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Malone TL, Gurzenda S, Reiter KL, Pink GH, Greenwood-Ericksen MB. Suitability of Low-Volume Rural Emergency Departments to New Rural Emergency Hospital Designation. Ann Emerg Med 2024; 83:177-180. [PMID: 37747385 DOI: 10.1016/j.annemergmed.2023.08.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Tyler L Malone
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill.
| | - Susie Gurzenda
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Kristin L Reiter
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill
| | - George H Pink
- North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Margaret B Greenwood-Ericksen
- Department of Emergency Medicine, University of New Mexico, Albuquerque; Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque
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Mamalelala TT, Holzemer W, Seloilwe ES, Iwu E, Kamienski M. Experiences of rural nurses with emergency patient transport in a resource limited setting. Int Emerg Nurs 2023; 71:101379. [PMID: 37951060 DOI: 10.1016/j.ienj.2023.101379] [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] [Received: 07/20/2023] [Revised: 10/05/2023] [Accepted: 10/25/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Registered nurses are primary care providers during most patient transfers from rural areas. Various local conditions and circumstances impact the provision of nursing care prior to and during transportation. These include clinic staffing, uneven access to functioning equipment and other necessary infrastructure across settings, the wide-ranging clinical need for specialty care, and complex social and interpersonal circumstances that play a role in care-seeking and transport decision-making. This study explored the experiences of nurses with emergency patient transport in rural health facilities in Botswana. METHOD A qualitative descriptive approach was used using a semi structured interview. Twenty-six registered nurses from four remote, isolated rural health districts in Botswana participated in this study. Purposive convenience sampling technique was employed. RESULTS The ten main themes under transporter were infringement of scope of practice, inadequate knowledge and skills, distressful practice, restriction from making decisions, challenges with staffing, Ineffective facilities clustering, lack of support from the managers, shortage of technology and tools, non-enabling infrastructure, and transport related tasks. DISCUSSION AND CONCLUSION The perceived ineffective emergency transfer of patients was associated with work system shortfalls. The work system needs to be balanced and consider the requirements of the various stakeholders involved in the processes for optimal performance of patient transport.
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Affiliation(s)
- Tebogo T Mamalelala
- School of Nursing, Rutgers, The State University of New Jersey, United States; School of Nursing, University of Botswana, Botswana.
| | - William Holzemer
- School of Nursing, Rutgers, The State University of New Jersey, United States
| | - Esther S Seloilwe
- Faculty of Health Sciences, School of Nursing, University of Botswana, Gaborone, Botswana
| | - Emilia Iwu
- School of Nursing, Rutgers, The State University of New Jersey, United States
| | - Mary Kamienski
- School of Nursing, Rutgers, The State University of New Jersey, United States
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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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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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Min HS, Sung HK, Choi G, Sung H, Lee M, Kim SJ, Ko E. Operation of national coordinating service for interhospital transfer from emergency departments: experience and implications from Korea. BMC Emerg Med 2023; 23:15. [PMID: 36765283 PMCID: PMC9913013 DOI: 10.1186/s12873-023-00782-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/30/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Since 2014, Korea has been operating the National Emergency Medical Situation Room (NEMSR) to provide regional emergency departments (EDs) with coordination services for the interhospital transfer of critically ill patients. The present study aimed to describe the NEMSR's experience and interhospital transfer pattern from EDs nationwide, and investigate the factors related to delayed transfers or transfers that could not be arranged by the NEMSR. METHODS This study was a retrospective cross-sectional analysis of the NEMSR's coordination registry from 2017 to 2019. The demographic and hospital characteristics related to emergency transfers were analyzed with hierarchical logistic models. RESULTS The NEMSR received a total of 14,003 requests for the arrangement of the interhospital transfers of critically ill patients from 2017 to 2019. Of 10,222 requests included in the analysis, 8297 (81.17%) successful transfers were coordinated by the NEMSR. Transfers were requested mainly due to a shortage of medical staff (59.79%) and ICU beds (30.80%). Delayed transfers were significantly associated with insufficient hospital resources. The larger the bed capacity of the sending hospital, the more difficult it was to coordinate the transfer (odds ratio [OR] for transfer not arranged = 2.04; 95% confidence interval [CI]: 1.48-2.82, ≥ 1000 beds vs. < 300 beds) and the longer the transfer was delayed (OR for delays of more than 44 minutes = 2.08; 95% CI: 1.57-2.76, ≥ 1000 beds vs. < 300 beds). CONCLUSIONS The operation of the NEMSR has clinical importance in that it could efficiently coordinate interhospital transfers through a protocolized process and resource information system. The coordination role is significant as information technology in emergency care develops while regional gaps in the distribution of medical resources widen.
