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Vakkalanka JP, Gadag K, Lavin L, Ternes S, Healy HS, Merchant KAS, Scott W, Wiggins W, Ward MM, Mohr NM. Telehealth Use and Health Equity for Mental Health and Substance Use Disorder During the COVID-19 Pandemic: A Systematic Review. Telemed J E Health 2024; 30:1205-1220. [PMID: 38227387 DOI: 10.1089/tmj.2023.0588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Background: As a result of the COVID-19 public health emergency (PHE), telehealth utilization accelerated to facilitate health care management and minimize risk. However, those with mental health conditions and substance use disorders (SUD)-who represent a vulnerable population, and members of underrepresented minorities (e.g., rural, racial/ethnic minorities, the elderly)-may not benefit from telehealth equally. Objective: To evaluate health equality in clinical effectiveness and utilization measures associated with telehealth for clinical management of mental health disorders and SUD to identify emerging patterns for underrepresented groups stratified by race/ethnicity, gender, age, rural status, insurance, sexual minorities, and social vulnerability. Methods: We performed a systematic review in PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL through November 2022. Studies included those with telehealth, COVID-19, health equity, and mental health or SUD treatment/care concepts. Our outcomes included general clinical measures, mental health or SUD clinical measures, and operational measures. Results: Of the 2,740 studies screened, 25 met eligibility criteria. The majority of studies (n = 20) evaluated telehealth for mental health conditions, while the remaining five studies evaluated telehealth for opioid use disorder/dependence. The most common study outcomes were utilization measures (n = 19) or demographic predictors of telehealth utilization (n = 3). Groups that consistently demonstrated less telehealth utilization during the PHE included rural residents, older populations, and Black/African American minorities. Conclusions: We observed evidence of inequities in telehealth utilization among several underrepresented groups. Future efforts should focus on measuring the contribution of utilization disparities on outcomes and strategies to mitigate disparities in implementation.
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Affiliation(s)
- J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Khyathi Gadag
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Lauren Lavin
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Sara Ternes
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Heather S Healy
- Hardin Library for the Health Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Wakina Scott
- Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, USA
| | - Whitney Wiggins
- Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Department of Anesthesia and Critical Care, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Koch EC, Ward MJ, Jeffery AD, Reese TJ, Dorn C, Pugh S, Rubenstein M, Ellen Wilson J, Campbell C, Han JH. Factors Associated with Acute Telemental Health Consultations in Older Veterans. West J Emerg Med 2024; 25:312-319. [PMID: 38801035 PMCID: PMC11112672 DOI: 10.5811/westjem.17996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 11/17/2023] [Accepted: 01/10/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction The United States Veterans Health Administration is a leader in the use of telemental health (TMH) to enhance access to mental healthcare amidst a nationwide shortage of mental health professionals. The Tennessee Valley Veterans Affairs (VA) Health System piloted TMH in its emergency department (ED) and urgent care clinic (UCC) in 2019, with full 24/7 availability beginning March 1, 2020. Following implementation, preliminary data demonstrated that veterans ≥65 years old were less likely to receive TMH than younger patients. We sought to examine factors associated with older veterans receiving TMH consultations in acute, unscheduled, outpatient settings to identify limitations in the current process. Methods This was a retrospective cohort study conducted within the Tennessee Valley VA Health System. We included veterans ≥55 years who received a mental health consultation in the ED or UCC from April 1, 2020-September 30, 2022. Telemental health was administered by a mental health clinician (attending physician, resident physician, nurse practitioner, or physician assistant) via iPad, whereas in-person evaluations were performed in the ED. We examined the influence of patient demographics, visit timing, chief complaint, and psychiatric history on TMH, using multivariable logistic regression. Results Of the 254 patients included in this analysis, 177 (69.7%) received TMH. Veterans with high-risk chief complaints (suicidal ideation, homicidal ideation, or agitation) were less likely to receive TMH consultation (adjusted odds ratio [AOR]: 0.47, 95% confidence interval [CI] 0.24-0.95). Compared to attending physicians, nurse practitioners and physician assistants were associated with increased TMH use (AOR 4.81, 95% CI 2.04-11.36), whereas consultation by resident physicians was associated with decreased TMH use (AOR 0.04, 95% CI 0.00-0.59). The UCC used TMH for all but one encounter. Patient characteristics including their visit timing, gender, additional medical complaints, comorbidity burden, and number of psychoactive medications did not influence use of TMH. Conclusion High-risk chief complaints, location, and type of mental health clinician may be key determinants of telemental health use in older adults. This may help expand mental healthcare access to areas with a shortage of mental health professionals and prevent potentially avoidable transfers in low-acuity situations. Further studies and interventions may optimize TMH for older patients to ensure safe, equitable mental health care.
