Preadmission testing (PAT) before surgical procedures ensures patient safety and decreases last minute case cancellations.
PAT before surgery improves efficiency for the health system; however, the ...process is often inconvenient for the patient. We sought to determine the impact of telemedicine on the presurgical assessment.
We performed a retrospective review comparing patients who participated in telemedicine-based PAT to patients who had a routine, on-site PAT. Our outcomes aligned with National Quality Forum recommended domains for telehealth measures: access (time spent in evaluation), experience (patient satisfaction), and effectiveness (case cancellation rate).
There were 7,803 people evaluated; 361 with telemedicine and 7,442 without telemedicine. Compared with those not using telemedicine, the telemedicine group spent less time in the PAT by 24 min (95% confidence interval, 21.4-26.5), and had no case cancellations (0% vs. 1.1%; 95% confidence interval for the difference, 0.028-1.25%). Patient experience showed high rates of satisfaction with telemedicine.
We found that using telemedicine for PAT had benefits in terms of access, patient experience, and effectiveness, the three domains recommended for use in telehealth quality measures by the National Quality Forum. The improvements in evaluation times are beneficial for both patients and providers.
PAT utilizing telemedicine reduced overall patient time in the PAT and improved patient satisfaction without increasing the operative case cancellation rate.
Objectives
More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele‐intake at ...the time of presentation would reduce LWBS rates and ED throughput measures.
Methods
We conducted a before‐and‐after study at an urban community hospital. The intervention was use of a tele‐intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele‐intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24‐hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6‐month tele‐intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program.
Results
Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24‐hour LWBS rate was reduced from 2.30% (95% confidence interval CI = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 interquartile range {IQR} = 9 to 38 minutes vs. 16.2 IQR = 7.8 to 34.3 minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 IQR = 100 to 292 minutes vs. 184.3 IQR = 104.4 to 300 minutes; p < 0.001). There was an increase in door to discharge times (median = 146 IQR = 83 to 231 minutes vs. 148 IQR = 88.2 to 233.6 minutes; p < 0.001) and door to admit times (median = 330 IQR = 253 to 432 minutes vs. 357.6 IQR = 260.3 to 514.5 minutes; p < 0.001). We saw an increase in LWTC (0.59% 95% CI = 0.49% to 0.70% vs. 1.1% 95% CI = 0.9% to 1.2%; p < 0.001), but no change in AMA (1.4% 95% CI = 1.2% to 1.6% vs. 1.6% 95% CI = 1.4% to 1.78%; p = 0.21) or LWOT (4.3% 95% CI = 4.1% to 4.6% vs. 4.4% 95% CI = 4.1% to 4.7%; p = 0.7). Tele‐intake providers thought tele‐intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in‐person triage. Of the receiving physicians, most agreed with statements that tele‐intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%).
Conclusions
Remote tele‐intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.
Introduction
The global pandemic has raised awareness of the need for alternative ways to deliver care, notably telehealth. Prior to this study, research has been mixed on its effectiveness and ...impact on downstream utilization, especially for seniors. Our multi-institution study of more than 300,000 telehealth visits for seniors evaluates the clinical outcomes and healthcare utilization for urgent and non-emergent symptoms.
Methods
We conducted a retrospective cohort study from November 2015 to March 2019, leveraging different models of telehealth from three health systems, comparing them to in-person visits for urgent and non-emergent needs of seniors based on International Classification of Diseases, 10th edition diagnoses. The study population was adults aged 60 years or older who had access to telehealth and were affiliated with and resided in the geographic region of the healthcare organization providing telehealth. The primary outcomes of interest were visit resolution and episodes of care for those that required follow-up.
Results
In total, 313,516 telehealth visits were analysed across three healthcare organizations. Telehealth encounters were successful in resolving urgent and non-emergent needs in 84.0–86.7% of cases. When visits required follow-up, over 95% were resolved in less than three visits for both telehealth and in-person cohorts.
Discussion
While in-person visits have traditionally been the gold standard, our results suggest that when deployed within the confines of a patient’s existing primary care and health system provider, telehealth can be an effective alternative to in-person care for urgent and non-emergent needs of seniors without increasing downstream utilization.
Objectives:
Patients presenting with chest pain or related symptoms suggestive of myocardial ischemia, without ST‐segment elevation (NSTE) on their presenting electrocardiograms, often present a ...diagnostic challenge in the emergency department (ED). Prompt and accurate risk stratification to identify those patients with NSTE chest pain who are at highest risk for adverse events is essential, however, to optimal management. Although validated and used frequently in patients already enrolled in acute coronary syndrome trials, the Thrombolysis in Myocardial Infarction (TIMI) risk score never has been examined for its value in risk stratification in an all‐comers, non–trial‐based ED chest pain population.
