A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program.

BACKGROUND: As a third of all community dwellers aged 65+ fall each year, falls are common reasons for older adults to present to an Emergency Department (ED). Although EDs should assess patients' multifactorial fall risks to prevent future fall-related injuries, this frequently does not occur. We describe our protocol to determine the feasibility, acceptability, and safety of a pilot ED Virtual Observation Unit (VOU) Falls program. METHODS: To ensure standardized conduct and reporting, the Standard Protocol Items for Intervention Trials (SPIRIT) guidelines will be used. The VOU is a program where patients are sent home from the ED but are part of a virtual observation unit in that they can call on-call ED physicians while they are being treated for conditions such as cellulitis, congestive heart failure, or pneumonia. A paramedic conducts daily visits with the patient and facilitates a telemedicine consult with an ED physician. VOU nursing staff conduct daily assessments of patients via telemedicine. The ED VOU Falls program is one of the VOU pathways and is a multi-component fall prevention program for fall patients who present after an ED visit. The paramedic conducts a home safety evaluation, a Timed Up and Go Test (TUG). During the VOU visit, the ED physician conducts a telemedicine visit, while the paramedic is visiting the home, to review patients' fall-risk-increasing drugs and their TUG test. We will determine feasibility by calculating rates of patient enrollment refusal, and adherence to fall-risk prevention recommendations using information from 3-month follow-up telephone calls, as well as qualitative interviews with the paramedics. We will determine the acceptability of the ED VOU Falls program based on patient and provider surveys using a Likert scale. We will ask VOU nursing staff to report any safety issues encountered while the patient is in the ED VOU Falls program (e.g., tripping hazards). We will use the chi-square test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and Mann-Whitney for nonparametric data. We will review interview transcripts and generate codes. Codes will then be extracted and organized into concepts to generate an overall theme following grounded theory methods. This is a pilot study; hence, results cannot be extrapolated. However, a definite trial would be the next step in the future to determine if such a program could be implemented as part of fall prevention interventions. DISCUSSION: This study will provide insights into the feasibility and acceptability of a novel ED VOU Falls program with the aim of ultimately decreasing falls. In the future, such a program could be implemented as part of fall prevention interventions.

Patient Perceptions of Emergency Department Observation Care at Home.

Introduction: The Virtual Observation Unit (VOU) utilizes telehealth and community paramedicine to provide observation-level care in patients' homes. Patients' experience of this novel program has not been reported. Methods: A phone-based patient experience survey was administered to the patients who were admitted to the VOU at an urban, academic Emergency Department in the Northeast United States. The survey asked about patient's perception of the program's quality of care (0 = worst care possible, 10 = best care possible). t Tests with a Bonferroni adjustment assessed for differences between patient demographic groups. Results: The survey response rate was 40% (124/307). Overall mean scores for perceived quality of care were very high (9.51 ± 1.19). There were no significant differences in patient's perception of quality of care between demographic cohorts of age, gender, race, or ethnicity. Conclusions: Patient experience with a novel VOU program was very positive and did not differ significantly by demographic cohort. Further research is warranted.

The Value of an Emergency Medicine Virtual Observation Unit.

STUDY OBJECTIVE: We implemented a virtual observation unit in which emergency department (ED) patients receive observation-level care at home. Our primary aim was to compare this new care model to in-person observation care in terms of brick-and-mortar ED length of stay (inclusive of ED observation unit time) as well as secondarily on inpatient admission and 72-hour return visits (overall and with admission). METHODS: In a retrospective analysis of electronic health record data on ED observation patients from January 1, 2022 to December 29, 2022 from an academic urban ED, we used propensity matching to compare virtual to in-person observation patients on outcomes of interest. Patients were matched 1:1 based on age, sex, Charlson Comorbidity Index, and reason for observation. We also conducted real-time review of all virtual observation cases for potential safety concerns. RESULTS: Of 8,218 observation stays, 361 virtual observation patients were matched with 361 in-person observation patients. Virtual observation patients experienced lower median brick-and-mortar ED + EDOU LOS [14.6 (IQR 10.2, 18.9) versus 33.3 (IQR 28.1, 38.1) hours] and lower inpatient admission rates (10.2% [SD 5.0] versus 24.7% [SD 11.3]). The 72-hour return rate was higher for virtual observation patients (3.6% [SD 3.0] versus 2.5% [SD 3.0]). Among those with return visits, the rate of inpatient admission was higher among virtual observation patients (53.8% [SD 3.2] versus 11.1% [13.0]). There were no significant patient safety events recorded. CONCLUSION: Virtual observation unit patients used fewer hours in ED and ED observation relative to on-site observation patients. This new care delivery model warrants further study because it has the potential to positively impact ED capacity.

