Acute Care Consultation Research Articles

Effect of COVID-19 on asthma exacerbation

Understanding the effect of the coronavirus disease 2019 (COVID-19) pandemic, and the efforts taken to combat it, on specific diseases is difficult owing to the many ways in which COVID-19 is impacting patients and health care systems. A significant decrease in the utilization of emergency services for asthma exacerbation (AEX) has been reported.1 However, health care system avoidance has also been reported and has resulted in delayed or decreased primary and acute care consultations, making it difficult to assess the extent to which decreased health utilization is related to patient avoidance of health services versus actual changes in asthma control.

Diagnosing community-acquired pneumonia via a smartphone-based algorithm: a prospective cohort study in primary and acute-care consultations.

Community-acquired pneumonia (CAP) is an essential consideration in patients presenting to primary care with respiratory symptoms; however, accurate diagnosis is difficult when clinical and radiological examinations are not possible, such as during telehealth consultations. To develop and test a smartphone-based algorithm for diagnosing CAP without need for clinical examination or radiological inputs. A prospective cohort study using data from participants aged >12 years presenting with acute respiratory symptoms to a hospital in Western Australia. Five cough audio-segments were recorded and four patient-reported symptoms (fever, acute cough, productive cough, and age) were analysed by the smartphone-based algorithm to generate an immediate diagnostic output for CAP. Independent cohorts were recruited to train and test the accuracy of the algorithm. Diagnostic agreement was calculated against the confirmed discharge diagnosis of CAP by specialist physicians. Specialist radiologists reported medical imaging. The smartphone-based algorithm had high percentage agreement (PA) with the clinical diagnosis of CAP in the total cohort (n = 322, positive PA [PPA] = 86.2%, negative PA [NPA] = 86.5%, area under the receiver operating characteristic curve [AUC] = 0.95); in participants 22-<65 years (n = 192, PPA = 85.7%, NPA = 87.0%, AUC = 0.94), and in participants aged ≥65 years (n = 86, PPA = 85.7%, NPA = 87.5%, AUC = 0.94). Agreement was preserved across CAP severity: 85.1% (n = 80/94) of participants with CRB-65 scores 1 or 2, and 87.7% (n = 57/65) with a score of 0, were correctly diagnosed by the algorithm. The algorithm provides rapid and accurate diagnosis of CAP. It offers improved accuracy over current protocols when clinical evaluation is difficult. It provides increased capabilities for primary and acute care, including telehealth services, required during the COVID-19 pandemic.

Applying Telehealth Technologies and Strategies to Provide Acute Care Consultation and Treatment of Patients With Confirmed or Possible COVID-19.

Background and PurposeThe COVID-19 pandemic continues to grow, with 19% of total confirmed patients classified as severe or critical experiencing complications such as dyspnea, hypoxia, acute respiratory distress syndrome, or multiorgan failure. These complications require rehabilitative care. Considering the contagious nature of COVID-19 and the necessity to decrease the volume of health care professionals entering confirmed COVID-19 patient rooms and becoming a potential disease vector, can audiovisual technologies employed by telehealth and telerehabilitation help?Case Description:This case discusses the Baylor Scott and White Institute for Rehab (BSWIR) Physical Medicine and Rehabilitation (PMR) department COVID-19 acute care therapy team's creation of a telehealth strategy to provide early rehabilitative intervention without increasing the odds of disease transmission.Outcomes:The COVID-19 therapy team created a simple process for identifying and triaging care for patients with possible or confirmed COVID-19. These patients were evaluated and treated by the dedicated team using telehealth strategies. A structured risk-benefit analysis was used to determine when in-room care was indicated.Discussion:Acute care physical therapy, occupational therapy, and speech-language pathology telehealth strategies can add value by mitigating COVID-19–related harm and influencing recovery, while not unnecessarily becoming additional disease vectors consuming personal protective equipment. COVID-19 is not only an aggressive respiratory illness similar to acute respiratory distress syndrome but also highly contagious and a risk for health care providers. Telehealth strategies allow therapists to intervene early, opening the possibility to maximize recovery and prevent harm or decompensation. Telehealth strategies can be more prevention-focused while the patient is experiencing relatively good health with goals to maximize strength and endurance before the disease process evolves to critical illness. As COVID-19 progresses, therapy can help mitigate potential complications associated with prolonged intensive care unit stay and ventilator management.

