The role of increasing synchronous telehealth use during the COVID-19 pandemic on disparities in access to healthcare: A systematic review

INTRODUCTION

The COVID-19 public health emergency led to an unprecedented rapid increase in telehealth use, but the role of telehealth in reducing disparities in access to care has been questioned. The objective of this study was to conduct a systematic review to summarize the available evidence on how telehealth during the COVID-19 pandemic was associated with telehealth utilization for minority groups and its role in health disparities.

METHODS

We conducted a systematic review focused on health equity and access to care by searching for interventional and observational studies using the following four search domains: telehealth, COVID-19, health equity, and access to care. We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, telehealth.hhs.gov, and the Rural Health Research Gateway, and included any study that reported quantitative results with a control group.

RESULTS

Our initial search yielded 1970 studies, and we included 48 in our final review. The most common dimensions of health equity studied were race/ethnicity, rurality, insurance status, language, and socioeconomic status, and the telehealth applications studied were diverse. Included studies had a moderate risk of bias. In aggregate, most studies reported increased telehealth use during the pandemic, with the greatest increase in non-minority populations, including White, younger, English-speaking people from urban areas.

DISCUSSION

We found that despite rapid adoption and increased telehealth use during the public health emergency, telehealth did not reduce existing disparities in access to care. We recommend that future work measuring the impact of telehealth focus on equity so that features of telehealth innovation can reduce disparities in health outcomes.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments

BACKGROUND

Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs.

METHODS

Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions.

RESULTS

In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar.

CONCLUSIONS

Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Race, Ethnicity, and Delayed Time to COVID-19 Testing Among US Health Care Workers

Importance

Access to COVID-19 testing is critical to reducing transmission and supporting early treatment decisions; when made accessible, the timeliness of testing may also be an important metric in mitigating community spread of the infection. While disparities in transmission and outcomes of COVID-19 have been well documented, the extent of timeliness of testing and the association with demographic factors is unclear.

Objectives

To evaluate demographic factors associated with delayed COVID-19 testing among health care personnel (HCP) during the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional study used data from the Preventing Emerging Infections Through Vaccine Effectiveness Testing study, a multicenter, test-negative, case-control vaccine effectiveness study that enrolled HCP who had COVID-19 symptoms and testing between December 2020 and April 2022. Data analysis was conducted from March 2022 to Junne 2023.

Exposure

Displaying COVID-19-like symptoms and polymerase chain reaction testing occurring from the first day symptoms occurred up to 14 days after symptoms occurred.

Main Outcomes and Measures

Variables of interest included patient demographics (sex, age, and clinical comorbidities) and COVID-19 characteristics (vaccination status and COVID-19 wave). The primary outcome was time from symptom onset to COVID-19 testing, which was defined as early testing (≤2 days) or delayed testing (≥3 days). Associations of demographic characteristics with delayed testing were measured while adjusting for clinical comorbidities, COVID-19 characteristics, and test site using multivariable modeling to estimate relative risks and 95% CIs.

Results

A total of 5551 HCP (4859 female [82.9%]; 1954 aged 25-34 years [35.2%]; 4233 non-Hispanic White [76.3%], 370 non-Hispanic Black [6.7%], and 324 non-Hispanic Asian [5.8%]) were included in the final analysis. Overall, 2060 participants (37.1%) reported delayed testing and 3491 (62.9%) reported early testing. Compared with non-Hispanic White HCP, delayed testing was higher among non-Hispanic Black HCP (adjusted risk ratio, 1.18; 95%CI, 1.10-1.27) and for non-Hispanic HCP of other races (adjusted risk ratio, 1.17; 95% CI, 1.03-1.33). Sex and age were not associated with delayed testing. Compared with clinical HCP with graduate degrees, all other professional and educational groups had significantly delayed testing.

Conclusions and Relevance

In this cross-sectional study of HCP, compared with non-Hispanic White HCP and clinical HCP with graduate degrees, non-Hispanic Black HCP, non-Hispanic HCP of other races, and HCP all other professional and education backgrounds were more likely to have delayed COVID-19 testing. These findings suggest that time to testing may serve as a valuable metric in evaluating sociodemographic disparities in the response to COVID-19 and future health mitigation strategies.