Emergency Department and Health Care System Factors Associated with Telehealth Innovation During the COVID-19 Pandemic.

Objective: Telehealth capacity may be an important component of pandemic response infrastructure. We aimed to examine changes in the telehealth use by the US emergency departments (EDs) during COVID-19, and to determine whether existing telehealth infrastructure or increased system integration were associated with increased likelihood of use. Methods: We analyzed 2016-2020 National ED Inventory (NEDI)-USA data, including ED characteristics and nature of telehealth use for all US EDs. American Hospital Association data characterized EDs' system integration. An ordinary least-squares regression model obtained one-step-ahead forecast of the expected proportion of EDs using telehealth in 2020 based on growth observed from 2016 to 2019. Among EDs without telehealth in 2019, we used logistic regression models to examine whether system membership or existing telehealth infrastructure were associated with odds of innovation in telehealth use in 2020, accounting for ED characteristics. Results: Of 4,038 EDs responding to telehealth questions in 2019 and 2020 (73% response rate), 3,015 used telehealth in 2020. Telehealth use by US EDs increased more than expected in 2020 (2016: 58%, 2017: 61%, 2018: 65%, 2019: 67%, 2020: 74%, greater than predicted 71%, p = 0.004). Existing telehealth infrastructure was associated with increased telehealth innovation (OR = 1.88, 95% CI: 1.49-2.36), whereas hospital system membership was not (odds ratio [OR] = 1.00, 95% confidence interval [CI]: 0.80-1.25). Conclusions: Telehealth use by US EDs in 2020 grew more than expected and preexisting telehealth infrastructure was associated with increased innovation in its use. Preparation for future pandemic responses may benefit from considering strategies to invest in local infrastructure to facilitate technology adoption and innovation.

Pediatric Patients Discharged After Transfer to a Pediatric Emergency Department: Opportunities for Telehealth?

STUDY OBJECTIVE: Interemergency department pediatric transfers can be costly, involve risk, and may be disruptive to patients and families. Telehealth could be a way to safely reduce the number of transfers. We made an estimate of the proportion of transfers of pediatric patients to our emergency department (ED) that may have been avoidable using telehealth. METHODS: This was a retrospective analysis of electronic health record data of all pediatric patients (younger than 19 years) who were transferred to a single urban, academic medical center pediatric emergency department (PED) (annual pediatric volume approximately 15,000) between June 1, 2016, and December 29, 2021. We defined transfers as potentially avoidable with telehealth (the primary outcome) when the encounter at the receiving ED resulted in ED discharge and 1) met our definition of low-resource intensity (had no laboratory tests, diagnostic imaging, procedures, or consultations) or 2) could have used initial ED resources with telehealth guidance. RESULTS: Among 4,446 PED patients received in transfer during the study period, 406 (9%) were low-resource intensity. Of the non-low-resource intensity encounters, as many as another 1,103 (24.8%) potentially could have been avoided depending on available telehealth and initial ED resources, ranging from 210 (4.7%) with only telehealth specialty consultation to 538 (7.4%) with imaging and telehealth specialty consultation, and up to 1,034 (23.3%) with laboratory, imaging, and telehealth specialty consultation. CONCLUSION: Our results suggest that depending on available telehealth and initial ED resources, between 9% and 33% of pediatric inter-ED transfers may have been avoidable. This information may guide health system design and PED operations when considering implementing pediatric telehealth.

Simulated video-based telehealth training for emergency physicians.

