilization of teleED service) predicting discharge disposition adjusting for age, sex, and clinical diagnosis. RESULTS Patients for whom teleED was activated were more likely to be transferred [adjusted odds ratio (aOR) = 12.04; 95% confidence interval (CI), 10.97-13.21] and more likely to be admitted to the local hospital (aOR = 3.23; 95% CI, 2.84-3.67) than to be routinely discharged. This pattern was confirmed for patients presenting with chest pain, mental illness, and injury/poisoning. However, in the period following teleED implementation, patients presenting to EDs after telemedicine was available, but not necessarily utilized, were less likely to be admitted to the local hospital (aOR = 0.79; 95% CI, 0.76-0.82) than to be routinely discharged. CONCLUSIONS Telemedicine availability in CAH EDs is associated with a higher likelihood of routine discharges from the ED possibly due to changes in care associated with teleED implementation. The relationship between teleED use and disposition may be related to selection in activating teleED for cases more likely to require hospital inpatient care.
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Affiliation(s)
- Nabil Natafgi
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa.,Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | | | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa
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Cornwall K, Oliver M, Bein K, Roncal S, Chu M, Dinh M. Outcomes at non-trauma centres within a trauma referral network: A five-year retrospective cohort study from Australia. Australas Emerg Care 2019; 22:42-46. [DOI: 10.1016/j.auec.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 02/03/2023]
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Fairchild RM, Ferng-Kuo SF, Laws S, Rahmouni H, Hardesty D. Telehealth Decreases Rural Emergency Department Wait Times for Behavioral Health Patients in a Group of Critical Access Hospitals. Telemed J E Health 2019; 25:1154-1164. [PMID: 30735100 DOI: 10.1089/tmj.2018.0227] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: Telehealth has been proposed as an important care delivery strategy to increase access to behavioral health care, especially in rural and medically-underserved settings where mental health care provider shortage areas predominate, to speed access to behavioral health care, and reduce health disparities. Introduction: This study was conducted to determine the effects of telehealth-based care delivery on clinical, temporal, and cost outcomes for behavioral health patients in rural emergency departments (EDs) of four Midwestern critical access hospitals (CAHs). Materials and Methods: Observational matched cohort study of adult (age ≥18 years) behavioral health patients treated in participating CAH EDs from 2015 to 2017 (N = 287). Telehealth cases were matched 2:1 retrospectively to nontelehealth control cases based on gender, age ±10 years, diagnosis group, and CAH, before implementation of telehealth in the rural hospitals (2005-2013; N = 153). Results: The greatest number of behavioral health cases evaluated was in the mood, anxiety, and other mental health disorders category. The majority of patients in the telehealth (74%) and nontelehealth (68%) cohorts were 18-44 years. Mean ED wait time for the telehealth cohort was significantly shorter at 12 min (95% CI 11-14 min) (p < 0.001) compared to a mean time of 27 min (95% CI 22-32 min) for the nontelehealth case controls (local provider only). The ED length of stay (LOS) for the telehealth cohort was significantly longer (M = 318 min vs. 147 min, p < 0.001) compared to the nontelehealth cohort. The end of telehealth visit to departure (EOTVtD) from the ED in minutes was evaluated to highlight factors potentially influencing delivery of behavioral health care in the ED. Across three behavioral diagnostic categories, time in minutes from end of telehealth visit to disposition/discharge was significantly longer for suicide and intentional self-injury cases (n = 100; 113 min, 95% CI 88-145; p = 0.004) compared to anxiety, mood, and other mental health disorders (n = 126; 66 min, 95% CI 52-83). There was a clinically meaningful difference in EOTVtD in minutes for substance abuse-related cases, which were shorter in length on average (n = 58; 71 min, 95% CI 54-94). Total ED costs for substance abuse-related cases for the telehealth (n = 58; $4556, 95% CI $3963-$5238) cohort were significantly higher than for the two other behavioral diagnostic groups (p < 0.001). Conclusions: Telehealth consultation in the ED for behavioral health cases was associated with decreased wait time and longer ED LOS. Similar to recent studies, the most common behavioral health cases involved mood and anxiety disorders. Costs related to treatment were highest for substance abuse-related cases, likely due to the additional interventions needed, especially related to resuscitation There are opportunities to improve ED efficiencies and post-telehealth visit protocols related to the timeframe extending from the EOTVtD from the ED, which continues to be a focus of future research. Additional research is also needed to determine if telehealth lends itself more effectively to specific categories of behavioral health cases.