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Affiliation(s)
- Erica C. Koch
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
- Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center, Nashville, Tennessee
- Veterans Affairs Quality Scholars Program, Nashville, Tennessee
| | - Michael J. Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
- Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center, Nashville, Tennessee
- Vanderbilt University Medical Center, Department of Biomedical Informatics, Nashville, Tennessee
| | - Alvin D. Jeffery
- Vanderbilt University School of Nursing, Nashville, Tennessee
- Vanderbilt University Medical Center, Department of Biomedical Informatics, Nashville, Tennessee
- Tennessee Valley Healthcare System, Nursing Services, Nashville, Tennessee
| | - Thomas J. Reese
- Vanderbilt University Medical Center, Department of Biomedical Informatics, Nashville, Tennessee
| | - Chad Dorn
- Vanderbilt University Medical Center, Department of Biomedical Informatics, Nashville, Tennessee
| | - Shannon Pugh
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Melissa Rubenstein
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Jo Ellen Wilson
- Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center, Nashville, Tennessee
- Vanderbilt University Medical Center, Department of Psychiatry, Nashville, Tennessee
| | - Corey Campbell
- Tennessee Valley Healthcare System, Psychiatric Services, Nashville, Tennessee
| | - Jin H. Han
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
- Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center, Nashville, Tennessee
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Vashi AA, Urech T, Wu S, Tran LD. Community Emergency Care Use by Veterans in an Era of Expanding Choice. JAMA Netw Open 2024; 7:e241626. [PMID: 38457180 PMCID: PMC10924239 DOI: 10.1001/jamanetworkopen.2024.1626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/18/2024] [Indexed: 03/09/2024] Open
Abstract
Importance Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown. Objective To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics. Design, Setting, and Participants Retrospective, observational cross-sectional study of ED visits over fiscal years (FY) 2016 to 2022. VA and community ED encounter data were obtained from the VA Corporate Data Warehouse and the Office of Integrated Veteran Care. Participants were veterans receiving ED care at VA facilities or paid for by the VA in the community. Data were analyzed from June to September 2023. Main Outcomes and Measures The primary outcome measures included community ED visit volume, disposition, and payments over time. Also, the most common and costly ED visits were assessed. Negative binomial regression analysis examined associations between facility and regional characteristics and the rate of ED visits purchased in community settings relative to all ED visits. Results There were 19 787 056 ED visits, predominantly at VA facilities (14 532 261 visits [73.4%]), made by 3 972 503 unique veterans from FY 2016 to 2022. The majority of ED users were male (3 576 120 individuals [90.0%]), and the median (IQR) age was 63 (48-73) years. The proportion of community ED visits increased in absolute terms from 18% in FY 2016 to 37% in FY 2022. Total community ED payments, adjusted to 2021 dollars, were $1.18 billion in FY 2016 and over $6.14 billion in FY 2022. The most common reasons for ED visits in the community were for nonspecific chest pain (305 082 visits [6%]), abdominal pain (174 836 visits [3%]), and septicemia (149 968 visits [3%]). The average proportion of ED visits purchased by a VA facility increased from 14% in FY 2016 to 32% by FY 2022. In multivariable analyses, facilities with greater ED volume and low-complexity facilities had higher expected rates of community emergency care than lower volume and high-complexity facilities, respectively. Conclusions and Relevance As veterans increasingly use community EDs for acute, unscheduled needs, attention to factors associated with veterans' use of acute care services in different settings are important to identify access barriers and to ensure veterans' health care needs are met.