Introduction: Little exists in the literature describing video-based telehealth training, especially for practicing Emergency Physicians. Materials and methods: This was a retrospective, pre- and post-assessment of physicians' knowledge and confidence on video-based telehealth after two simulated telehealth encounters. Attending physicians voluntarily participated in Zoom-based trainings and received feedback from the patient actors immediately after each simulation. Post-experience surveys queried participants on the training, aspects of telehealth, and confidence in features of optimal telehealth practice. Results: The survey had 100% response rate (13/13 physicians). Participants recommended the simulated training experience, mean of 8.38 (SD 1.89; 0 = Not at all likely, 10 = Extremely likely). Pre- and post-response means increased in two questions: "I can describe at least two ways to improve my video-based clinical care": delta: 1.54, t(12) = 3.83, p = 0.002, Cohen's d effect size of 1.06, and "I know when video-based telehealth could be helpful in clinical practice": delta: 0.99, t(12) = 3.09, p = 0.009, Cohen's d effect size of 0.86. Conclusion: In this pilot, participants viewed telehealth more favorably after the experience and indicated improved confidence in focused telehealth skills. Further study is needed to determine what simulated case content provides the most value for decision-making via telehealth.

Can tablet video-based telehealth assessment of the abdomen safely determine the need for abdominal imaging? A pilot study.

Objective: There is limited evidence on the reliability of video-based physical examinations. We aimed to evaluate the safety of a remote physician-directed abdominal examination using tablet-based video. Methods: This was a prospective observational pilot study of patients >19 years old presenting with abdominal pain to an academic emergency department July 9, 2021-December 21, 2021. In addition to usual care, patients had a tablet video-based telehealth history and examination by an emergency physician who was otherwise not involved in the visit. Both telehealth and in-person clinicians were asked about the patient's need for abdominal imaging (yes/no). Thirty-day chart review searched for subsequent ED visits, hospitalizations, and procedures. Our primary outcome was agreement between telehealth and in-person clinicians on imaging need. Our secondary outcome was potentially missed imaging by the telehealth physicians leading to morbidity or mortality. We used descriptive and bivariate analyses to examine characteristics associated with disagreement on imaging needs. Results: Fifty-six patients were enrolled; the median age was 43 years (interquartile range: 27-59), 31 (55%) were female. The telehealth and in-person clinicians agreed on the need for imaging in 42 (75%) of the patients (95% confidence interval [CI]: 62%-86%), with moderate agreement with Cohen's kappa ((k = 0.41, 95% CI: 0.15-0.67). For study patients who had a procedure within 24 hours of ED arrival (n = 3, 5.4%, 95% CI: 1.1%-14.9%) or within 30 days (n = 7, 12.5%, 95% CI: 5.2%-24.1%), neither telehealth physicians nor in-person clinicians missed timely imaging. Conclusion: In this pilot study, telehealth physicians and in-person clinicians agreed on the need for imaging for the majority of patients with abdominal pain. Importantly, telehealth physicians did not miss the identification of imaging needs for patients requiring urgent or emergent surgery.

Patient Experience With an In-Home COVID Virtual Observation Unit: An Analysis.

We performed a retrospective cohort study of patients admitted to a novel, home-based COVID Virtual Observation Unit (CVOU) from an urban, university-affiliated emergency department with ∼112,000 annual visits. Telephone-based survey questions were administered by nursing staff working with the program. Of 402 patients enrolled in the CVOU, 221 (55%) were able to be contacted during the study period; 180 (45%) agreed to participate in the telephone interview. Overall, 95% (169 out of 177) of the surveyed patients reported 8 to 10 on the likelihood to recommend CVOU and 82% (100 out of 122) rated the quality of care as 10 out of 10. Over 90% of respondents reported that all role groups (nurses, paramedics, and physicians) treated them with courtesy and respect, explained things in an understandable way, and listened to them carefully. Over 80% of respondents reported that the program kept them at home. In summary, patient experiences with this novel home-based care program were highly positive. These data help underscore the importance of patient-centeredness in home-based care, and further support the concept of these innovative care models.

Implementing a COVID-19 Virtual Observation Unit in Emergency Medicine: Frontline Clinician and Staff Experiences.

