Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort.

OBJECTIVE: To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days. SUMMARY BACKGROUND DATA: The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes. METHODS: We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations. RESULTS: The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret. CONCLUSIONS: Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02800785.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

The critical role of the specialized social worker as part of ED/hospital-based elder mistreatment response teams.

The emergency department and hospital provide a unique and important opportunity to identify elder mistreatment and offer intervention. To help manage these complex cases, multi-disciplinary response teams have been launched. In developing these teams, it quickly became clear that social workers play a critical role in responding to elder mistreatment. Their unique skillset allows them to establish close connections with community resources, collaborate with various hospital stakeholders, support patients/families/caregivers through challenging situations, navigate the legal and protective systems, and balance patient safety and quality of life in disposition decision-making. The role of the social worker on these multi-faceted teams includes conducting a comprehensive biopsychosocial assessment, helping to develop a safe discharge plan, and making appropriate referrals, among other responsibilities. Any institution considering developing a multi-disciplinary program should recognize the critical importance of social work.

Strategies for dissemination of ED/hospital elder mistreatment response team model.

Interdisciplinary Emergency Department/hospital-based teams represent a promising care model to improve identification of and intervention for elder mistreatment. Two institutions, Weill Cornell Medicine/NewYork-Presbyterian Hospital and the University of Colorado Anschutz Medical Campus have launched such programs and are exploring multiple strategies for effective dissemination. These strategies include: (1) program evaluation research, (2) framing as a new model of geriatric care, (3) understanding the existing incentives of health systems, EDs, and hospitals to align with them, (4) connecting to ongoing ED/hospital initiatives, (5) identifying and collaborating with communities with strong elder mistreatment response that want to integrate the ED/hospital, (6) developing and making easily accessible high-quality, comprehensive protocols and training materials, (7) offering technical assistance and support, (8) communications outreach to raise awareness, and (9) using an existing framework to inform implementation in new hospitals and health systems.

Use and Perceptions of Shared Decision-Making by General Surgery Faculty and Trainees.

INTRODUCTION: The purpose of this study was to assess the practice and perceptions of shared decision-making (SDM) by both faculty and residents at Boston Medical Center and explore barriers and facilitators to implementing SDM at our institution. METHODS: We created and distributed an online survey assessing provider demographic and training characteristics, experiences with the informed consent process, practices in SDM, and perceptions about SDM. We used descriptive statistics to summarize provider characteristics and survey responses and univariate analysis to determine associations between them. RESULTS: Fifteen surgeons and 19 surgical residents completed the survey (49% response rate). Most respondents were aware of and had a positive attitude toward SDM (91% and 76%, respectively); 35% reported having SDM training. Providers had varying levels of engagement with different SDM practices, and there were inconsistent associations between provider characteristics and the use of SDM. Often providers thought the patient's health literacy, foreign primary language, clinical condition, and socioeconomic factors were barriers to the SDM process. CONCLUSIONS: Although most general surgery faculty and residents at our institution had a positive view of SDM, they engaged in SDM behaviors inconsistently, with no clear association between clinician characteristics and specific behaviors. We identified several barriers to SDM consistent with those identified by providers in other specialties. This highlights the need for further research to study live general surgery provider-patient interactions, as well as structured SDM education to train general surgery providers to reliably engage their patients in effective SDM.

Social Vulnerability and Appendicitis: Single-Institution Study in a High Insurance State.