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Affiliation(s)
- Anita A. Vashi
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Department of Emergency Medicine, University of California, San Francisco
- Department of Emergency Medicine (Affiliated), Stanford University, Stanford, California
| | - Tracy Urech
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Siqi Wu
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Primary Care and Population Health, Stanford University, Stanford, California
| | - Linda D. Tran
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, California
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Vakkalanka JP, Nataliansyah MM, Merchant KAS, Mack LJ, Parsons S, Mohr NM, Ward MM. Evaluation of Telepsychiatry Services Implementation in Medical and Psychiatric Inpatient Settings: A Mixed-Methods Study. Telemed J E Health 2023; 29:1224-1232. [PMID: 36595509 DOI: 10.1089/tmj.2022.0436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Introduction: Telepsychiatry consultation for rural providers may help address local staffing needs while ensuring timely and appropriate care from behavioral health experts. The purpose of this study was to assess the implementation of a telepsychiatry consultation service within medical and psychiatry inpatient units of hospitals serving predominantly rural areas. Methods: A mixed-methods study with qualitative interviews of site personnel and quantitative assessment of electronic health record data was conducted across 6 facilities in 3 U.S. states between June 2019 and May 2021. We interviewed 15 health care professionals 6 months after telepsychiatry was implemented, and we identified emerging themes related to the inpatient telepsychiatry service implementation and utilization through an inductive qualitative analysis approach. We then applied the themes emerging from this study to existing implementation science theoretical frameworks. Results: Telepsychiatry consultation was utilized for 437 medical inpatient cases and 531 psychiatric inpatient units. Average encounters by site ranged from 1 to 20 per month. The three main domains from the qualitative assessment included the impact on the care process (the partnership between inpatient units and the telehealth hub, and logistical dynamics), the care provider (resource availability in inpatient units and changes in inpatient units' capability), and the patient (impact on patient safety and care). Discussion: Implementation of a telepsychiatry service in the inpatient setting holds the promise of being beneficial to the patient, local hospital, and the rural community. In this study, we found that implementing this telepsychiatry service improved the clinical care processes, while addressing both the providers' and patients' needs.
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Affiliation(s)
- J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - M Muska Nataliansyah
- Division of Surgical Oncology, Department of Surgery, Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Luke J Mack
- Avel eCare, Sioux Falls, South Dakota, USA
- Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Seth Parsons
- Avel eCare, Sioux Falls, South Dakota, USA
- Department of Psychiatry, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Department of Anesthesia Critical Care, University of Iowa Carver College of Medicine, 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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Roddy MK, Chen P, Jeffery AD, Gutierrez J, Rubenstein M, Campbell C, Blake E, Ward MJ. Telemental health in emergency care settings: A qualitative analysis of considerations for sustainability and spread. Acad Emerg Med 2023; 30:368-378. [PMID: 36786633 PMCID: PMC10983773 DOI: 10.1111/acem.14682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/20/2023] [Accepted: 02/03/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVES Following rapid uptake of telehealth during the COVID-19 pandemic, we examined barriers and facilitators for sustainability and spread of telemental health video (TMH-V) as policies regarding precautions from the pandemic waned. METHODS We conducted a qualitative study using semistructured interviews and observations guided by RE-AIM. We asked four groups, local clinicians, facility leadership, Veterans, and external partners, about barriers and facilitators impacting patient willingness to engage in TMH-V (reach), quality of care (effectiveness), barriers and facilitators impacting provider uptake (adoption), possible adaptations to TMH-V (implementation), and possibilities for long-term use of TMH-V (maintenance). Interviews were recorded, transcribed, and analyzed using framework analysis. We also observed TMH-V encounters in one emergency department (ED) and one urgent care (UC) to understand how clinicians and Veterans engaged with the technology. RESULTS We conducted 35 interviews with ED/UC clinicians and staff (n = 10), clinical and facility leadership (n = 7), Veterans (n = 5), and external partners (n = 13), January-May 2022. We completed 10 observations. All interviewees were satisfied with the TMH-V program, and interviewees highlighted increased comfort discussing difficult topics for Veterans (reach). Clinicians identified that TMH-V allowed for cross-coverage across sites as well as increased safety and flexibility for clinicians (adoption). Opportunities for improvement include alleviating technological burdens for on-site staff, electronic health record (EHR) modifications to accurately capture workload and modality (telehealth vs. in-person), and standardizing protocols to streamline communication between on-site and remote clinical staff (implementation). Finally, interviewees encouraged its spread (maintenance) and thought there was great potential for service expansion. CONCLUSIONS Interviewees expressed support for continuing TMH-V locally and spread to other sites. Ensuring adequate infrastructure (e.g., EHR integration and technology support) and workforce capacity are key for successful spread. Given the shortage of mental health (MH) clinicians in rural settings, TMH-V represents a promising intervention to increase the access to high-quality emergency MH care.
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Affiliation(s)
- McKenzie K. Roddy
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Alvin D. Jeffery
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | | | - Melissa Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Corey Campbell
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Eric Blake
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Michael J. Ward
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Ward MJ, Kessler C, Abel EA, Ahern J, Bravata DM. Continuing the transformation: charting the path for the future delivery of Veteran emergency care. Acad Emerg Med 2023; 30:232-239. [PMID: 36692104 PMCID: PMC11135051 DOI: 10.1111/acem.14670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/14/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023]
Abstract
Important changes in the delivery of Veteran emergency care in the early 2000s in the Department of Veteran Affairs (VA) emergency departments and urgent care clinics substantially elevated the role of emergency medicine (EM) in Veteran health care. Focused on enhancing the quality of care, emergency care visits in both VA and non-VA (community) care locations have nearly doubled from the 1980s to more than 3 million visits in Fiscal Year 2022. Recognizing the need to plan for continued growth and the opportunity to address key research priorities, the VA Office of Emergency Medicine, together with the VA Health Services Research and Development Service, collaborated to convene a State of the Art Conference on Veteran Emergency Medicine (SAVE) in the winter of 2022. The goal of this conference was to identify research gaps and priorities for implementation of policies for three priority groups: geriatric Veterans, Veterans with mental health and substance use complaints, and Veterans presenting to non-VA (community) emergency care sites. In this article we discuss the rationale for the SAVE conference including a brief history of VA EM and the planning process and conclude with next steps for findings from the conference.