The COVID-19 pandemic pushed hospitals to deliver care outside of their four walls. To successfully scale virtual care delivery, it is important to understand how its implementation affects frontline workers, including their teamwork and patient-provider interactions. We conducted in-depth interviews of 17 clinicians and staff involved with the COVID-19 Virtual Observation Unit (CVOU) in the emergency department (ED) of an academic hospital. The program leveraged remote patient monitoring and mobile integrated health care. In the CVOU (vs. the ED), participants observed increases in interactions among clinicians and staff, patient participation in care delivery, attention to nonmedical factors, and involvement of coordinators and paramedics in patient care. These changes were associated with unintended, positive consequences for staff, namely, feeling heard, experience of meaningfulness, and positive attitudes toward virtual care. This study advances research on reconfiguration of roles following implementation of new practices using digital tools, virtual work interactions, and at-home care delivery.

Can video-based telehealth examinations of the abdomen safely determine the need for imaging?

There is little evidence on the reliability of the video-based telehealth physical examinations. Our objective was to evaluate the feasibility of a physician-directed abdominal examination using telehealth. This was a prospective, blinded observational study of patients >19 years of age presenting with abdominal pain to a large, academic emergency department. In addition to their usual care, patients had a video-based telehealth examination by an emergency physician early in the visit. We compared the in-person and telehealth providers' decisions on imaging. Thirty patients were enrolled and providers' recommendations for imaging were YES (telehealth: 18 (60%); in-person: 22 (73%)), UNSURE (telehealth: 9 (30%); in-person: 2 (7%)) and NO (telehealth: 6 (20%); in-person: 3 (10%)). There were 20 patients for whom both telehealth and in-person providers were not unsure; of these, 16 (80%, 95% confidence interval 56.3-94.3%) patients had a provider agreement on the need for imaging. While the use of video-based telehealth may be feasible for patients seeking emergency department care for abdominal pain, further study is needed to determine how it may be safely deployed. Currently, caution should be exercised when evaluating the need for abdominal imaging remotely.

Emergency Departments' Uptake of Telehealth for Stroke Versus Pediatric Care: Observational Study.

BACKGROUND: Telehealth for emergency stroke care delivery (telestroke) has had widespread adoption, enabling many hospitals to obtain stroke center certification. Telehealth for pediatric emergency care has been less widely adopted. OBJECTIVE: Our primary objective was to determine whether differences in policy or certification requirements contributed to differential uptake of telestroke versus pediatric telehealth. We hypothesized that differences in financial incentives, based on differences in patient volume, prehospital routing policy, and certification requirements, contributed to differential emergency department (ED) adoption of telestroke versus pediatric telehealth. METHODS: We used the 2016 National Emergency Department Inventory-USA to identify EDs that were using telestroke and pediatric telehealth services. We surveyed all EDs using pediatric telehealth services (n=339) and a convenience sample of the 1758 EDs with telestroke services (n=366). The surveys characterized ED staffing, transfer patterns, reasons for adoption, and frequency of use. We used bivariate comparisons to examine differences in reasons for adoption and use between EDs with only telestroke services, only pediatric telehealth services, or both. RESULTS: Of the 442 EDs surveyed, 378 (85.5%) indicated use of telestroke, pediatric telehealth, or both. EDs with both services were smaller in bed size, volume, and ED attending coverage than those with only telestroke services or only pediatric telehealth services. EDs with telestroke services reported more frequent use, overall, than EDs with pediatric telehealth services: 14.1% (45/320) of EDs with telestroke services reported weekly use versus 2.9% (8/272) of EDs with pediatric telehealth services (P<.001). In addition, 37 out of 272 (13.6%) EDs with pediatric telehealth services reported no consults in the past year. Across applications, the most frequently selected reason for adoption was "improving level of clinical care." Policy-related reasons (ie, for compliance with outside certification or standards or for improving ED performance on quality metrics) were rarely indicated as the most important, but these reasons were indicated slightly more often for telestroke adoption (12/320, 3.8%) than for pediatric telehealth adoption (1/272, 0.4%; P=.003). CONCLUSIONS: In 2016, more US EDs had telestroke services than pediatric telehealth services; among EDs with the technology, consults were more frequently made for stroke than for pediatric patients. The most frequently indicated reason for adoption among all EDs was related to clinical care.