Emergency medicine residency pathways for MD/PhD trainees: A national cross-sectional study of physician-scientist training programs

Background

Combined clinical and research training is common in residency programs outside emergency medicine (EM), and these pathways are particularly valuable for combined MD/PhD graduates planning to pursue a career as a physician-scientist. However, EM departments may not know what resources to provide these trainees during residency to create research-focused, productive, future faculty, and trainees may not know which programs support their goal of becoming a physician-scientist in EM. The objective of this study was to describe research training and resources available to MD/PhD graduates in EM residency training with a focus on dedicated research pathways.

Methods

This study was a cross-sectional inventory conducted through an electronic survey of EM residency program directors. We sought to identify dedicated MD/PhD research training pathways, with a focus on both resources and training priorities. Descriptive statistics were used to summarize survey responses.

Results

We collected 192 survey responses (69.6% response rate). Among respondents, 41 programs (21.4%) offered a research pathway/track, 52 (27.4%) offered a research fellowship, 22 (11.5%) offered both a residency research pathway/track and a research fellowship, and two (1.0%) offered a dedicated EM physician-scientist training pathway. Most programs considered research a priority and were enthusiastic about interviewing applicants planning a research career, but recruitment of physician-scientist applicants was not generally prioritized.

Conclusions

Some EM residency programs offer combined clinical and mentored research training for prospective physician-scientists, and nearly all residency programs considered research important. Future work will focus on improving the EM physician-scientist pipeline by optimizing pathways available to trainees during residency and fellowship.

Long-Term Impacts of a Targeted Intervention in the Emergency Department on Inpatient Prescribing Practices

Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide.

Telehealth Use and Health Equity for Mental Health and Substance Use Disorder During the COVID-19 Pandemic: A Systematic Review

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.

Chronic Disease Management through Clinical Video Telehealth on Health Care Utilization, and Mortality in the Veterans Health Administration: A Retrospective Cohort Study

Background: Chronic health diseases such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM) affect 6 in 10 Americans and contribute to 90% of the $4.1 trillion health care expenditures. The objective of this study was to measure the effect of clinical video telehealth (CVT) on health care utilization and mortality. A retrospective cohort study of Veterans ≥65 years with CHF, COPD, or DM was conducted. Measures: Veterans using CVT were matched 1:3 on demographic characteristics to Veterans who did not use CVT. Outcomes included 1-year incidence of ED visits, inpatient admissions, and mortality, reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Final analytical cohorts included 22,280 Veterans with CHF, 51,872 Veterans with COPD, and 170,605 Veterans with DM. CVT utilization was associated with increased ED visits for CHF (aOR: 1.24; 95% CI: 1.15-1.34), COPD (aOR: 1.20; 95% CI: 1.14-1.26), and DM (aOR: 1.07; 95% CI: 1.00-1.10). For CHF, there was no difference between CVT utilization and inpatient admissions (aOR: 0.98; 95% CI 0.91-1.05) or mortality (aOR: 1.03; 95% CI: 0.93-1.15). For COPD, CVT was associated with increased inpatient admissions (aOR: 1.08; 95% CI: 1.02-1.13) and mortality (aOR: 1.36; 95% CI: 1.25-1.48). For DM, CVT utilization was associated with lower risk of inpatient admissions (aOR: 0.83; 95% CI: 0.80-0.86) and mortality (aOR: 0.89; 95% CI: 0.84-0.95). Conclusions: CVT use as an alternative care site might serve as an early warning system, such that this mechanism may indicate when an in-person assessment is needed for potential exacerbation of conditions. Although inpatient and mortality varied, ED utilization was higher with CVT. Exploring pathways accessing clinical care through CVT, and how CVT is directly or indirectly associated with immediate and long-term clinical outcomes would be valuable.