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Affiliation(s)
- Michael J. Ward
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, TN
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Chad Kessler
- Department of Emergency Medicine, Duke University, Durham, NC
- Durham VA Health Care System VA, Durham, NC
| | - Erica A. Abel
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Justin Ahern
- VA Maine Healthcare System, Togus, ME
- Veterans Rural Health Resource Center- Gainesville (VRHRC-GNV), Gainesville, FL
| | - Dawn M. Bravata
- HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical Center, Indianapolis, IN
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN
- Regenstrief Institute, Indianapolis, IN
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Ward MJ, Hwang U, Hastings SN, Timko C, Chen JI, Vashi AA, Mattocks K, Abel EA, Bravata DM. Research and policy recommendations from the SOTA XVI: State of the Art Conference on VA Emergency Medicine. Acad Emerg Med 2023; 30:240-251. [PMID: 36775279 PMCID: PMC11166248 DOI: 10.1111/acem.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/14/2023]
Abstract
To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED. For Veterans with mental health needs, priorities included enhancing the reach of effective, multicomponent suicide prevention interventions; development and evaluation of interventions to manage substance use disorders; and identifying and examining safety and effective acute psychosis practices. Community (non-VA) emergency care priorities included examining changes in patterns of use and costs in VA and the community care settings as a result of recent policy and coverage changes (with an emphasis on modifiable factors); understanding quality, safety, and Veteran experience differences between VA and community settings; and better understanding follow-up needs among Veterans who received emergency care (or urgent care) and how well those needs are being coordinated, communicated, and met. Beyond these three groups, cross-cutting themes included the use of telehealth and implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. Findings from this conference will be disseminated through multiple mechanisms and contribute to future funding applications focused on improving Veteran health.
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Affiliation(s)
- Michael J. Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
| | - Ula Hwang
- James J. Peters VA Medical Center, Geriatric Research, Education and Clinical Center (GRECC), Bronx NY
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - S. Nicole Hastings
- Durham VA Health Care System, HSR&D Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC
| | - Christine Timko
- HSR&D Center for Innovation to Implementation; Center for Innovation to Implementation, VHA Palo Alto Health Care System, Menlo Park, CA
- Department of Psychiatry and Behavioral Science, Stanford University School of Medicine, Stanford, CA
| | - Jason I. Chen
- Portland VA Medical Center, HSR&D Center to Improve Veteran Involvement in Care
- Department of Psychiatry, School of Medicine, Oregon Health & Science University
| | - Anita A. Vashi
- HSR&D Center for Innovation to Implementation; Center for Innovation to Implementation, VHA Palo Alto Health Care System, Menlo Park, CA
- Department of Emergency Medicine, University of California, San Francisco, CA
- Department of Emergency Medicine (Affiliated), Stanford University, Stanford, CA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester MA
| | - Erica A. Abel
- VA Connecticut Healthcare System, HSR&D Pain Research, Informatics, Multi-morbidities, and Education Center, West Haven, CT
- Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT
| | - Dawn M. Bravata
- Richard L. Roudebush VA Medical Center, VA HSR&D Center for Health Information and Communication, Indianapolis, IN
- Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis, IN
- Regenstrief Institute, Indianapolis, IN
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Han JH, Koch E, Jeffery AD, Reese TJ, Dorn C, Pugh S, Rubenstein M, Wilson JE, Campbell C, Ward MJ. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. Acad Emerg Med 2023; 30:262-269. [PMID: 36762876 PMCID: PMC11106754 DOI: 10.1111/acem.14688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/27/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES We sought to characterize how telemental health (TMH) versus in-person mental health consults affected 30-day postevaluation utilization outcomes and processes of care in Veterans presenting to the emergency department (ED) and urgent care clinic (UCC) with acute psychiatric complaints. METHODS This exploratory retrospective cohort study was conducted in an ED and UCC located in a single Veterans Affairs system. A mental health provider administered TMH via iPad. The primary outcome was a composite of return ED/UCC visits, rehospitalizations, or death within 30 days. The following processes of care were collected during the index visit: changes to home psychiatric medications, admission, involuntary psychiatric hold placement, parenteral benzodiazepine or antipsychotic medication use, and physical restraints or seclusion. Data were abstracted from the Veterans Affairs electronic health record and the Clinical Data Warehouse. Multivariable logistic regression was performed. Adjusted odds ratios (aORs) with their 95% confidence intervals (95% CIs) were reported. RESULTS Of the 496 Veterans in this analysis, 346 (69.8%) received TMH, and 150 (30.2%) received an in-person mental health evaluation. There was no significant difference in the primary outcome of 30-day return ED/UCC, rehospitalization, or death (aOR 1.47, 95% CI 0.87-2.49) between the TMH and in-person groups. TMH was significantly associated with increased ED/UCC length of stay (aOR 1.46, 95% CI 1.03-2.06) and decreased use of involuntary psychiatric holds (aOR 0.42, 95% CI 0.23-0.75). There were no associations between TMH and the other processes-of-care outcomes. CONCLUSIONS TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Erica Koch