Association of Emergency Department Payer Mix with ED Receipt of Telehealth Services: An Observational Analysis.

INTRODUCTION: Telehealth is commonly used to connect emergency department (ED) patients with specialists or resources required for their care. Its infrastructure requires substantial upfront and ongoing investment from an ED or hospital and may be more difficult to implement in lower-resourced settings. Our aim was to examine for an association between ED payer mix and receipt of telehealth services. METHODS: Using data from the National Emergency Department Inventory (NEDI)-USA 2016 survey, we categorized EDs based on receipt of telehealth services (yes/no). The NEDI-USA data for EDs in New York state was linked with data from state ED datasets (SEDD) and state inpatient data (SID) to determine EDs' payer mix (percent self-pay or Medicaid). Other ED characteristics of interest were rural location, academic status, and annual ED visit volume. We compared EDs with and without telehealth receipt, and used a logistic regression model to examine the relationship between ED payer mix and telehealth receipt after accounting for other ED characteristics. RESULTS: Of the 162 New York EDs in the SEDD-SID dataset, 160 (99%) were linked to the NEDI-USA dataset and 133 of those responded (83%) to the survey. Telehealth receipt was reported by 48 EDs (36%, 95% confidence interval [CI], 28-44%). Emergency departments with and without telehealth receipt were similar (all P >0.40) with respect to rurality (6% vs 9%, respectively), academic status (13% vs 8%), and annual volume (median 36,728 vs 43,000). By contrast, median percent of Medicaid or self-pay patients was lower in telehealth EDs (36%) vs non-telehealth EDs (45%, P = 0.02). In adjusted analysis, increasing proportion of Medicaid and self-pay patients was associated with decreased odds of telehealth receipt (odds ratio 0.87 per 5% increase; 95% CI, 0.77-0.99). Rural location, academic status, and ED volume were not significantly associated with odds of ED telehealth receipt in the adjusted model. CONCLUSION: Among EDs in the state of New York, increasing proportion of self-pay and Medicaid patients was associated with decreased odds of ED telehealth receipt, even after accounting for rural location, academic status, and ED volume. The findings support the need for additional infrastructural investment in EDs serving a greater proportion of disadvantaged patients to ensure equitable access.

Crossing the Virtual Chasm: Practical Considerations for Rethinking Curriculum, Competency, and Culture in the Virtual Care Era.

Virtual care, introduced previously as a replacement for in-person visits, is now being integrated into clinical care delivery models to complement in-person visits. The COVID-19 pandemic sped up this process. The rapid uptake of virtual care at the start of the pandemic prevented educators from taking deliberate steps to design the foundational elements of the related learning environment, including workflow, competencies, and assessment methods. Educators must now pursue an informed and purposeful approach to design a curriculum and implement virtual care in the learning environment. Engaging learners in virtual care offers opportunities for novel ways to teach and assess their performance and to effectively integrate technology such that it is accessible and equitable. It also offers opportunities for learners to demonstrate professionalism in a virtual environment, to obtain a patient's history incorporating interpersonal and communication skills, to interact with multiple parties during a patient encounter (patient, caregiver, translator, telepresenter, faculty member), to enhance physical examination techniques via videoconferencing, and ideally to optimize demonstrations of empathy through "webside manner." Feedback and assessment, important features of training in any setting, must be timely, specific, and actionable in the new virtual care environment. Recognizing the importance of integrating virtual care into education, leaders from across the United States convened on September 10, 2020, for a symposium titled, "Crossing the Virtual Chasm: Rethinking Curriculum, Competency, and Culture in the Virtual Care Era." In this article, the authors share recommendations that came out of this symposium for the implementation of educational tools in the evolving virtual care environment. They present core competencies, assessment tools, precepting workflows, and technology to optimize the delivery of high-quality virtual care that is safe, timely, effective, efficient, equitable, and patient-centered.

Assessing Clinical Skills Via Telehealth Objective Standardized Clinical Examination: Feasibility, Acceptability, Comparability, and Educational Value.