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Affiliation(s)
- Hye Sook Min
- grid.415619.e0000 0004 1773 6903Public Health Research Institute, National Medical Center, Seoul, South Korea
| | - Ho Kyung Sung
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea
| | - Goeun Choi
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea
| | - Hyehyun Sung
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea ,grid.31501.360000 0004 0470 5905Seoul National University College of Nursing, Seoul, South Korea
| | - Minhee Lee
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea ,grid.254187.d0000 0000 9475 8840Department of Nursing, Graduate School, Chosun University, Gwangju, South Korea
| | - Seong Jung Kim
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea ,grid.254187.d0000 0000 9475 8840Department of Emergency Medicine, College of Medicine, Chosun University, Gwangju, South Korea
| | - Eunsil Ko
- National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564, South Korea.
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Mamalelala TT, Mokone DJ, Obeng-Adu F. Health-related reasons patients transfer from a clinic or health post to the Emergency Department in a District Hospital in Botswana. Afr J Emerg Med 2022; 12:339-343. [PMID: 35967086 PMCID: PMC9363965 DOI: 10.1016/j.afjem.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 06/21/2022] [Accepted: 07/24/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Rural health clinics in low-resource settings worldwide are usually staffed with health care workers with limited knowledge and skills in managing acute emergencies. The Emergency Centre (EC) at the district hospital or primary hospital serves as an entry point for patients with diverse medical needs from health posts and community clinics. The study described the socio-demographic characteristics, primary diagnosis, and disposition of patients transferred from the clinics and health posts to the district hospital in the Kweneng district. Method This study is a chart audit of the triage sheets and admitting medical records (Botswana Integrated Patient Management System, IPMS) conducted for the period June through to December 2020. Descriptive statistics were used to analyze the quantitative data. Frequencies, percentages, and measures of central tendency were calculated using the software, SPSS version 27. Results A total of 1565 charts were reviewed; 56% (n = 877) were females and 43.5% (n = 681) were males. Half of the patients presenting to the EC ranged from ages 21 to 50, with a mean age of 36.49. The most frequently reported reason for referral was “trauma,” (23.5%, n = 368) whereas the second common reason for referral was abortion-related complications (14.2%, n = 222). The highest admissions were from abortion-related complications (20.2%, n = 169). Most patients’ transfers were from clinics and health posts outside Molepolole (59.4%, n = 930). More than half of the patients (64.2%, n = 537) transferred from outside Molepolole were admitted than discharged from the EC. Discussion Our study has shown significant transfers to a higher facility for emergency care. The higher number of transfers are trauma-related cases, whereas most patients were admitted for abortion-related complications indicating the need for skill-building in trauma care and management of abortions.
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Affiliation(s)
- Tebogo T Mamalelala
- School of Nursing, University of Botswana, Gaborone, Botswana
- Rutgers University School of Nursing, New Brunswick, New Jersey, United States
- Corresponding author.
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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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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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Adequacy of care during interfacility transfer in Taiwan: A pilot study. J Formos Med Assoc 2022; 121:1864-1871. [DOI: 10.1016/j.jfma.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/13/2022] [Accepted: 03/21/2022] [Indexed: 11/19/2022] Open
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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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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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Greenwood-Ericksen M, Kamdar N, Lin P, George N, Myaskovsky L, Crandall C, Mohr NM, Kocher KE. Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries. JAMA Netw Open 2021; 4:e2134980. [PMID: 34797370 PMCID: PMC8605483 DOI: 10.1001/jamanetworkopen.2021.34980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). OBJECTIVE To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. DESIGN, SETTING, AND PARTICIPANTS This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. RESULTS The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. CONCLUSIONS AND RELEVANCE The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.
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Affiliation(s)
- Margaret Greenwood-Ericksen
- Department of Emergency Medicine, University of New Mexico, Albuquerque
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Naomi George
- Department of Emergency Medicine, University of New Mexico, Albuquerque
- Division of Critical Care, Department of Emergency Medicine, University of New Mexico, Albuquerque
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque
| | - Cameron Crandall
- Department of Emergency Medicine, University of New Mexico, Albuquerque
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City
- Department of Anesthesia–Critical Care Medicine, University of Iowa, Iowa City
| | - Keith E. Kocher
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
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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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