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Alvin D Jeffery
- Vanderbilt University School of Nursing, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Nursing Services, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chad Dorn
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shannon Pugh
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jo Ellen Wilson
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Corey Campbell
- Psychiatric Services, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Kim B, Grech SM, Rembisz AE, Pinkerson AI, Topor DR, Ramirez DM, Budson AE, Funk MC. Development and Pilot of a Process for Regularly Sharing Summary Patient Safety Data. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2023; 47:53-58. [PMID: 35704161 PMCID: PMC10803175 DOI: 10.1007/s40596-022-01671-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/22/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Dissemination of patient safety data is key to understanding safety events and improving the quality of patient care. However, there is limited guidance on how psychiatry residency programs can create a supportive environment in which to disclose and discuss such information. The authors developed and piloted a resident-led Patient Safety Presentation process at an Accreditation Council for Graduate Medical Education-accredited psychiatry residency program, sharing patient safety data while enhancing residents' education and engagement in patient safety. METHODS From September 2020 through February 2021, the authors convened a workgroup of psychiatry residents and faculty members to devise and conduct the presentation process. The process consisted of an introductory hour-long training of residents in patient safety concepts, followed a week later by the presentation by two psychiatry residents. The authors evaluated the pilot presentation process using pre- and post-presentation resident surveys. RESULTS The introductory training and the Patient Safety Presentation were included into the didactic schedules of all 32 program residents. Twenty (62.5%) and 17 (53.1%) residents completed the pre- and post-presentation surveys, respectively. Improvements were seen in residents' knowledge regarding the medical center's patient safety practices and perspectives on patient safety practices. On the post-presentation survey, all 17 residents reported overall satisfaction with the presentation. CONCLUSIONS The piloted Patient Safety Presentation process increased psychiatry residents' knowledge of and engagement in patient safety. The development and pilot of the presentation process serve as an illustrative case study for other residency programs that are aspiring to grow this aspect of their curriculum.
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Affiliation(s)
- Bo Kim
- VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA.
| | - Sabina M Grech
- VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
| | - Alison E Rembisz
- VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
| | | | - David R Topor
- VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
| | - D Marcela Ramirez
- VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
| | - Andrew E Budson
- VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Margo C Funk
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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10
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Van Schaik G, Self WH, Hennessy C, Ward MJ. Potentially avoidable interfacility transfers following reduced emergency department volumes due to COVID-19 "Safer-at-Home" orders. Am J Emerg Med 2022; 61:68-73. [PMID: 36057211 PMCID: PMC9389782 DOI: 10.1016/j.ajem.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We sought to assess if a state-wide lockdown implemented due to COVID-19 was associated with increased odds of being a potentially avoidable transfer (PAT). METHODS We conducted a retrospective observational analysis using hospital administrative data of interfacility ED-to-ED transfers to a single, quaternary care adult ED after "Safer at Home" orders were issued March 23rd, 2020 in [Blinded for submission]. Using the PAT classification to identify transfers rapidly discharged from the ED or hospital and may not require in-person care, we used a multivariable logistic regression model to examine the association of the lockdown order with odds of a transfer being a PAT. We compared the period January 1, 2018 to March 23, 2020 with March 24, 2020 to September 30, 2020, adjusting for seasonality, patient, and situational factors. RESULTS There were 20,978 ED-to-ED transfers from during this period that were eligible and 4806 (23%) that met PAT criteria. While the first month post-lockdown saw a decrease in PATs (28%), this was not sustained. In the multivariable model there was a significant seasonal effect; May through September had the highest number of transfers as well as PATs. After adjusting for seasonality, the lockdown was not associated with PATs (adjusted odds ratio [aOR] 0.99, 95% CI 0.2, 5.2) and PATs decreased over time. CONCLUSIONS We did not find an effect of the COVID-19 lockdown on PATs though there was a considerable seasonal effect and an overall downward trend in PATs over time.