Introduction: In March 2020, students' in-person clinical assessments paused due to COVID-19. The authors adapted the June Objective Standardized Clinical Examination (OSCE) to a telehealth OSCE to preserve live faculty observation of students' skills and immediate feedback dialogue between students, standardized patients, and faculty members. The authors assessed students' reactions and comparative performance. Materials and Methods: OSCE and telehealth educators used draft Association of American Medical Colleges (AAMC) telehealth competencies to create educational materials and adapt OSCE cases. Students anonymously answered queries about the challenges of the telehealth encounters, confidence in basic telehealth competencies, and educational value of the experience. Cohort-level performance data were compared between the January in-person and June telehealth OSCEs. Results: One hundred sixty students participated in 29 Zoom® two-case telehealth OSCEs, equaling 58 h of assessment time. Survey response rate: 59%. Students indicated moderate challenge in adapting physical examinations to the telehealth format and indicated it to be cognitively challenging. Confidence in telehealth competencies was rated "moderate" to "very," but was most pronounced for the technical aspects of telehealth, rather than safety engagement with a patient. Although authors found no significant difference in cohort-level performance in total scores and history-taking between the OSCEs, physical examination and communication scores differed between the two assessments. Discussion: It was feasible to adapt a standardized OSCE to a telehealth format when in-person clinical skills assessment was impossible. Students rated this necessary innovation positively, and it adequately assessed foundational clinical skills performance. Conclusion: Given future competency needs in telehealth, we suggest several education and training priorities.

Association of Simulation Participation With Diagnostic Reasoning Scores in Preclinical Students.

PURPOSE: The aim of the study was to evaluate for an association between the number of voluntary mannequin simulation sessions completed during the school year with scores on a year-end diagnostic reasoning assessment among second-year medical students. METHOD: This is retrospective analysis of participation in 0 to 8 extracurricular mannequin simulation sessions on diagnostic reasoning assessed among 129 second-year medical students in an end-of-year evaluation. For the final skills assessment, 2 physicians measured students' ability to reason through a standardized case encounter using the Diagnostic Justification (DXJ) instrument (4 categories each scored 0-3 by raters reviewing students' postencounter written summaries). Rater scores were averaged for a total DXJ score (0-12). To provide additional baseline comparison, zero participation students were divided into 2 groups based on intent to participate: those who signed up for extracurricular sessions but never attended versus those who never expressed interest. Scores across the attendance groups were compared with an analysis of variance and trend analysis. RESULTS: The class DXJ mean equaled 7.56, with a standard deviation of 2.78 and range of 0 to 12. Post hoc analysis after a significant analysis of variance (F = 4.91, df = 8, 128, P < 0.001) showed those participating in 1 or more extracurricular sessions had significantly higher DXJ scores than those not participating. Students doing 7 extracurricular sessions had significantly higher DXJ scores than those doing 0 and 2 (P < 0.05). Zero attendance groups were not different. A significant linear trend (R = 0.48, F = 38.0, df = 1, 127, P < 0.001) was found with 9 groups. A significant quadratic effect, like a dose-response pattern, was found (F = 18.1, df = 2, 125, P < 0.001) in an analysis including both zero attendance groups, a low (1-4 extracurricular sessions) group and a high (5-8) group. CONCLUSIONS: Higher year-end diagnostic reasoning scores were associated with increased voluntary participation in extracurricular mannequin-based simulation exercises in an approximate dose-response pattern.

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.

Are state telemedicine parity laws associated with greater use of telemedicine in the emergency department?

BACKGROUND: Telemedicine is a valuable tool to improve access to specialty care in emergency departments (EDs), and states have passed telemedicine parity laws requiring insurers to reimburse for telemedicine visits. Our objective was to determine if there is an association between such laws and the use of telemedicine in an ED. METHODS: As part of the 2016 and 2017 National ED Inventory-USA surveys, directors of all 5404 EDs in the United States were surveyed on the use of telemedicine. States were divided into those with any form of telemedicine parity law and those without (as of January 2016). We investigated the association between a telemedicine parity law and the use of telemedicine controlling for ED characteristics; state was included as a random intercept. RESULTS: In 2016, among the 50 states and the District of Columbia (DC), 21 (41%) had a telemedicine parity law, whereas 30 (59%) did not. Among the 4418 ED respondents to the telemedicine question (82% response rate), 2352 (53%) received telemedicine. The proportion of EDs receiving telemedicine varied widely across the states and DC, ranging from 13% in DC to 89% in Maine. Neither the presence nor duration of state telemedicine parity laws were independently associated with ED receipt of telemedicine in 2016 nor the adoption of telemedicine from 2016 to 2017. CONCLUSION: Telemedicine parity laws were not associated with use of telemedicine in the ED. These results suggest that other factors are driving the wide variation in ED use of telemedicine across states.