INTRODUCTION: Multiple factors signifying higher social vulnerability, including lower socioeconomic status and minority race, have been associated with presentation with complicated appendicitis (CA). In this study, we compared the Social Vulnerability Index (SVI) of our population by appendicitis severity (uncomplicated appendicitis [UA] versus CA). We hypothesized that SVI would be similar between patients with UA and CA presenting to our institution, a safety-net hospital in a state with high healthcare insurance coverage. METHODS: We included all patients at our hospital aged 18 y and older who underwent appendectomy for acute appendicitis between 2012 and 2016. SVI values were determined based on the 2010 census data using ArcMap software. We used nonparametric univariate statistics to compare the SVI of patients with CA versus UA and multivariable regression to model the likelihood of operative CA. RESULTS: A total of 997 patients met inclusion criteria, of which 177 had CA. The median composite SVI score for patients with CA was lower than for patients with UA (80% versus 83%, P = 0.004). UA was associated with higher socioeconomic (83% versus 80%, P = 0.007), household/disability (68% versus 55%, P = 0.037), and minority/language SVI scores (91% versus 89%, P = 0.037). On multivariable analysis controlling for age, sex, ethnicity, insurance status, relevant comorbidities, and chronicity of symptoms, there was an inverse association between SVI and the likelihood of CA (odds ratio 0.59, 95% confidence interval 0.4-0.87, P = 0.008). CONCLUSIONS: In the setting of high healthcare insurance and a medical center experienced in caring for vulnerable populations, patients presenting with UA have a higher composite SVI, and thus greater social vulnerability, than patients presenting with CA.

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes.

BACKGROUND: Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management. OBJECTIVE: Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries. METHODS: We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center. RESULTS: A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia. CONCLUSIONS: Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

Burnout in Pediatric Emergency Medicine Physicians: A Predictive Model.

OBJECTIVES: This study aims to determine the prevalence of and identify predictors associated with burnout in pediatric emergency medicine (PEM) physicians and to construct a predictive model for burnout in this population to stratify risk. METHODS: We conducted a cross-sectional electronic survey study among a random sample of board-certified or board-eligible PEM physicians throughout the United States and Canada. Our primary outcome was burnout assessed using the Maslach Burnout Inventory on 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. We defined burnout as scoring in the high-degree range on any 1 of the 3 subscales. The Maslach Burnout Inventory was followed by questions on personal demographics and work environment. We compared PEM physicians with and without burnout using multivariable logistic regression. RESULTS: We studied a total of 416 PEM board-certified/eligible physicians (61.3% women; mean age, 45.3 ± 8.8 years). Surveys were initiated by 445 of 749 survey recipients (59.4% response rate). Burnout prevalence measured 49.5% (206/416) in the study cohort, with 34.9% (145/416) of participants scoring in the high-degree range for emotional exhaustion, 33.9% (141/416) for depersonalization, and 20% (83/416) for personal accomplishment. A multivariable model identified 6 independent predictors associated with burnout: 1) lack of appreciation from patients, 2) lack of appreciation from supervisors, 3) perception of an unfair clinical work schedule, 4) dissatisfaction with promotion opportunities, 5) feeling that the electronic medical record detracts from patient care, and 6) working in a nonacademic setting (area under the receiver operating characteristic curve, 0.77). A predictive model demonstrated that physicians with 5 or 6 predictors had an 81% probability of having burnout, whereas those with zero predictors had a 28% probability of burnout. CONCLUSIONS: Burnout is prevalent in PEM physicians. We identified 6 independent predictors for burnout and constructed a scoring system that stratifies probability of burnout. This predictive model may be used to guide organizational strategies that mitigate burnout and improve physician well-being.

Development of the Verbal Autopsy Instrument for COVID-19 (VAIC).

BACKGROUND: Improving accuracy of identification of COVID-19-related deaths is essential to public health surveillance and research. The verbal autopsy, an established strategy involving an interview with a decedent's caregiver or witness using a semi-structured questionnaire, may improve accurate counting of COVID-19-related deaths. OBJECTIVE: To develop and pilot-test the Verbal Autopsy Instrument for COVID-19 (VAIC) and a death adjudication protocol using it. METHODS/KEY RESULTS: We used a multi-step process to design the VAIC and a protocol for its use. We developed a preliminary version of a verbal autopsy instrument specifically for COVID. We then pilot-tested this instrument by interviewing respondents about the deaths of 15 adults aged ≥65 during the initial COVID-19 surge in New York City. We modified it after the first 5 interviews. We then reviewed the VAIC and clinical information for the 15 deaths and developed a death adjudication process/algorithm to determine whether the underlying cause of death was definitely (40% of these pilot cases), probably (33%), possibly (13%), or unlikely/definitely not (13%) COVID-19-related. We noted differences between the adjudicated cause of death and a death certificate. CONCLUSIONS: The VAIC and a death adjudication protocol using it may improve accuracy in identifying COVID-19-related deaths.