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Affiliation(s)
- Graham Van Schaik
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, United States of America
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America; VA Tennessee Valley Healthcare System, United States of America; Department of Biomedical Informatics, Vanderbilt University Medical Center, United States of America; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America.
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11
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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] [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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Jouffroy R, Brami E, Scannavino M, Daniel Y, Bertho K, Abriat A, Salomé M, Lemoine S, Jost D, Prunet B, Travers S. Association between prehospital shock index and mortality among patients with COVID-19 disease. Am J Emerg Med 2022; 56:133-136. [PMID: 35397353 PMCID: PMC8970620 DOI: 10.1016/j.ajem.2022.03.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022] Open
Abstract
Background There exists a need for prognostic tools for the early identification of COVID-19 patients requiring intensive care unit (ICU) admission and mortality. Here we investigated the association between a clinical (initial prehospital shock index (SI)) and biological (initial prehospital lactatemia) tool and the ICU admission and 30-day mortality among COVID-19 patients cared for in the prehospital setting. Methods We retrospectively analysed COVID-19 patients initially cared for by a Paris Fire Brigade advanced (ALS) or basic life support (BLS) team in the prehospital setting between 2020, March 08th and 2020, May 30th. We assessed the association between prehospital SI and prehospital lactatemia and ICU admission and mortality using logistic regression model analysis after propensity score matching with Inverse Probability Treatment Weighting (IPTW) method. Covariates included in the IPTW propensity analysis were: age, sex, body mass index (BMI), initial respiratory rate (iRR), initial pulse oximetry without (SpO2i) and with oxygen supplementation (SpO2i.O2), initial Glasgow coma scale (GCSi) value, initial prehospital SI and initial prehospital lactatemia. Results We analysed 410 consecutive COVID-19 patients [254 males (62%); mean age, 64 ± 18 years]. Fifty-seven patients (14%) deceased on the scene, of whom 41 (72%) were male and were significantly older (71 ± 12 years vs. 64 ± 19 years; P 〈10−3). Fifty-three patients (15%) were admitted in ICU and 39 patients (11%) were deceased on day-30. The mean prehospital SI value was 1.5 ± 0.4 and the mean prehospital lactatemia was 2.0 ± 1.7 mmol.l−1. Multivariate logistic regression analysis on matched population after IPTW propensity analysis reported a significant association between ICU admission and age (adjusted Odd-Ratio (aOR), 0.90; 95% confidence interval (95%CI): 0.93–0.98;p = 10−3), SpO2i.O2 (aOR, 1.10; 95%CI: 1.02–1.20;p = 0.002) and BMI (aOR, 1.09; 95% CI: 1.03–1.16;p = 0.02). 30-day mortality was significantly associated with SpO2i.O2 (aOR, 0.92; 95% CI: 0.87–0.98;p = 0.01 P < 10−3) and GCSi (aOR, 0.90; 95% CI: 0.82–0.99;p = 0.04). Neither prehospital SI nor prehospital lactatemia were associated with ICU admission and 30-day mortality. Conclusion Neither prehospital initial SI nor lactatemia were associated with ICU admission and 30-day mortality among COVID-19 patients initially cared for by a Paris Fire Brigade BLS or ALS team. Further prospective studies are needed to confirm these preliminary results.
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Affiliation(s)
- Romain Jouffroy
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France.
| | - Elise Brami
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Marine Scannavino
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Yann Daniel
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Kilian Bertho
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Amandine Abriat
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Marina Salomé
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Sabine Lemoine
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Daniel Jost
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Bertrand Prunet
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
| | - Stéphane Travers
- Paris Fire Brigade, Emergency Medicine dpt, 1 place Jules Renard, 75017 Paris, France
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Mohr NM, Wu C, Ward MJ, McNaughton CD, Faine B, Pomeranz K, Richardson K, Kaboli PJ. Transfer boarding delays care more in low-volume rural emergency departments: A cohort study. J Rural Health 2022; 38:282-292. [PMID: 33644911 PMCID: PMC8715860 DOI: 10.1111/jrh.12559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals. METHODS A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas. FINDINGS A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs. CONCLUSIONS Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.