The Impact of Introducing a Physical Medicine and Rehabilitation Consultation Service to an Academic Burn Center.

Prior retrospective studies suggest that physical medicine and rehabilitation (PM&R) acute care consultation improves outcome and reduces acute care length of stay (ACLOS) in trauma patients. There have not been prospective studies to evaluate this impact in burn patients. This cohort study compared outcomes before and after the introduction of a PM&R consultation service to the acute burn program, and the inpatient rehabilitation program, at a large academic hospital. The primary outcome measures were length of stay (LOS) in acute care and during subsequent inpatient rehabilitation. For the acute care phase, there were 194 patients in the preconsultation group and 114 who received a consultation. There was no difference in age, Baux score, or LOS in these patients. For the rehabilitation phase, there were 109 patients in the prephysiatrist group and 104 who received PM&R care. The LOS was significantly shorter in the latter group (24 days vs 30 days, P = .002). Functional independence measure (FIM) change, unexpected readmission, and discharge destination were not significantly different. The addition of a burn physiatrist did not influence ACLOS. However, there was a significant reduction in inpatient rehabilitation LOS.

Academic Physical Medicine and Rehabilitation Acute Care Consultations.

The objective of this study was to describe the provision of Physical Medicine and Rehabilitation acute care consultations in the United States and Canada. Physical Medicine and Rehabilitation department chairs/division directors at academic centers in Canada and the United States were mailed an 18-item questionnaire. Seven of 13 (54%) Canadian and 26/78 (33%) American surveys were returned. A majority of Canadian and American academic institutions provide acute care consultations; however, there were some national differences. American institutions see larger volumes of patients, and more American respondents indicated using a dedicated acute care consultation service model compared with Canadians.

Why the Perioperative Surgical Home Makes Sense for Veterans Affairs Health Care.

Why the Perioperative Surgical Home Makes Sense for Veterans Affairs Health Care.

Lessons learned from the reimbursement profile of a mature private medical toxicology practice: office-based practice pays.

We previously reported the financial data for the first 5 years of one of the author's medical toxicology practice. The practice has matured; changes have been made. The practice is increasing its focus on office-based encounters and reducing hospital-based acute care encounters. We report the reimbursement rates and other financial metrics of the current practice. Financial records from October 2009 through September 2013 were reviewed. This is a period of 4 fiscal years and represents the currently available financial data. Charges, payments, and reimbursement rates were recorded according to the type and setting of the medical toxicology encounter: forensic consultations, outpatient clinic encounters, nonpsychiatric inpatient consultations, emergency department (ED) consultations, and inpatient psychiatric consultations. All patients were seen regardless of ability to pay or insurance status. The number of billed Current Procedural Terminology (CPT) codes for office-based encounters increased over the study period; the number of billed CPT codes for inpatient and ED consultations reduced. Office-based encounters demonstrate a higher reimbursement rate and higher payments. In the fiscal year (FY) of 2012, office-based revenue exceeded hospital-based acute care revenue by over $140,000 despite a higher number of billed CPT encounters in acute care settings, and outpatient payments were 2.39 times higher than inpatient, inpatient psychiatry, observation unit, and ED payments combined. The average payment per CPT code was higher for outpatient clinic encounters than inpatient encounters for each fiscal year studied. There was an overall reduction in CPT billing volume between FY 2010 and FY 2013. Despite this, there was an increase in total practice revenue. There was no change in payor mix, practice logistics, or billing/collection service company. In this medical toxicology practice, office-based encounters demonstrate higher reimbursement rates and overall payments compared to inpatient and ED consultations. While consistent with our previous studies, these differences have been accentuated. This study demonstrates the results of changes to the practice--reduced inpatient/ED consultations and increased outpatient encounters. These practice changes resulted in higher overall revenue despite a lower patient volume. In this analysis, the office-based practice of medical toxicology has higher reimbursement rates, nearly 2.5 times higher, when compared to hospital-based acute care consultations.