Use of Physician-Estimated and Patient Self-Reported Weights to Guide Initial Fluid Resuscitation in Emergency Department Patients With Suspected Sepsis.

BACKGROUND: Knowledge of patient weight is required to guide initial intravenous fluid therapy for patients with sepsis-associated hypotension or elevated lactate. Previous studies have shown patients are better estimators of their weight than medical providers are; critically ill patients, however, may be unable to provide this information. OBJECTIVES: This study compares the accuracy of physician-estimated and patient self-reported weights to subsequent inpatient bed/stretcher scale weights for guiding initial protocol-based intravenous fluid therapy in the treatment of emergency department patients with suspected sepsis. METHODS: Adult patients presenting with a suspected diagnosis of severe sepsis to a large, urban, academic emergency department had either physician-estimated or patient self-reported weights recorded on presentation. All patients had subsequent inpatient bed/stretcher scale weights recorded on the first day of hospitalization. RESULTS: Physician-estimated and patient self-reported weights linearly correlated (P < .001) with inpatient bed/stretcher scale weights. Median accuracy error for physicians (5.4% [2.0-10.1]) and patients (3.9% [1.6-6.4]) was not significantly different (P = .28). Physician-estimated and patient self-reported weights accuracy was determined at multiple levels: within 5% (46%, 57%, respectively), 10% (75%, 90%), 15% (90%, 95%), and 20% (100%, 95%) error tolerances, as well accurate estimates within 5 kg (69.2%, 70.0%). CONCLUSIONS: Both physician-estimated and patient self-reported weights are reliable when calculating initial protocol-based intravenous fluid resuscitation for emergency department patients with sepsis.

Telemedicine Medical Screening Evaluation Expedites the Initiation of Emergency Care for Children.

OBJECTIVE: Prior studies show that staffing a physician at triage expedites care in the emergency department. Our objective was to describe the novel application and effect of a telemedicine medical screening evaluation (Tele-MSE) at triage on quality metrics in the pediatric emergency department (PED). METHODS: We conducted a retrospective quasi-experimental pre-post intervention study of patients presenting to an urban PED from December 2017 to November 2019 who received a Tele-MSE at triage. We analyzed 4 diagnostic cohorts: gastroenteritis, psychiatry evaluation, burn injury, and extremity fracture. We matched cases with controls who received standard triage, from December 2015 to November 2017, by age, diagnosis, weekday versus weekend, and season of presentation. Outcome measures included door-to-provider time, time-to-intervention order, and PED length of stay (LOS). RESULTS: We included 557 patients who received Tele-MSE during the study period. Compared with controls, patients who received a Tele-MSE at triage had a shorter median door-to-provider time (median difference [MD], 8.4 minutes; 95% confidence interval [CI], 6.0-11.0), time-to-medication order (MD, 27.3 minutes; 95% CI, 22.9-35.2), time-to-consult order (MD, 10.0 minutes; 95% CI, 5.3-12.7), and PED LOS (MD, 0.4 hours; 95% CI, 0.3-0.6). CONCLUSIONS: A Tele-MSE is an innovative modality to expedite the initiation of emergency care and reduce PED LOS for children. This novel intervention offers potential opportunities to optimize provider and patient satisfaction and safety during the COVID-19 pandemic.

An Evaluation of Kiosks for Direct-to-Consumer Telemedicine Using the National Quality Forum Assessment Framework.