Effect of Chronic Disease Home Telehealth Monitoring in the Veterans Health Administration on Healthcare Utilization and Mortality

BACKGROUND

The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes.

OBJECTIVE

To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM.

DESIGN

Comparative effectiveness matched cohort study.

PATIENTS

Veterans aged 65 years and older treated for CHF, COPD, or DM.

MAIN MEASURES

We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality.

KEY RESULTS

A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16).

CONCLUSIONS

The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.

Pediatric lawn mower-related injuries and contributing factors for bystander injuries

BACKGROUND

Riding lawn mower injuries are the most common cause of major limb loss in young U.S. children. Our study objective was to investigate the circumstances surrounding pediatric riding lawn mower injuries and to identify potential contributing risk factors and behaviors leading to these events.

METHODS

Followers/members of both a public and a private lawn mower injury support and prevention Facebook page who had or were aware of children who had suffered a lawn mower-related injury were invited to complete an electronic survey on Qualtrics. Duplicate cases and those involving push mowers were removed. Frequencies and chi-square analyses were performed.

RESULTS

140 injured children were identified with 71% of surveys completed by parents and 19% by an adult survivor of a childhood incident. The majority of injured children were Caucasian (94%), male (64%), and ≤ 5 years of age at the time of the incident (63%). Bystanders were 69% of those injured, 24% were lawn mower riders, and mower operators and others accounted for 7%. The lawn mower operator was usually male (77%), being the father/stepfather in almost half. Overall, 59% of injuries occurred while traveling in reverse, 29% while moving forward. Nearly all (92%) had an amputation and/or permanent disability. Subgroup analysis (n = 130) found injured bystanders were younger than injured passengers with 71% versus 45% being < 5 years of age, respectively (p = 0.01). Over three-quarters of bystander incidents occurred while moving in reverse as compared to 17% of passenger incidents (p < 0.01). Amputations and/or permanent disabilities were greater among bystanders (97%) as compared to passengers (79%, p = 0.01). Only 3% of bystanders had an upper extremity injury as compared to 21% of passengers (p = 0.01). Seventy-three percent of bystander victims had received at least one ride on a lawn mower prior to their injury incident.

CONCLUSIONS

Child bystanders seriously injured by riding lawn mowers were frequently given prior rides likely desensitizing them to their inherent dangers and leading them to seek rides when mowers were being used. Engineering changes preventing blade rotation when traveling in reverse and not giving children rides (both when and when not mowing) may be critical in preventing mower-related injuries.

Evaluation of Telepsychiatry Services Implementation in Medical and Psychiatric Inpatient Settings: A Mixed-Methods Study

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.

Virtual Partnership Addressing Mental Health Crises: Mixed Methods Study of a Coresponder Program in Rural Law Enforcement

BACKGROUND

A mental health crisis can create challenges for individuals, families, and communities. This multifaceted issue often involves different professionals from law enforcement and health care systems, which may lead to siloed and suboptimal care. The virtual crisis care (VCC) program was developed to provide rural law enforcement with access to behavioral health professionals and facilitated collaborative care via telehealth technology.

OBJECTIVE

This study was designed to evaluate the implementation and use of a VCC program from a telehealth hub for law enforcement in rural areas.

METHODS

This study used a mixed methods approach. The quantitative data came from the telehealth hub's electronic record system. The qualitative data came from in-depth interviews with law enforcement in the 18 counties that adopted the VCC program.

RESULTS

Across the 181 VCC encounters, the telehealth hub's recommended disposition and the actual disposition were similar for remaining in place (n=141, 77.9%, and n=137, 75.7%, respectively), voluntary admission (n=9, 5.0%, and n=10, 5.5%, respectively), and involuntary committal (IVC; n=27, 14.9%, and n=19, 10.5%, respectively). Qualitative insights related to the VCC program's implementation, use, benefits, and challenges were identified, providing a comprehensive view of the virtual partnership between rural law enforcement and behavioral health professionals.

CONCLUSIONS

Use of a VCC program likely averts unnecessary IVCs. Law enforcement interviews affirmed the positive impact of VCC due to its ease of use and the benefits it provides to the individuals in need, the first responders involved, law enforcement resources, and the community.