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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;,Department of Emergency Medicine, University of Iowa Carver College of Medicine;,Department of Anesthesia, University of Iowa Carver College of Medicine
| | - Chaorong Wu
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, Iowa
| | - Michael J. Ward
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Candace D. McNaughton
- Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee;,Department of Emergency Medicine, Vanderbilt University Medical Center
| | - Brett Faine
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kaila Pomeranz
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Kelly Richardson
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA
| | - Peter J. Kaboli
- Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA;,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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14
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Ward MJ, Shuster JL, Mohr NM, Kaboli PJ, Mixon AS, Kemmer J, Campbell C, McNaughton CD. Implementation of Telehealth for Psychiatric Care in VA Emergency Departments and Urgent Care Clinics. Telemed J E Health 2021; 28:985-993. [PMID: 34788149 DOI: 10.1089/tmj.2021.0263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To conduct a mixed-methods evaluation of an emergency telehealth intervention in unscheduled settings (emergency department [ED] and urgent care clinic [UCC]) within the Veterans Health Administration (VHA). Materials and Methods: We used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to conduct a mixed-methods evaluation of a novel telehealth program implemented in the VHA (Hospital System) in March 2020. We compared the 3 months preimplementation (December 1, 2019 through February 29, 2020) with the 3 months postimplementation (April 1, 2020 through June 30, 2020), then followed sustainability through January 31, 2021. Qualitative data were obtained from surveys and semistructured interviews of staff and providers and analyzed with thematic analysis. Results: Patient demographics and dispositions were similar pre- and postimplementation. The telemental health intervention was used in 319 (83%) unscheduled mental health consultations in the postimplementation phase. After implementation, we did not detect adverse trends in length of stay, 7-day revisits, or 30-day mortality. Use remained high with 82% (n = 1,010) of all unscheduled mental health consultations performed by telemental health in the sustainability phase. Staff and clinician interviews identified the following themes in the use of telemental health: (1) enhanced efficiency without compromising quality and safety, (2) initial apprehension, (3) the COVID-19 pandemic, and (4) sustainability after resolution of the COVID-19 pandemic. Conclusions: This mixed-methods evaluation of unscheduled telemental health implementation found that its use was feasible, did not impact the safety and efficacy of mental health consultations, and was highly acceptable and sustainable in unscheduled settings.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt University Department of Biomedical Informatics, Nashville, Tennessee, USA.,VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - John L Shuster
- VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Nicholas M Mohr
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Department of Emergency Medicine, and University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Peter J Kaboli
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Amanda S Mixon
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Jennifer Kemmer
- VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Corey Campbell
- VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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Wright MK, Gong W, Hart K, Self WH, Ward MJ. Association of insurance status with potentially avoidable transfers to an academic emergency department: A retrospective observational study. J Am Coll Emerg Physicians Open 2021; 2:e12385. [PMID: 33733247 PMCID: PMC7936794 DOI: 10.1002/emp2.12385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/08/2021] [Accepted: 01/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interfacility transfers between emergency department (EDs) are common and at times unnecessary. We sought to examine the role of health insurance status with potentially avoidable transfers. METHODS We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED-to-ED transfers to a single, quaternary care adult ED in 2018. We defined a potentially avoidable transfer as an ED-to-ED transfer in which the patient did not receive a procedure from a specialist at the receiving hospital and was discharged from the ED or the receiving hospital within 24 hours of arrival. We constructed a multivariable logistic regression model to examine whether insurance status was associated with potentially avoidable transfers among all ED-to-ED transfers adjusting for patient demographics, severity, mode of arrival, clinical condition, and rurality. RESULTS Among 7508 transfers, 1862 (25%) were potentially avoidable and were more likely to be uninsured (20% vs 9%). In the multivariable analysis, among ED-to-ED transfers for adults aged 18-64 years old who were uninsured (vs any insurance) were significantly more likely to be potentially avoidable (adjusted odds ratio [aOR] 2.1 [1.7, 2.4]) and there is a significant interaction with age. Potentially avoidable transfers increased with younger age, male sex, black (vs white), small rural classification (vs urban), and arrival by ground ambulance (vs flight). CONCLUSIONS Potentially avoidable transfers comprised 1 in 4 transfers. Patients who lack insurance were more than twice as likely to be classified as potentially avoidable even after evaluating for confounders and interactions. This effect was most pronounced among younger patients. Further research is needed to explore why uninsured patients are disproportionately more likely to experience potentially avoidable transfers.
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Affiliation(s)
- Megan K. Wright
- Vanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Wu Gong
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Kimberly Hart
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Wesley H. Self
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Michael J. Ward
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- VA Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
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Fernandes-Taylor S, Yang DY, Schumacher J, Ljumani F, Fertel BS, Ingraham A. Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments. Am J Emerg Med 2020; 40:83-88. [PMID: 33360394 DOI: 10.1016/j.ajem.2020.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States. METHOD We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital. RESULTS Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals. CONCLUSION Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.
