Factors associated with emergency department adoption of telemedicine: 2014 to 2018

The Impact of Virtual Care in an Emergency Department Observation Unit

STUDY OBJECTIVE(S)

We report the impact of telemedicine virtual rounding in emergency department observation units (EDOU) on the effectiveness, safety, and cost relative to traditional observation care.

METHODS

In this retrospective diff-in-diff study, we compared observation visit outcomes from 2 EDOUs before (pre) and after (post) full adoption of telemedicine rounding tele-observation (tele-obs) with usual care in control EDOU and care in a hospital bed in an integrated health system without tele-obs. Tele-obs physicians did not work at the control hospital. Outcomes were the length of stay, total direct costs, admission status, and adverse events (ICU and death). Difference-in-differences modeling evaluated outcomes with covariates including age, sex, payer type, and clinical classification software diagnostic category. Data from a system data warehouse and a cost accounting database were used.

RESULTS

Of the 20,861 EDOU visits, 15,630 (74.9%) were seen in the preperiod and 6,657 (31.9%) in control EDOU. Of 23,055 non-EDOU inpatient visits assigned to observation status (nonobservation unit), 76% were seen in the preperiod. Adjusted length of stay was not significantly different for tele-obs and control EDOUs (26.4 hours versus 23.5 hours), which remained lower than in hospital settings (37.9 hours). The pre-post diff-in-diff was not significant (P=.78). Inpatient admission status was similar for tele-obs and control EDOUs (20.9% versus 22.4.%) and lower than in hospital settings (30.3%). Prepost odds ratios for inpatient admission and adverse outcomes did not change significantly for all study groups. Adjusted costs increased over time for all settings; however, the prepost median cost change was not significantly different between tele-obs EDOUs and control EDOUs ($162.5 versus $235) and was lower than the change for control hospital settings ($783). Median tele-obs EDOU cost over both periods ($1,541) remained significantly lower than hospital costs ($2,413).

CONCLUSION

Using tele-obs to manage observation patients in an ED observation unit was not associated with significant differences in length of stay, admission status, measured adverse events, or total direct cost.

Factors Affecting Telemedicine Implementation in Emergency Departments and Nurses' Perceptions of Virtual Sexual Assault Nurse Examiner Consultation for Sexual Assault Survivors

INTRODUCTION

Emergency department (ED) nurses play a critical role in caring for sexual assault patients, but many have not received training on how to conduct a proper sexual assault forensic medical examination. Live or real-time sexual assault nurse examiner (SANE) consultation provided via telemedicine (known as "teleSANE") during sexual assault examinations is a promising new practice to address this issue.

PURPOSE

The purpose of this study was to assess ED nurses' perceptions of influences on telemedicine use, as well as the utility and feasibility of teleSANE, and identify potential influences on teleSANE implementation in EDs.

METHODS

Guided by the Consolidated Framework for Implementation Research, this developmental evaluation involved semistructured qualitative interviews with 15 ED nurses from 13 EDs.

RESULTS

Interviews revealed facilitators and barriers to current telemedicine use across Consolidated Framework for Implementation Research levels. Facilitators included state-level grant funding and technical assistance. Barriers included clinician discomfort being on video and access to ongoing training. Participants believed teleSANE consultation would improve patient care and forensic evidence collection but had concerns for patient privacy and acceptability. Most participants worked in EDs that have the information technology support and telemedicine equipment needed to support teleSANE implementation, although many requested ongoing education and trainings on teleSANE and sexual assault care to improve clinician confidence and account for high staff turnover.

DISCUSSION

Findings highlight the unique needs of sexual assault survivors receiving telemedicine services in EDs, particularly those in rural communities with heightened privacy concerns and limited access to specialty care.