Inpatient boarding definitions and mitigation strategies: A cross-sectional survey of academic emergency departments in the United States

OBJECTIVE

Conceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management.

METHODS

This was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated.

RESULTS

Of the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 h, while 34% considered patients boarded >4 h after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%).

CONCLUSIONS

We found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding.

The impact of fellowship-trained medical toxicology faculty on emergency medicine resident in-training examination scores

BACKGROUND

The American Board of Emergency Medicine (ABEM) In Training Exam (ITE) gauges residents' medical knowledge and has been shown to correlate with subsequent performance on the ABEM board qualifying examination. It is common for emergency medicine (EM) residencies to employ subspecialty-trained faculty members with the expectation of improved resident education and subspecialty knowledge. We hypothesized that the presence of subspecialty faculty in toxicology would increase residents' scores on the toxicology portion of the ITE.

METHODS

We assessed ABEM ITE scores at our institution from 2013-2022 and compared these to national data. The exposure of interest was the absence or presence of fellowship-trained toxicology faculty. The primary outcome was performance on the toxicology portion of the ITE, and secondary outcome was overall performance on the exam.

RESULTS

Residents who had ≥1 toxicology faculty were 37% (95% CI: 1.01-1.87) more likely to surpass the national average for toxicology scores, and those who had ≥2 toxicology faculty were 77% (95% CI: 1.28-2.44) more likely to surpass the national average for toxicology scores on the ABEM ITE. With the presence of ≥2 toxicology faculty, there was also an increase in toxicology score by years in training, with residents being 63% (95% CI: 1.01-2.64), 68% (95% CI: 1.08-2.61), and 92% (95% CI: 1.01-3.63) more likely to surpass the national average for toxicology score in first, second, and third years of residency, respectively. There was no significant relationship between the presence of toxicology faculty and the overall ABEM ITE scores.

CONCLUSIONS

The presence of fellowship-trained toxicology faculty positively impacted residents' performance on the toxicology portion of the ABEM ITE but did not significantly impact the overall score. With the presence of ≥2 toxicology faculty we noted an improvement in toxicology scores throughout the 3 years of training, indicating that an individual rotation or educational block is probably less important than spaced repetition through a longitudinal curriculum.

Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans

OBJECTIVE

Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment.

METHODS

A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.

RESULTS

Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65).

CONCLUSIONS

As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.

Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America

OBJECTIVES

The objective was to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit in the emergency department (ED) on hospital admissions, ED length of stay, and 30-day follow-up for patients presenting with suicidal ideation or attempt.

METHODS

This study was a before-and-after analysis of introducing the EmPATH unit within a Midwestern academic medical center on outcomes of adult patients (≥18 years) presenting with suicidal ideation or suicidal attempt. The primary outcome in this study was the change in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED before and after implementation of the EmPATH unit. Secondary outcomes compared were changes in proportion of any admission, incomplete admission defined as discharge from the ED after admission request placed, outpatient follow-up, return ED visits within 30 days of admission, and ED boarding time. Association between the EmPATH unit implementation and categorical outcomes were determined using log-binomial regression to estimate relative risks (RRs) and 95% confidence intervals (CIs). Continuous outcomes were log-transformed and generalized estimating equations were used to examine as the mean difference by time period.

RESULTS

There were 962 patients presenting with suicidal ideation (n = 435 before EmPATH unit, n = 527 after EmPATH unit). Compared to the pre-EmPATH-unit period, there was a reduction in psychiatric admission (RR = 0.48, 95% CI = 0.40 to 0.56), any admission (RR = 0.65, 95% CI = 0.58 to 0.73), incomplete admission (RR = 0.22, 95% CI = 0.11 to 0.43), and 30-day return to the ED (RR = 0.74, 95% CI = 0.56 to 0.98). ED boarding time among admitted patients was reduced by approximately two-thirds both in admitted patients (RR = 0.34, 95% CI = 0.30 to 0.39) and among those with incomplete admissions (RR = 0.37, 95% CI = 0.23 to 0.61). There was a 60% increase in a 30-day follow-up care established at the time of discharge (RR = 1.60, 95% CI = 1.40 to 1.82).