Background: Evaluation of direct-to-consumer (DTC) telemedicine programs has focused on care delivery via personal electronic devices. Telemedicine kiosks for the delivery of virtual urgent care services have not been systematically described. Introduction: Our institution has placed kiosks for DTC urgent care in pharmacies. These kiosks can be used without a personal electronic device. Materials and Methods: Retrospective review of adult patients using pharmacy-based kiosks (kiosk) or personal electronic devices (app) for DTC evaluation. Data for patient characteristics, wait time, technical quality, visit duration diagnosis codes, follow-up recommendations, and whether the patient was traveling were compared. Results were interpreted using the National Quality Forum framework for telemedicine service evaluation, focused on access, experience, and effectiveness. Comparisons were made using chi-square test, Student's t-test, and Wilcoxon rank-sum tests. Results: Over 1 year there were 1,996 DTC visits; 238 (12%) initiated from kiosks. Kiosk patients were slightly older (mean age 38 ± 13 vs. 35 ± 11; p < 0.001), more likely to be male (52% vs. 39%; p < 0.001), more likely to be remote from home (25% vs. 3%; p < 0.001), and had less technical difficulty (10% vs. 19%; p = 0.003). Referral for urgent in-person evaluation was low in both groups (10% kiosk vs. 16%; app p = 0.017). Discussion: Kiosks may increase access to care and improve technical experience. Low urgent referral rates suggest effective care for both types of visit. Conclusions: Despite their potential advantages, kiosk visits accounted for a minority of overall visits for our DTC telemedicine service line, and daily use of each kiosk location was low.

Telemedicine Surge for Pediatric Patients in Response to the COVID-19 Pandemic in New York City.

Background: Our objective is to describe our pediatric virtual urgent care (VUC) experience at a large urban academic medical center, in response to the COVID-19 pandemic in New York City (NYC). Materials and Methods: We conducted a retrospective cohort study of our pediatric VUC program of patients less than age 18 years, from March 1 to May 31, 2020. We include data on expansion of staffing, patient demographics, virtual care, and outcomes. Results: We rapidly onboarded, educated, and trained pediatric telemedicine providers. We evaluated 406 pediatric patients with median age 4.4 years and 53.9% male. Median call time was 5:12 pm, median time to provider was 5.7 min, and median duration of call was 11.1 min. The most common reasons for a visit were COVID-19-related symptoms (36%), dermatologic (15%), and trauma (10%). Virtual care for patients consisted of conservative management (72%), medication prescription (18%), and referral to an urgent care or pediatric emergency department (PED) (10%). Of 16 patients referred and presented to our emergency department, 2 required intensive care for multisystem inflammatory syndrome in children. Oral antibiotics were prescribed for 7.1% of all patients. Only 0.005% of patients had an unplanned 72-h PED visit resulting in hospitalization after a VUC visit. Conclusion: Pediatric emergency VUC allowed for high-quality efficient medical care for patients during the peak of the COVID-19 pandemic in NYC. Although most patients were managed conservatively in their home, telemedicine also enabled rapid identification of patients who required in-person emergency care.

Research priorities for elder abuse screening and intervention: A Geriatric Emergency Care Applied Research (GEAR) network scoping review and consensus statement.

The Geriatric Emergency Care Applied Research (GEAR) Network (1) conducted a scoping review of the current literature on the identification of and interventions to address elder abuse among patients receiving care in emergency departments and (2) used this review to prioritize research questions for knowledge development. Two questions guided the scoping review: What is the effect of universal emergency department screening compared to targeted screening or usual practice on cases of elder abuse identified, safety outcomes, and health care utilization?; and What is the safety, health, legal, and psychosocial impact of emergency department-based interventions vs. usual care for patients experiencing elder abuse? We searched five article databases. Additional material was located through reference lists of identified publications, PsychInfo, and Google Scholar. The results were discussed in a consensus conference; and stakeholders voted to prioritize research questions. No studies were identified that directly addressed the first question regarding assessment strategies, but four instruments used for elder abuse screening in the emergency department were identified. For the second question, we located six articles on interventions for elder abuse in the emergency department; however, none directly addressed the question of comparative effectiveness. Based on these findings, GEAR participants identified five questions as priorities for future research - two related to screening, two related to intervention, and one encompassed both. In sum, research to identify best practices for elder abuse assessment and intervention in emergency departments is still needed. Although there are practical and ethical challenges, rigorous experimental studies are needed.

Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases.

