Beyond the Four Walls: The American College of Emergency Physicians 2022 New Practice Models Task Force Report.

Emergency physicians are highly trained to deliver acute unscheduled care. The emergency physician core skillset gained during emergency medicine residency can be applied to many other roles that benefit patients and extend and diversify emergency physician careers. In 2022, the American College of Emergency Physicians (ACEP) convened the New Practice Models Task Force to describe new care models and emergency physician opportunities outside the 4 walls of the emergency department. The Task Force consisted of 21 emergency physicians with broad experience and 2 ACEP staff. Fifty-nine emergency physician roles were identified (21 established clinical roles, 16 emerging clinical roles, 9 established nonclinical roles, and 13 emerging nonclinical roles). A strength-weakness-opportunity-threat (SWOT) analysis was performed for each role. Using the analysis, the Task Force made recommendations for guiding ACEP internal actions, advocacy, education, and research opportunities. Emphasis was placed on urgent care, rural medicine, telehealth/virtual care, mobile integrated health care, home-based services, emergency psychiatry, pain medicine, addiction medicine, and palliative care as roles with high or rising demand that draw on the emergency physician skillset. Advocacy recommendations focused on removing state and federal regulatory and legislative barriers to the expansion of new and emerging roles. Educational recommendations focused on aggregating available resources, developing a centralized resource for career guidance, and new educational content for emerging roles. The Task Force also recommended promoting research on potential advantages (eg, improved outcomes, lower cost) of emergency physicians in certain roles and new care models (eg, emergency physician remote supervision in rural settings).

Can Untrained Patients Perform Their Own Skin and Soft Tissue Ultrasound Examination by Teleguidance?

Objectives: This pilot study aims to determine if patients untrained in performing ultrasound can self-scan to obtain images under remote clinician teleguidance during a simulated telehealth encounter. This study also seeks to describe the patients' comfort level and barriers to performing an ultrasound examination on themselves using a handheld ultrasound device. Methods: This was a single center prospective observational cohort study conducted over a 4-month period in 2021. Patients were eligible if they had no prior training in the use of ultrasound and in the use of teleguidance. They voluntarily consented to participate at a single ambulatory internal medicine clinic. Results: 20 participants were enrolled and underwent teleguidance to ultrasound their own skin and soft tissues at the antecubital fossae. Six second video clips were evaluated by 2 subject matter experts using the Point of Care Ultrasound Image Quality scale. A score >7 was considered adequate for diagnostic interpretation. The average score was 10.15/14, with a minimum score of 5/14, and maximum score of 14/14 and a standard deviation (SD) of 2.39 using a two tailed Z-score. Setting alpha at 0.05 the 95% CI was (5.47-14.83). Conclusion: In a pilot study of 20 participants with no ultrasound experience, untrained healthy volunteers were able to perform technically acceptable and interpretable ultrasound scans using teleguidance by a trained clinician.

National Estimates of Workplace Telehealth Use Among Emergency Nurses and All Registered Nurses in the United States.

INTRODUCTION: The goal of this research was to quantify the baseline status of prepandemic workplace emergency nursing telehealth as a key consideration for ongoing telehealth growth and sustainable emergency nursing care model planning. The purpose of this research was to: (1) generate national estimates of prepandemic workplace telehealth use among emergency and other inpatient hospital nurses and (2) map the geographic distribution of prepandemic workplace emergency nurse telehealth use by state of nurse residence. METHODS: We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses. Data were analyzed using jack-knife estimation procedures coherent with the complex sampling design selected as representative of the population and requiring analysis with survey weights. RESULTS: Weighted estimates of the 161 865 emergency nurses, compared with 1 191 287 other inpatient nurses revealed more reported telehealth in the workplace setting (49% vs 34%) and individual clinical practice telehealth use (36% vs 15%) among emergency nurses. The geographic distribution of individual clinical practice emergency nurse telehealth use indicates greatest adoption per 10 000 state residents in Maine, Alaska, and Missouri with more states in the Midwest demonstrating emergency nurse adoption of telehealth into clinical practice per population than other regions in the United States. DISCUSSION: By quantifying prepandemic national telehealth use, the results provide corroborating evidence to the potential long-term adoptability and sustainability of telenursing in the emergency nursing specialty. The results also implicate the need to proactively define emergency nursing telehealth care model standards of practice, nurse competencies, and reimbursement.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine.

INTRODUCTION: Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. METHODS: Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." RESULTS: Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety). CONCLUSION: The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Defining emergency telehealth.