CONCLUSIONS

The introduction of the EmPATH unit has improved management of patients presenting to the ED with suicidal attempts/ideation by reducing ED boarding and unnecessary admissions and establishing post-ED follow-up care.

Mobile Crisis Outreach and Emergency Department Utilization: A Propensity Score-matched Analysis

Introduction

Mental health and substance use disorder (MHSUD) patients in the emergency department (ED) have been facing increasing lengths of stay due to a shortage of inpatient beds. Previous research indicates mobile crisis outreach (MCO) reduces long ED stays for MHSUD patients. Our objective was to assess the impact of MCO contact on future ED utilization.

Methods

We conducted a retrospective chart review of patients presenting to a large Midwest university ED with an MHSUD chief complaint from 2015–2018. We defined the exposure as those who had MCO contact and any MHSUD-related ED visit within 30 days of MCO contact. The MCO patients were 2:1 propensity score–matched by demographic data and comorbidities matched to patients with no MCO contact. Outcomes were all-cause and psychiatric-specific reasons for return to the ED within one year of the index ED visit. We report descriptive statistics and odds ratios (OR) to describe the difference between the two groups, and hazard ratios (HR) to estimate the risk of return ED visit.

Results

The final sample included 106 MCO and 196 non-MCO patients. The MCO patients were more likely to be homeless (OR 14.8; 95% confidence interval [CI],1.87, 117), less likely to have adequate family or social support (OR 0.51; 95% CI, 0.31, 0.84), and less likely to have a hospital bed requested for them in the index visit by ED providers (OR 0.50; 95% CI, 0.29, 0.88). For those who returned to the ED, the median time for all-cause return to the ED was 28 days (interquartile range [IQR]: 6–93 days) for the MCO patients and 88 days (IQR: 20–164 days) for non-MCO patients. The risk of all-cause return to the ED was greater among MCO patients (67%) compared to non-MCO patients (49%) (adjusted HR: 1.66; 95% CI, 1.22, 2.27).

Conclusion

The MCO patients had less family and social support; however, they were less likely to require hospitalization for each visit, likely due to MCO involvement. Patients with MCO contact presented to the ED more frequently than non-MCO patients, which implies a strong linkage between the ED and MCO in our community. An effective referral to community service from the ED and MCO and collaboration could be the next step to improve healthcare utilization.

Agricultural workers in meatpacking plants presenting to an emergency department with suspected COVID-19 infection are disproportionately Black and Hispanic

Objective

Facilities that process and package meat for consumer sale and consumption (meatpacking plants) were early sites of coronavirus disease 2019 (COVID‐19) outbreaks. The aim of this study was to characterize the association between meatpacking plant exposure and clinical outcomes among emergency department (ED) patients with COVID‐19 symptoms.

Methods

This was a retrospective cohort study of patients presenting to a single ED, from March 1 to May 31, 2020, who had: 1) symptoms consistent with COVID‐19 and 2) a COVID‐19 test performed. The primary outcome was COVID‐19 positivity, and secondary outcomes included hospital admission from the ED, ventilator use, intensive care unit (ICU) admission, hospital length of stay (LOS; <48 or ≥48 h), and mortality.

Results

Patients from meatpacking plants were more likely to be Black or Hispanic than the ED patients without this occupational exposure. Patients with a meatpacking plant exposure were more likely to test positive for COVID‐19 (adjusted relative risk [aRR] = 2.37, 95% confidence interval [CI] = 1.59 to 3.53) but had similar rates of hospital admission (aRR = 0.94, 95% CI = 0.82 to 1.07) and hospital LOS (aRR = 0.76, 95% CI = 0.45 to 1.23). There was no significant difference in ventilator use among patients with meatpacking and nonmeatpacking plant exposure (8.2% vs. 11.1%, p = 0.531), ICU admissions (4.1% vs. 12.0%, p = 0.094), and mortality (2.0% vs. 4.1%, p = 0.473).