Optimizing Multidisciplinary Simulation in Medical School for Larger Groups: Role Assignment by Lottery and Guided Learning.

PURPOSE: Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups. PATIENTS AND METHODS: We devised a low technology "Orchestra Leader's" chart approach to prominently display students' roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017-2019) with a range of 8 to 19 students per laboratory session. RESULTS: Our 2017-2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method. CONCLUSION: We designed a novel, "Orchestra Leader's" chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

The effect of prior experience on diagnostic reasoning: exploration of availability bias.

Objectives Diagnostic reasoning has been shown to be influenced by a prior similar patient case. However, it is unclear whether this process influences diagnostic error rates or whether clinicians at all experience levels are equally susceptible. The present study measured the influence of specific prior exposure and experience level on diagnostic accuracy. Methods To create the experience of prior exposure, participants (pre-clerkship medical students, emergency medicine residents, and faculty) first verified diagnoses of clinical vignettes. The influence of prior exposures was measured using equiprobable clinical vignettes; indicating two diagnoses. Participants diagnosed equiprobable cases that were: 1) matched to exposure cases (in one of three conditions: a) similar patient features, similar clinical features; b) dissimilar patient features, similar clinical features; c) similar patient features, dissimilar clinical features), or 2) not matched to any prior case (d) no exposure). A diagnosis consistent with a matched exposure case was scored correct. Cases with no prior exposure had no matched cases, hence validated the equiprobable design. Results Diagnosis A represented 47% of responses in condition d, but there was no influence of specific similarity of patient characteristics for Diagnosis A, F(3,712)=7.28, p=0.28 or Diagnosis B, F(3,712)=4.87, p=0.19. When re-scored based on matching both equiprobable diagnoses, accuracy was high, but favored faculty (n=40) 98%, and residents (n=39) 98% over medical students (n=32) 85%, F(2,712)=35.6, p<0.0001. Accuracy for medical students was 84, 87, 94, and 73% for conditions a-d, respectively, interaction F(2,712)=3.55, p<0.002. Conclusions The differential diagnosis of pre-clerkship medical students improved with prior exposure, but this was unrelated to specific case or patient features. The accuracy of medical residents and staff was not influenced by prior exposure.

Telemedicine Facilitation of Transfer Coordination From Emergency Departments.

STUDY OBJECTIVE: Interhospital transfers are costly to patients and to the health care system. The use of telemedicine may enable more efficient systems by decreasing transfers or diverting transfers from crowded referral emergency departments (EDs) to alternative appropriate facilities. Our primary objective is to describe the prevalence of telemedicine for transfer coordination among US EDs, the ways in which it is used, and characteristics of EDs that use telemedicine for transfer coordination. METHODS: We used the 2016 National Emergency Department Inventory-USA survey to identify telemedicine-using EDs. We then surveyed all EDs using telemedicine for transfer coordination and a sample of EDs using telemedicine for other clinical applications. We used a multivariable logistic regression model to identify characteristics independently associated with use of telemedicine for transfer coordination. RESULTS: Of the 5,375 EDs open in 2016, 4,507 responded to National Emergency Department Inventory-USA (84%). Only 146 EDs used telemedicine for transfer coordination; of these, 79 (54%) used telemedicine to assist with clinical care for local admission, 117 (80%) to assist with care before transfer, and 92 (63%) for arranging transfer to a different hospital. Among telemedicine-using EDs, lower ED annual visit volume (odds ratio 5.87, 95% CI 2.79 to 12.36) was independently associated with use of telemedicine for transfer coordination. CONCLUSION: Although telemedicine has potential to improve efficiency of regional emergency care systems, it is infrequently used for coordination of transfer between EDs. When used, it is most often to assist with clinical care before transfer.