The American College of Emergency Physicians Emergency Telehealth Section was charged with development of a working definition of emergency telehealth that aligns with the College's definition of emergency medicine. A modified Delphi method was used by the section membership who represented telehealth providers in both private and public health-care delivery systems, academia and industry, rural and urban settings. Presented in this manuscript is the final definition of emergency telehealth developed with an additional six clarifying statements to address the context of the definition. Emergency telehealth is a core domain of emergency medicine and is inclusive of remotely providing all types of care for acute conditions of any kind requiring expeditious care irrespective of any prior relationship. The development of this definition is important to the global community of emergency physicians and all patients seeking acute care to ensure that appropriately trained clinicians are providing the highest quality of emergency services via the telehealth modality. We recommend implementing emergency telehealth in a manner that ensures appropriate qualifications of providers, appropriate/parity reimbursement for telehealth services and, most importantly, the delivery of quality care to patients in a safe, efficient, timely and cost-effective manner.

Solving Community SARS-CoV-2 Testing With Telehealth: Development and Implementation for Screening, Evaluation and Testing.

BACKGROUND: Telehealth has emerged as a crucial component of the SARS-CoV-2 pandemic emergency response. Simply stated, telehealth is a tool to provide health care from a distance. Jefferson Health has leveraged its acute care telehealth platform to screen, order testing, and manage patients with COVID-19-related concerns. OBJECTIVE: This study aims to describe the expansion and results of using a telehealth program to increase access to care while minimizing additional potential exposures during the early period of the COVID-19 pandemic. METHODS: Screening algorithms for patients with SARS-CoV-2-related complaints were created, and 150 new clinicians were trained within 72 hours to address increased patient demand. Simultaneously, Jefferson Health created mobile testing sites throughout eastern Pennsylvania and the southern New Jersey region. Visit volume, the number of SARS-CoV-2 tests ordered, and the number of positive tests were evaluated, and the volume was compared with preceding time periods. RESULTS: From March 8, 2020, to April 11, 2020, 4663 patients were screened using telehealth, representing a surge in visit volume. There were 1521 patients sent to mobile testing sites, and they received a telephone call from a centralized call center for results. Of the patients who were tested, nearly 20% (n=301) had a positive result. CONCLUSIONS: Our model demonstrates how using telehealth for a referral to central testing sites can increase access to community-based care, decrease clinician exposure, and minimize the demand for personal protective equipment. The scaling of this innovation may allow health care systems to focus on preparing for and delivering hospital-based care needs.

Telehealth in the time of COVID-19.

Telehealth or using technology for a remote medical encounter has become an efficient solution for safe patient care during the severe acute respiratory syndrome coronavirus 2 or COVID-19 pandemic. This medium allows patient immediate healthcare access without the need for an in-person visit. We designed a time-sensitive, practical, effective and innovative scale-up of telehealth services as a response to the demand for COVID-19 evaluation and testing. As more patients made appointments through the institution's telehealth programme, we increased the number of clinicians available. JeffConnect, the acute care telehealth programme, was expanded to increase staffing from a standing staff of 37-187 doctors within 72 hours. Telehealth care clinicians primarily trained in emergency medicine, internal medicine and family medicine followed a patient decision pathway to risk stratify patients into three groups: home quarantine no testing, home quarantine with outpatient COVID-19 testing and referral for in-person evaluation in the ED, for symptomatic and potentially unstable patients.

Hospital Telehealth Adoption Increased in 2014 and 2015 and Was Influenced by Population, Hospital, and Policy Characteristics.

Background: Telehealth can increase value by reducing gaps in care, access, and cost for patients, providers, and payers. Medicare reimbursement policies aim to increase health access in areas with a provider shortage. Introduction: The influences of telehealth adoption over time are not well known, and would be beneficial for further policy discussion. Materials and Methods: Using the Information Technology Supplement to the American Hospital Association Annual Survey of Acute Care Hospitals, we determined several predictors of telehealth adoption in California hospitals from 2012 to 2015. Results: There were 870 hospitals evaluated. Telehealth adoption was more likely in 2014 and 2015. Compared with those not using telehealth, hospitals using telehealth were less likely to be located in more populated areas (odds ratio [OR] = 0.74; 95% confidence interval [CI]: 0.57-0.98), nonrural areas as defined by metropolitan statistical area (OR = 0.37; 95% CI: 0.20-0.70), and have a higher percentage of employed individuals (OR = 0.0001; 95% CI: 0.00-0.010). Hospitals were more likely to adopt telehealth if they had mobile device integration into the electronic health record (EHR) (OR = 2.97; 95% CI: 1.39-6.33) or a higher percentage of commuters in their ZIP code (OR = 20.24; 95% CI: 1.29-317.4). Telehealth reimbursement for health professional shortage areas did not contribute to increased telehealth adoption. Discussion: The findings suggest how addressing current infrastructural and policy barriers may improve value-based care. Conclusion: Our analysis suggests that telehealth has become more prominent since 2014, and factors such as significant commuting population, mobile device/EHR integration, and nonrural location influence adoption.

Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics.

OBJECTIVES: More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures. METHODS: We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. RESULTS: Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). CONCLUSIONS: Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.