Conclusions

Workers in meatpacking plants in Iowa had a higher rate of testing positive for COVID‐19 but were not more likely to be hospitalized for their illness. These patients were disproportionately Black and Hispanic.

Outcomes Associated with Lower Doses of Ketamine by Emergency Medical Services for Profound Agitation

Introduction

Ketamine is commonly used to treat profound agitation in the prehospital setting. Early in ketamine’s prehospital use, intubation after arrival in the emergency department (ED) was frequent. We sought to measure the frequency of ED intubation at a Midwest academic medical center after prehospital ketamine use for profound agitation, hypothesizing that intubation has become less frequent as prehospital ketamine has become more common and prehospital dosing has improved.

Methods

We conducted a retrospective cohort study of adult patients receiving ketamine in the prehospital setting for profound agitation and transported to a midwestern, 60,000-visit, Level 1 trauma center between January 1, 2017–March 1, 2021. We report descriptive analyses of patient-level prehospital clinical data and ED outcomes. The primary outcome was proportion of patients intubated in the ED.

Results

A total of 78 patients received ketamine in the prehospital setting (69% male, mean age 36 years). Of the 42 (54%) admitted patients, 15 (36% of admissions) were admissions to the intensive care unit. Overall, 12% (95% confidence interval [CI]), 4.5–18.6%)] of patients were intubated, and indications included agitation (n = 4), airway protection not otherwise specified (n = 4), and respiratory failure (n = 1).

Conclusion

Endotracheal intubation in the ED after prehospital ketamine use for profound agitation in our study sample was found to be less than previously reported.

Substance use history is associated with lower opioid use for emergency department pain management

INTRODUCTION

In the current national opioid crisis, where 10% of the US population has or has had a substance use disorder (SUD), emergency department (ED) clinicians are challenged when treating pain in the ED and when prescribing pain medications to these patients on discharge as there is concern for contributing to the cycle of addiction. The objective of this study was to examine whether acute pain is treated differently in patients with and without current or past SUD by quantifying the amount of opioid analgesia given in the ED and prescribed on discharge.

METHODS

Retrospective cohort study of patients presenting to a 60,000-visit tertiary referral ED with acute fracture between January 1, 2016 and June 30, 2019. The primary exposure was indication of SUD (SUD+) versus those without SUD (SUD-). The primary outcome was receipt of opioids in the ED, and the secondary outcome was opioids prescribed at discharge.

RESULTS

117 matched pairs (n = 234) were included in the sample. Overall, 53.4% and 62.4% of patients received opioids in the ED or a prescription for opioids, respectively. Opioid receipt in the ED was lower among SUD+ patients compared to SUD- patients (48.7% and 58.1%, respectively; aOR: 0.33; 95%CI: 0.14, 0.77). Similarly, receipt of a prescription for opioids was lower among SUD+ patients compared to SUD- patients (56.4% and 68.4%, respectively; aOR: 0.50; 95%CI: 0.26, 0.95).

CONCLUSIONS

Overall, ED clinicians gave opioids less frequently to SUD+ patients in the ED and on discharge from the ED compared to SUD- patients with acute pain secondary to acute fracture.

Is the Emergency Department an Inappropriate Venue for Code Status Discussions?

BACKGROUND

Historically, it has been assumed that the Emergency Department (ED) is a place for maximally aggressive care and that Emergency Medicine Providers (EMPs) are biased towards life-prolonging care. However, emphasis on early recognition of code status preferences is increasingly making the ED a venue for code status discussions (CSDs). In 2018, our hospital implemented a policy requiring EMPs to place a code status order (CSO) for all patients admitted through the ED. We hypothesized that if EMPs enter CSDs with a bias toward life-prolonging care, or if the venue of the ED biases CSDs towards life-prolonging care, then we would observe a decrease in the percentage of patients selecting DNR status following our institution's aforementioned CSO mandate.