STUDY OBJECTIVE: Elder abuse is common and has serious health consequences but is underrecognized by health care providers. An important reason for this is difficulty in distinguishing between elder abuse and unintentional trauma. Our goal was to identify injury patterns associated with physical elder abuse in comparison with those of patients presenting to the emergency department (ED) with unintentional falls. METHODS: We partnered with a large, urban district attorney's office and examined medical, police, and legal records from successfully prosecuted cases of physical abuse of victims aged 60 years or older from 2001 to 2014. RESULTS: We prospectively enrolled patients who presented to a large, urban, academic ED after an unintentional fall. We matched 78 cases of elder abuse with visible injuries to 78 unintentional falls. Physical abuse victims were significantly more likely than unintentional fallers to have bruising (78% versus 54%) and injuries on the maxillofacial, dental, and neck area (67% versus 28%). Abuse victims were less likely to have fractures (8% versus 22%) or lower extremity injuries (9% versus 41%). Abuse victims were more likely to have maxillofacial, dental, or neck injuries combined with no upper and lower extremity injuries (50% versus 8%). Examining precise injury locations yielded additional differences, with physical elder abuse victims more likely to have injuries to the left cheek or zygoma (22% versus 3%) or on the neck (15% versus 0%) or ear (6% versus 0%). CONCLUSION: Specific, clinically identifiable differences may exist between unintentional injuries and those from physical elder abuse. This includes specific injury patterns that infrequently occur unintentionally.

Heart rate variability measures for prediction of severity of illness and poor outcome in ED patients with sepsis.

INTRODUCTION: This study evaluates the utility of heart rate variability (HRV) for assessment of severity of illness and poor outcome in Emergency Department (ED) patients with sepsis. HRV measures evaluated included low frequency (LF) signal, high frequency (HF) signal, and deviations in LF and HF signal from age-adjusted reference values. METHODS: This was a prospective, observational study. Seventy-two adult ED patients were assessed within 6 h of arrival. RESULTS: Severity of illness as defined by sepsis subtype correlated with decreased LF signal (sepsis: 70.68 ± 22.95, severe sepsis: 54.00 ± 28.41, septic shock: 45.54 ± 23.31, p = 0.02), increased HF signal (sepsis: 27.87 ± 19.42, severe sepsis: 44.63 ± 27.29, septic shock: 47.66 ± 20.98, p = 0.01), increasingly negative deviations in LF signal (sepsis: 0.41 ± 24.53, severe sepsis: -21.43 ± 30.09, septic shock -30.39 ± 26.09, p = 0.005) and increasingly positive deviations in HF signal (sepsis: -1.86 ± 21.09, severe sepsis: 20.07 ± 29.03, septic shock: 23.6 ± 24.17, p = 0.004). Composite poor outcome correlated with decreased LF signal (p = 0.008), increased HF signal (p = 0.03), large negative deviations in LF signal (p = 0.004) and large positive deviations in HF signal (p = 0.02). Deviations in LF and HF signal from age-adjusted reference values correlated with individual measures of poor outcome with greater consistency than LF or HF signal. DISCUSSION: Accounting for the influence of age on baseline HRV signal improves the predictive value of HRV measures in ED patients with sepsis.

Implementation of a Pediatric Emergency Telemedicine Program.

OBJECTIVES: Our goal was to describe the experiences after the launch of a pediatric emergency telemedicine program at a large, urban, academic medical center. METHODS: We launched 3 unique pediatric emergency telemedicine programs at an urban, academic medical center: direct-to-consumer pediatric virtual urgent care, pediatric emergency department (PED) telemedicine follow-up, and telemedicine medical screening examination in the PED. RESULTS: We evaluated 84 patients via direct-to-consumer pediatric virtual urgent care with the most common chief complaint related to fever, dermatologic, or respiratory systems; we referred 12% to the PED, and 20% of those required hospital admission. We evaluated 38 patients via PED telemedicine follow-up; we referred 19% back to the PED, and 43% of those required hospital admission. Median duration for a telemedicine encounter was 10 minutes. We screened 3809 patients in the PED using telemedicine medical screening examination. CONCLUSIONS: We offer a description of an innovative and comprehensive new pediatric emergency telemedicine program implemented at a large, urban, academic medical center. Our initial findings demonstrate short visit times, antibiotic stewardship, and low rates of PED referral and subsequent admission for patients who use a telemedicine service. We plan to further examine the impact of pediatric emergency telemedicine on the care of children as our program expands.