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Affiliation(s)
| | - Shiaw-Fen Ferng-Kuo
- Department of Applied Health Sciences, Indiana State University, Terre Haute, Indiana
| | - Stephanie Laws
- Union Hospital, Richard Lugar Center for Rural Health, Terre Haute, Indiana
| | - Hicham Rahmouni
- Union Hospital, Richard Lugar Center for Rural Health, Terre Haute, Indiana
| | - Daniel Hardesty
- Union Hospital, Richard Lugar Center for Rural Health, Terre Haute, Indiana
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Abstract
Background: Several medical specialty organizations and the American Telemedicine Association have developed specialty-specific guidelines and tips for optimal telemedicine use. Formal introductory education for medical students appears to lag behind these other developments. Introduction: Leaders at the University of Iowa Hospitals and Clinics recognized that students would benefit from an introductory educational program pertinent across all specialties to prepare them for future telemedicine use. The program objective was to introduce a short educational intervention highlighting basic principles to improve knowledge and help students gain confidence with telemedicine technology. Materials and Methods: The program consists of three modules, a video, and a simulation session. The first module presents telemedicine history, current uses, terminology, Medicare-Medicaid rules, and legal issues. The second addresses efficacy, ethical concerns, and best practices. The third reviews steps for success, including environment (sound, lighting, color, and camera placement), communication tips, documentation, and follow-up. The video demonstrates an ideal telemedicine visit. A short quiz follows each module. A 1-h simulation session utilizes case scenarios, telemedicine software, and peripheral equipment. A retrospective pretest and posttest were used to gauge success. Results: One hundred fifty-three second year medical students completed the program during 2017. Ninety-three (60%) completed the questionnaire. Posttest results showed higher (positive) mean scores for all questions addressed in the program regarding basic telemedicine knowledge and confidence issues. Conclusion: This program model was effective in improving basic knowledge and confidence in telemedicine among second-year medical students. We speculate that they are more informed and prepared for future telemedicine rotations and practices.
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Affiliation(s)
- Clayton Walker
- 1The Signal Center for Innovation, University of Iowa Health Ventures (affiliate of University of Iowa Health Care), Iowa City, Iowa.,2University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Harriet Echternacht
- 1The Signal Center for Innovation, University of Iowa Health Ventures (affiliate of University of Iowa Health Care), Iowa City, Iowa.,3Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Patrick D Brophy
- 1The Signal Center for Innovation, University of Iowa Health Ventures (affiliate of University of Iowa Health Care), Iowa City, Iowa.,4Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Mohr NM, Young T, Harland KK, Skow B, Wittrock A, Bell A, Ward MM. Telemedicine Is Associated with Faster Diagnostic Imaging in Stroke Patients: A Cohort Study. Telemed J E Health 2018; 25:93-100. [PMID: 29958087 DOI: 10.1089/tmj.2018.0013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs. INTRODUCTION The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs. MATERIALS AND METHODS This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital. RESULTS Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy. CONCLUSIONS Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.
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Affiliation(s)
- Nicholas M Mohr
- 1 Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- 2 Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
- 3 Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Tracy Young
- 1 Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- 4 Injury Prevention Research Center, University of Iowa College of Public Health, Iowa City, Iowa
| | - Karisa K Harland
- 1 Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Brian Skow
- 5 Avera eCARE, Sioux Falls, South Dakota
| | | | | | - Marcia M Ward
- 6 Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa
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