METHODS

We present a retrospective analysis of rates of DNR orders placed for patients admitted through our ED comparing six-month periods before and after the implementation of the above policy.

RESULTS

Using quality improvement data, we identified patients admitted through the ED during pre (n=7,858) and post (n=8,069) study periods. We observed the following: after implementation DNR preference identified prior to hospital admission from the ED increased from 0.4% to 5.3% (relative risk (RR) 12.5; 95% CI: 5.2-29.9), defining CS in the ED setting at the time of admission increased from 2.4% to 98.6% (p <0.001), and DNR orders placed during inpatient admission was unchanged (RR=0.97 (95% CI = 0.88-1.07)).

DISCUSSION

Our results suggest that the ED can be an appropriate venue for CSDs.

State-level teen dating violence education laws and teen dating violence victimisation in the USA: a cross-sectional analysis of 36 states

BACKGROUND

Approximately 10% of teens report experiencing sexual dating violence (SDV) or physical dating violence (PDV), collectively represented as teen dating violence (TDV). This study examines the association between laws incorporating TDV education in schools on TDV prevalence.

METHODS

TDV prevalence was estimated using data contributed by 36 states that participated in the 2015 Youth Risk Behavioral Surveillance Survey (YRBS). Presence of TDV laws was determined using Westlaw, a legal search engine. The adjusted odds of TDV victimisation was estimated by the presence or absence of a state law and length of time the law was in effect using hierarchical regression modelling, clustering on state, controlling for individual-level and state-level covariates and incorporating the YRBS-weighted survey design.

RESULTS

After controlling for individual-level and state-level covariates, the presence of a law was not associated with TDV (adjusted OR (aOR) 0.97; 95% CI 0.88 to 1.06), PDV (aOR 1.12; 95% CI 0.95 to 1.33) or SDV (aOR 0.99; 95% CI 0.91 to 1.08). These odds did not differ across the length of time the policies were in effect.

CONCLUSIONS

This study suggest that just the presence of a law incorporating TDV education in schools is not associated with reduced TDV victimisation but further research is needed to understand the association of the content of these laws and their implementation on TDV victimisation.

Central Venous Access Capability and Critical Care Telemedicine Decreases Inter-Hospital Transfer Among Severe Sepsis Patients: A Mixed Methods Design

OBJECTIVES

Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer.

DESIGN

Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims.

SETTING AND SUBJECTS

Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54-0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54-0.88, respectively). A facility's participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10-2.39).

CONCLUSIONS

The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.

Sedation Depth is Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical Transport Patients: A Cohort Study

Background: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods: A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results: Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions: Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

End-tidal CO2 Monitoring is Available in Most Community Hospitals in a Rural State: A Health System Survey

Introduction

Procedural sedation and analgesia (PSA) provides safe and effective relief for pain, anxiety and discomfort during procedures performed in the emergency department (ED). Our objective was to identify hospital-level factors associated with routine PSA capnography use in the ED.

Methods

This study was a cross-sectional telephone survey of ED nurse managers and designees in a Midwestern state. Respondents identified information about hospital infrastructure, physician staffing, family practice (FP) physicians only, board-certified emergency physicians (EPs) only (or both), and critical intervention capabilities. Additional characteristics including ED volume and hospital designation (i.e., rural-urban classification) were obtained from the Centers for Medicare and Medicaid Services and the state hospital association database, respectively. The primary outcome was reported use of PSA capnography. We conducted univariate analyses (relative risks, 95% confidence interval [CI]) to identify associations between hospital-level characteristics and PSA capnography use.

Results

We had an overall response rate of 98% (n=118 participating hospitals). The majority of EDs were in rural settings (78%), with a median of 5,057 visits per year (interquartile range 2,823-14,322). Nearly half of the EDs were staffed by FP physicians only, while 16% had board-certified EPs only. Nearly all hospitals (n=114, 97%), reported using continuous capnography for ventilated patients, and 74% reported use of capnography during PSA. Urban hospitals were more likely to use PSA capnography than critical access hospitals (relative risk 1.45; 95% CI, 1.22-1.73), and PSA capnography use increased with each ED volume quartile. Facilities with only EPs were 1.46 (95% CI, 1.15-1.87) times more likely to use PSA capnography than facilities with FP physicians only.