Antibiotic Prescribing Practices: Is There a Difference Between Patients Seen by Telemedicine Versus Those Seen In-Person?

Background: Direct-to-consumer telemedicine is becoming part of mainstream medicine, but questions exist regarding the quality of care provided. We assessed antibiotic stewardship, one measure of quality, by comparing antibiotic prescription rates for acute respiratory infections (ARIs) between patients seen by telemedicine and patients seen in-person in two urban emergency departments (EDs). Methods: In two urban EDs where low-acuity patients in the ED have the option of being seen by telemedicine rather than in-person, we analyzed telemedicine and in-person visits of patients ≥18 years who received ARI diagnoses between July 2016 and September 2017. The identified ARI telemedicine visits were matched to in-person visits by diagnosis, treatment hospital, and Emergency Severity Index level. We compared antibiotic prescribing rates for telemedicine and in-person visits. Results: We identified 260 telemedicine visits and compared with 260 matched in-person visits. Antibiotics for ARIs were prescribed for 29% of telemedicine visits and 28% of in-person visits (odds ratio [OR] 1.038; 95% confidence interval [CI] 0.71-1.52; p = 0.846). This finding did not materially change after adjustment for age and gender (adjusted OR 1.034; 95% CI 0.70-1.53; p = 0.86). Conclusions: Antibiotic prescribing rates for ARIs were similar for patients seen by telemedicine and patients seen in-person at two urban EDs. If differences in antibiotic stewardship between telemedicine and in-person encounters are found, contextual factors unrelated to the video-based evaluation should be investigated.

Telemedicine Evaluations for Low-Acuity Patients Presenting to the Emergency Department: Implications for Safety and Patient Satisfaction.

Background:Telemedicine is being rapidly adopted by traditional health care systems. We have used telemedicine in a program we call Express Care to allow a single physician to remotely perform evaluations of low-acuity patients.Materials and Methods:We conducted a retrospective cohort study of quality assurance data comparing low-acuity patients treated by an emergency department (ED) physician through telemedicine (Express Care) with those treated by an ED physician in person between July 16, 2016 and September 30, 2017. We compared patient demographics, length of stay (LOS), visit severity as measured by emergency severity index (ESI), visit diagnosis type, return visits, and patient satisfaction scores.Results:There were 3,266 low-acuity patients seen through telemedicine and 21,129 seen in person during the observation period. Patients receiving evaluation by telemedicine were younger (mean age ± standard deviation [in years]: 42 ± 18 vs. 45 ± 17; p < 0.001) and more likely to be male (51% vs. 46%; p < 0.001). Median ESI was slightly lower for patients treated by telemedicine [4 (4-5) vs. 4 (4-4); p < 0.001], and there were modest differences in diagnosis type between the two groups. Median ED LOS was 63.6 (interquartile range [IQR] 42.6-93.6) min for telemedicine patients and 133.8 (IQR 90.6-196.8) min for patients seen in person (p < 0.001). Seventy-two hour returns (3.4% vs. 3.0%; p = 0.302) and 72-h returns requiring admission (0.2% vs. 0.3%; p = 0.252) were similar between groups. Patient satisfaction scores were also similar between the groups.Conclusion:Telemedicine evaluation for ED patients can be effective and safe when treating low-acuity conditions without compromising patient satisfaction.

Developing the Emergency Department Elder Mistreatment Assessment Tool for Social Workers Using a Modified Delphi Technique.

Elder mistreatment is common and has serious consequences. The emergency department (ED) may provide a unique opportunity to detect this mistreatment, with social workers often asked to take the lead in assessment and intervention. Despite this, social workers may feel ill-equipped to conduct assessments for potential mistreatment, due in part to a lack of education and training. As a result, the authors created the Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS) using a multiphase, modified Delphi technique with a national group of experts. This tool consists of both an initial and comprehensive component, with 11 and 17 items, respectively. To our knowledge, this represents the first elder abuse assessment tool for social workers designed specifically for use in the ED. The hope is that the ED-EMATS will increase the confidence of ED social workers in assessing for elder mistreatment and help ensure standardization between professionals.