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Affiliation(s)
- Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Jessica Schumacher
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Fiona Ljumani
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Baruch S Fertel
- Emergency Services Institute & Enterprise Quality and Safety Cleveland Clinic, Cleveland OH, United States of America
| | - Angela Ingraham
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
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The prehospital SIGARC score to assess septic shock in-hospital, 30-day and 90-day mortality. Am J Emerg Med 2020; 46:355-360. [PMID: 34348435 DOI: 10.1016/j.ajem.2020.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/05/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In the pre-hospital setting the early identification of septic shock (SS) patients presenting with a high risk of poor outcome remains a daily challenge. The development of a simple score to quickly identify these patients is essential to optimize triage towards the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the new SIGARC score and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS SS patients cared for by a MICU between 2017, April 15th, and 2019, December 1st were included in this retrospective study. The SIGARC score consists of the addition of 5 following items (1 point for each one): shock index≥1, Glasgow coma scale<13, age > 65, respiratory rate > 22 and comorbidity defined by the presence of at least 2 underlying conditions among: hypertension, coronaropathy, chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, diabetes mellitus, history of cancer and human immunodeficiency virus infection. A threshold of SIGARC score ≥ 2 was arbitrarily chosen to define severity for its usefulness in clinical practice. RESULTS Data from 406 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 71 ± 15 years and 268 of the patients (66%) were male. The presumed origin of SS was pulmonary (42%), digestive (25%) or urinary (17%) infection. Overall in-hospital mortality was 31% with, 30 and 90-day mortality was respectively 28% and 33%. A prehospital SIGARC score ≥ 2 is associated with an increase in 30 and 90-day mortality with HR = 1.57 [1.02-2.42] and 1.82 [1.21-2.72], respectively. CONCLUSION A SIGARC score ≥ 2 is associated with an increase in in-hospital, 30 and 90-day mortality of SS patients cared for by a MICU in the prehospital setting. These observational results need to be confirmed by prospective studies.
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Hypoxemia Index Associated with Prehospital Intubation in COVID-19 Patients. J Clin Med 2020; 9:jcm9093025. [PMID: 32962227 PMCID: PMC7563105 DOI: 10.3390/jcm9093025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There exists a need for prognostic tools for the early identification of COVID-19 patients requiring prehospital intubation. Here we investigated the association between a prehospital Hypoxemia Index (HI) and the need for intubation among COVID-19 patients in the prehospital setting. METHODS We retrospectively analyzed COVID-19 patients initially cared for by a Paris Fire Brigade advanced life support (ALS) team in the prehospital setting between 8th March and 18th April of 2020. We assessed the association between HI and prehospital intubation using receiver operating characteristic (ROC) curve analysis and logistic regression model analysis after propensity score matching. Results are expressed as odds ratio (OR) and 95% confidence interval (CI). RESULTS We analyzed 300 consecutive COVID-19 patients (166 males (55%); mean age, 64 ± 18 years). Among these patients, 45 (15%) were deceased on the scene, 34 (11%) had an active care restriction, and 18 (6%) were intubated in the prehospital setting. The mean HI value was 3.4 ± 1.9. HI was significantly associated with prehospital intubation (OR, 0.24; 95% CI: 0.12-0.41, p < 10-3) with a corresponding area under curve (AUC) of 0.91 (95% CI: 0.85-0.98). HI significantly differed between patients with and without prehospital intubation (1.0 ± 1.0 vs. 3.6 ± 1.8, respectively; p < 10-3). ROC curve analysis defined the optimal HI threshold as 1.3. Bivariate analysis revealed that HI <1.3 was significantly, positively associated with prehospital intubation (OR, 38.38; 95% CI: 11.57-146.54; p < 10-3). Multivariate logistic regression analysis demonstrated that prehospital intubation was significantly associated with HI (adjusted odds ratio (ORa), 0.20; 95% CI: 0.06-0.45; p < 10-3) and HI <3 (ORa, 51.08; 95% CI: 7.83-645.06; p < 10-3). After adjustment for confounders, the ORa between HI <1.3 and prehospital intubation was 3.6 (95% CI: 1.95-5.08; p < 10-3). CONCLUSION An HI of <1.3 was associated with a 3-fold increase in prehospital intubation among COVID-19 patients. HI may be a useful tool to facilitate decision-making regarding prehospital intubation of COVID-19 patients initially cared for by a Paris Fire Brigade ALS team. Further prospective studies are needed to confirm these preliminary results.
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