Conclusion

Continuous capnography was available in nearly all EDs, independent of size, location or patient volume. The implementation of capnography during PSA was less penetrant. Smaller, rural departments were less likely than their larger, urban counterparts to implement these national guidelines. Rurality and hospital size may be potential institutional barriers to capnography implementation.

Telemedicine Physical Examination Utilizing a Consumer Device Demonstrates Poor Concordance with In-Person Physical Examination in Emergency Department Patients with Sore Throat: A Prospective Blinded Study

BACKGROUND

Telemedicine allows patients to connect with healthcare providers remotely. It has recently expanded to evaluate low-acuity illnesses such as pharyngitis by using patients' personal communication devices. The purpose of our study was to compare the telemedicine-facilitated physical examination with an in-person examination in emergency department (ED) patients with sore throat.

MATERIALS AND METHODS

This was a prospective, observational, blinded diagnostic concordance study of patients being seen for sore throat in a 60,000-visit Midwestern academic ED. A telemedicine and a face-to-face examination were performed independently by two advanced practice providers (APP), blinded to the results of the other evaluator. The primary outcome was agreement on pharyngeal redness between the evaluators, with secondary outcomes of agreement and inter-rater reliability on 14 other aspects of the pharyngeal physical examination. We also conducted a survey of patients and providers to evaluate perceptions and preferences for sore throat evaluation using telemedicine.

RESULTS

Sixty-two patients were enrolled, with a median tonsil size of 1.0. Inter-rater agreement (kappa) for tonsil size was 0.394, which was worse than our predetermined concordance threshold. Other kappa values ranged from 0 to 0.434, and telemedicine was best for detecting abnormal coloration of the palate and tender superficial cervical lymph nodes (anterior structures), but poor for detecting abnormal submandibular lymph nodes or asymmetry of the posterior pharynx (posterior structures). In survey responses, telemedicine was judged easier to use and more comfortable for providers than patients; however, neither patients nor providers preferred in-person to telemedicine evaluation.

CONCLUSION

Telemedicine exhibited poor agreement with the in-person physical examination on the primary outcome of tonsil size, but exhibited moderate agreement on coloration of the palate and cervical lymphadenopathy. Future work should better characterize the importance of the physical examination in treatment decisions for patients with sore throat and the use of telemedicine in avoiding in-person healthcare visits.

Clinical and epidemiological variability in severe sepsis: an ecological study

BACKGROUND

To assess clinical and epidemiological trends of severe sepsis.

METHODS

Ecological study of patients presenting to the emergency department with severe sepsis or septic shock between 2005 and 2013. Patients were identified using the state-wide hospital administrative database. Key outcomes included incidence rates (IRs) and mortality rates (per 1000 population) by age and medically underserved areas (MUAs), sepsis case fatality rate (deaths per 100 sepsis cases), and proportions of transfer and comorbidities.

RESULTS

There were 154 019 sepsis cases identified. In 2005, 85+ yo in non-MUAs had a 44% increase in IR compared with those in MUAs, and this difference rose to 74% by 2013. Mortality rates were 1.6 (95% CI 1.3 to 1.8) times greater among 85+ yo in non-MUAs. Mortality rates increased by 1.8% annually, while the sepsis case fatality rate decreased by 7.7%. The proportion of transfer among sepsis cases decreased by 2.1% per year (3.8% in non-MUAs, 0.7% in MUAs).

CONCLUSIONS

Sepsis incidence varies geographically, and access to healthcare is one proposed mechanism that may explain heterogeneity. Over time, we may be capturing higher acuity sepsis cases with better recognition and management, as well as observing differential diagnostic coding documentation by location.

Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients

BACKGROUND

Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes.

OBJECTIVES

This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota.

METHODS

Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality.

RESULTS

Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.