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.
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.
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.
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.
ObjectiveThe 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.MethodsRetrospective 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.ResultsMean 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.ConclusionThe 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.
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.
There is a chronic shortage of physicians to cover emergency departments (EDs) in critical access hospitals. A 2013 memorandum from the Centers for Medicare and Medicaid Services clarified that a ...telemedicine physician could fulfill the regulatory requirements for physician backup when advanced practice providers were at telemedicine-equipped critical access hospital EDs but local physicians were not. In a sample of nineteen hospitals, coverage schedules in 2016 showed that seven had begun the use of tele-ED physician backup for advanced practice providers, decreasing local physician coverage in their EDs. These seven hospitals tended to have decreasing ED staffing costs, while the hospitals not applying this policy showed continually increasing staffing costs over time. Telemedicine also provided other benefits, such as improved physician recruitment and retention. In the future, more critical access hospitals will likely use telemedicine to provide physician backup for advanced practice providers staffing the ED.
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.
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.
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.
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.
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.
Tele-emergency models have been utilized for decades, with growing evidence of their effectiveness. Due to the variety of tele-emergency department (tele-ED) models used in practice, however, it is ...challenging to build standardized metrics for ongoing evaluation. This study describes two tele-ED programs, one specialized and one general, that provide care to paediatric populations. Through an examination of model structures and patient populations, we gain insight into how evaluative measures should reflect tele-ED model design and purpose.
Qualitative descriptions of the two tele-ED models are presented. We show a retrospective cohort analysis describing paediatric patients' key characteristics, reasons for visit, and disposition status by case/control status. Case/control patient encounter data were collected October 2015 through December 2017, from 15 spoke hospitals within each tele-ED program.
The two tele-ED models serve distinct paediatric populations, and measures of tele-ED utilization and disposition reflect those differences. In the specialized University of California (UC) Davis Health program, tele-ED was utilized in 36% of paediatric critical care encounters and 78% of those were transferred. In the Avera eCARE program, tele-ED was activated in 1.7% of paediatric encounters and 50.6% of those were transferred. When Avera eCARE paediatric encounters were stratified by severity, measures of tele-ED use and disposition status among high-severity encounters were more similar to UC Davis Health.
This study describes how design choices of tele-ED models have implications for evaluative measures. Measures of tele-ED model success need to reflect model purpose, populations served, and for whom tele-ED service use is appropriate.
Background Pediatric residencies expanding their point-of-care ultrasound (POCUS) education face barriers, including a lack of established curriculum and qualified educators. Prior studies report ...partnerships between pediatrics and pediatric emergency medicine (PEM); however, many non-PEM emergency medicine (EM) physicians with POCUS fellowship training also have experience with pediatric POCUS and represent an alternate educational partner. Objectives To improve pediatric residents' POCUS skills through collaborative education with EM and evaluate perceptions of the teaching format and instructors. Methods First through third-year pediatric residents attended a half-day didactic and hands-on session about renal, lung, and musculoskeletal (MSK) POCUS. These educational sessions were led by EM faculty with POCUS fellowship training and assisted by EM residents. Post-session surveys were administered to pediatric residents to assess prior POCUS experience, changes in confidence in acquiring and interpreting renal, lung, and MSK POCUS images, and opinions about the educational format. Statistical analyses of the post-session survey data were performed using SPSS. Results Thirty-nine pediatric residents attended the session and completed the survey of 45 total residents in the program (86.7%), with 89.7% completing 10 or fewer POCUS studies. Residents' comfort level with performing lung POCUS increased from 5.1% to 82.1% (
< .001), renal POCUS from 10.3% to 76.9% (
< .001), and MSK POCUS from 7.7% to 84.6% (
< .001). 87.2% rated the educational format as effective, and 94.9% (37/39) rated emergency medicine faculty as 'very effective' in providing ultrasound education relevant to the practice of pediatrics. Conclusion Pediatric resident POCUS education taught by EM faculty with POCUS fellowship training was well-received by pediatric residents and significantly improved confidence in acquiring and interpreting POCUS.
This text makes available in a concise format the chapters comprising the research methodology section of the Handbook of Research on Teaching the English Language Arts, Second Edition.An ...introduction, designed to give K-12 teachers an understanding of the basic categories and functions of research in teaching, is followed by chapters addressing teacher professionalism and the rise of "multiple literacies"; empirical research; longitudinal studies; case studies; ethnography; teacher research; teacher inquiry into literacy, social justice, and power; synthesis research; fictive representation; and contemporary methodological issues and future direction in research on the teaching of English. Methods of Research on Teaching the English Language Artsis well-suited for use in upper-level undergraduate and graduate-level literacy research methods courses.
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