Methods:
An analysis of an ED‐based prospective observational cohort study was conducted in 3,929 adult patients presenting with chest pain syndrome and warranting evaluation with an electrocardiogram. These patients had TIMI risk scores determined at ED presentation. The main outcome was the composite of death, acute myocardial infarction (MI), and revascularization within 30 days.
Results:
The TIMI risk score at ED presentation successfully risk‐stratified this unselected cohort of chest pain patients with respect to 30‐day adverse outcome, with a range from 2.1%, with a score of 0, to 100%, with a score of 7. The highest correlation of an individual TIMI risk indicator to adverse outcome was for elevated cardiac biomarker at admission. Overall, the score had similar performance characteristics to that seen when applied to other databases of patients enrolled in clinical trials and registries using a 14‐day end point.
Conclusions:
The TIMI risk score may be a useful tool for risk stratification of ED patients with chest pain syndrome.
In January 2015, the US Secretary of Health and Human Services announced targets for the transformation of Medicare reimbursement from a fee-for-service model to payments based on alternative payment ...models. People now use technology for virtually everything – from paying bills to purchasing almost anything; it is therefore natural to think that they will use technology to take ownership of their own health care. The remote provision of health care, where providers and patients are not in the same location, will allow patients to receive the right care, at the right time, at the right place, and in the manner they consider right for them. To date, much of the technological advances in medicine have been led by the technology creators rather than providers or patients. A meeting of leaders from academic medical centers was convened to brainstorm and explore new opportunities to educate the workforce, expand the science, and improve the delivery of quality care to patients through the use of telemedicine. The academic community needs to develop an evidence base that can inform new care delivery models, including the role for remote monitoring and wearable technology, as well as the methods by which the best patient-centered care can be provided. It is important that the future of medicine be determined by solid research and education rather than the latest “cool toy” to reach the market. Academic medical centers are in a unique position to help shape this future direction, collaborating to create innovative and efficient solutions for patient care. Specific calls for action are summarized.
We determined the additional cost of an extended emergency department (ED) length of stay for chest pain patients awaiting non-ICU, monitored (telemetry) beds.
This was a prospective cohort study of ...all ED chest pain patients aged 24 years or older and admitted to a telemetry bed in an urban university hospital during a 12-month period. Structured ED data collection included demographics, chest pain presentation, medical history, and laboratory test and ECG results. Hospital course was monitored daily, followed by a 30-day telephone follow-up. Risk severity scores (Goldman, Acute Cardiac Ischemia–Time-Insensitive Predictive Instrument, and Charlson) were calculated. Hospital charges, real costs, and revenues were obtained at discharge and 2 years later. The main outcome measure was risk-adjusted additional cost to the hospital of a delayed ED admission. Clinical outcome was a secondary measure.
Of the 817 patients with chest pain presenting to the ED during the study period, there were 904 hospitalizations. Of these, 825 patients waited more than 3 hours for their bed (91%). There were 21 patient visits with a final diagnosis of acute myocardial infarction. ED length of stay was not associated with total hospital length of stay (
r=0.01), hospital costs, or hospital or professional charges, revenues, or collection rates. The annual opportunity cost in lost hospital revenue for chest pain patients was US$168,300 (US$204 per patient waiting >3 hours for a hospital bed).
Extended ED length of stay demonstrated no association with total hospital costs or revenues or total hospital length of stay but imposed substantial ED opportunity costs, with decreased potential revenue. Interventions that reduce ED delays in hospital admissions have the potential to significantly increase hospital revenues.
Study Objective: Accurate identification of the presence of acute myocardial infarction in adult patients who present to the emergency department with anterior chest pain remains elusive. The ...artificial neural network is a powerful nonlinear statistical paradigm for the recognition of complex patterns, with the ability to maintain accuracy when some data required for network function are missing. Earlier studies revealed that the artificial neural network is able to accurately identify acute myocardial infarction in patients experiencing chest pain. However, these studies did not measure network performance in real time, when a significant amount of data required for network function may not be available. They also did not use chemical cardiac marker data. Methods: Two thousand two hundred four adult patients presenting to the ED with anterior chest pain were used to train an artificial neural network to recognize the presence of acute myocardial infarction. Only data available at the time of initial patient evaluation were used to replicate the conditions of real-time patient evaluation. Forty variables from patient histories, physical examinations, ECG results, and chemical cardiac marker determinations were used to train and then test the network. Results: The network correctly identified 121 of the 128 patients (sensitivity 94.5%; 95% confidence interval 90.6% to 97.9%) with myocardial infarction at a specificity of 95.9% (95% confidence interval 93.0% to 98.5%), despite the fact that an average of 5% (individual range 0% to 35%) of the input data required by the network were missing on all patients. Conclusion: Network accuracy and the maintenance of that accuracy when some data required for function are unavailable suggest that the artificial neural network may be a potential real time aid to the diagnosis of acute myocardial infarction during initial patient evaluation. Baxt WG, Shofer FS, Sites FD, Hollander JE. A neural computational aid to the diagnosis of acute myocardial infarction. Ann Emerg Med. April 2002;39:366-373.
Tele-intensive care units (ICUs) typically provide remote monitoring for ICUs of acute care, short-stay hospitals. As part of a joint venture project to establish a long-term acute level of care, ...Good Shepherd Penn Partners became the first facility to use tele-ICU technology in a nontraditional setting. Long-term acute care hospitals care for patients with complex medical problems. We describe describes the benefits and challenges of integrating a tele-ICU program into a long-term acute care setting and the impact this model of care has on patient care outcomes.
Study objective: Chest pain is the second most common chief complaint presented to the emergency department. Although the causes of chest pain span the clinical spectrum from the trivial to the life ...threatening, it is often difficult to identify which patients have the most common life-threatening cause, cardiac ischemia. Because of the potential for poor outcome if this diagnosis is missed, physicians have had a low threshold for admitting patients with chest pain to the hospital, the vast majority of whom are found not to have cardiac ischemia. In an earlier study with a large chest pain patient registry, an artificial neural network was shown to be able to identify the subset of patients who present to the ED with chest pain who have sustained acute myocardial infarction. The objective of this study was to use the same registry to determine whether a network could be trained accurately to identify the larger subset of patients who have cardiac ischemia. Methods: Two thousand two hundred four adult patients presenting to the ED with chest pain who received an ECG were used to train and test an artificial neural network to recognize the presence of cardiac ischemia. Only the data available at the time of initial patient contact were used to replicate the conditions of real-time evaluation. Forty variables from patient history, physical examination, ECG, and the first set of chemical cardiac marker determinations were used to train and subsequently test the network. The network was trained and tested by using the jackknife variance technique to allow for the network to be trained on as many of the features of the small subset of ischemic patients as possible. Network accuracy was compared with 2 existing aids to the diagnosis of cardiac ischemia, as well as a derived regression model. Results: The network had a sensitivity of 88.1% (95% confidence interval CI 84.8% to 91.4%) and a specificity of 86.2% (95% CI 84.6% to 87.7%) for cardiac ischemia despite the fact that a mean of 5% of all required network input data and 41% of cardiac chemical marker data were missing. The network also performed more accurately than the 3 other tested approaches. Conclusion: These data suggest that an artificial neural network might be able to identify which patients who present to the ED with chest pain have cardiac ischemia with useful sensitivities and specificities. Ann Emerg Med. 2002;40:575-583.
Low-risk patients with chest pain are often admitted to monitored beds; however, the use of telemetry beds in this cohort is not evidence based. We tested the hypothesis that monitoring admitted ...low-risk patients with chest pain for dysrhythmia is low yield (<1% detection of life-threatening dysrhythmias requiring treatment).
We conducted a prospective cohort study of emergency department (ED) patients with chest pain with a Goldman risk score of less than 8%, a normal initial creatine kinase–MB level, and a negative initial troponin I level admitted to non-ICU monitored beds. Investigators followed the hospital course daily. The main outcome was cardiovascular death and life-threatening ventricular dysrhythmia during telemetry.
Of 3,681 patients with chest pain who presented to the ED, 1,750 patients were admitted to non-ICU monitored beds. Of these, 1,029 patients had a Goldman risk score of less than 8%, a troponin I level of less than 0.3 ng/mL, and a creatine kinase–MB level of less than 5 ng/mL (accounting for 59% of all chest pain telemetry admissions). During hospitalization, there were no patients with sustained ventricular tachycardia/ventricular fibrillation requiring treatment on the telemetry service (0%; 95% confidence interval CI 0% to 0.3%). There were 2 deaths: neither was cardiovascular in nature or preventable by monitoring (cardiovascular preventable death rate=0%; 95% CI 0.0% to 0.3%).
The routine use of telemetry monitoring for low-risk patients with chest pain is of limited utility. Admission to nonmonitored beds might help alleviate ED crowding without increasing risk of adverse events caused by dysrhythmia in patients with a Goldman risk of less than 8%, an initial troponin I level of less than 0.3 ng/mL, and a creatine kinase–MB level of less than 5 ng/mL.
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