Use of Telemedicine to Improve Burn Care in Ukraine

Global burn injuries have been described as the "forgotten public health crises" by the World Health Organization. Nearly 11 million people a year suffer burns severe enough to require medical attention; more people are burned each year than are infected with human immunodeficiency virus/acquired immunodeficiency syndrome and tuberculosis combined. Telemedicine has the potential to link experts in specialized fields, such as burn care, to regions of the world that have limited or no access to such specialized care. A multilevel telemedicine program was developed between Massachusetts General Hospital/Shriners Hospital in Boston, Massachusetts, and City Hospital #8 in Lviv, Ukraine. The program should lead to a sustainable improvement in the care of burn victims in Ukraine. The authors helped establish a Learning Center at City Hospital #8 in Lviv, Ukraine, through which they were able to consult from Shriners Hospital in Boston, on a total of 14 acute burn patients in Ukraine. This article discusses two case reports with the use of telemedicine and how it has allowed the authors to provide not only acute care consultation on an international scale, but also to arrange for direct expert examination and international transport to their specialized burn center in the United States. The authors have established a program through doctors from Massachusetts General Hospital/Shriner's Hospital in Boston, which works with a hospital in Ukraine and has provided acute consultation, as well as patient transportation to the United States for treatment and direct assessment.

The costs and potential savings of telemedicine for acute care neonatal consultation: preliminary findings

Telemedicine was used as a substitute for the telephone (usual care) for some acute care consultations from nurseries at four peripheral hospitals in Queensland. Over a 12-month study period, there were 19 cases of neonatal teleconsultation. Five (26%) cases of avoided infant transport were confirmed by independent assessment, four of which were avoided helicopter retrievals. We conducted two analyses. In the first, the actual costs of providing telemedicine at the study sites were compared with the actual savings associated with confirmed avoided infant transport and nursery costs. There was a net saving to the health system of 54,400 Australian Dollars (AUD) associated with the use of telemedicine over the 12-month period. In the second analysis, we estimated the potential savings that might have been achieved if telemedicine had been used for all retrieval consultations from the study sites. The total projected costs were AUD 64,969 while the projected savings were AUD 271,042, i.e. a projected net saving to the health system of AUD 206,073 through the use of telemedicine. A sensitivity analysis suggested that the threshold proportion of retrievals needed to generate telemedicine-related savings under the study conditions was 5%. The findings suggest that from the health-service perspective, the use of telemedicine for acute care neonatal consultation has substantial economic benefits.

A Multicenter Study of the Revised Edmonton Staging System for Classifying Cancer Pain in Advanced Cancer Patients

The comparative analysis of analgesic interventions for cancer pain is greatly compromised by the lack of well-validated and clinically acceptable tools, which allow a composite classification of pain and patient population characteristics. Although the Edmonton Staging System (ESS) for cancer pain was developed for this purpose, clinical and research utility has been limited due to problems associated with the assessment of some items, especially in relation to definitions and terminology. To overcome these limitations, we designed a revised ESS (rESS) and conducted a multicenter study to determine its inter-rater reliability and predictive value. In revising the rESS, we hypothesized that patients with less problematic pain features would require a shorter time to achieve stable pain control, require less complicated analgesic regimens, be more responsive to opioid therapy, and use lower opioid doses. The rESS items include mechanism of pain, presence or absence of incidental pain, presence or absence of psychological distress and addictive behavior, and level of cognitive function. Patients with cancer pain who were consecutively admitted to two different hospice centers, an acute care consultation service in a teaching hospital or a tertiary palliative care unit in a second teaching hospital were evaluated for study entry. Two independent palliative care specialists completed the rESS where possible within 24 hours of each other. Patients' pain ratings and opioid consumption were recorded daily until the study endpoint (i.e. achievement of stable pain control, discharge or death). Seven hundred and forty-six patients were eligible for study entry and of these, 619 (83%) had a pain syndrome. Inter-rater reliability estimates ranged from 0.67 (pain mechanism) to 0.95 (presence of addiction). In the univariate Cox regression analysis, younger patients (< 60), as well as patients with neuropathic pain, incidental pain, psychological distress, or co-morbid psychological distress and addiction, required a significantly longer time to achieve stable pain control ( P < 0.05). In the multivariate Cox regression analysis, only age (< 60), neuropathic pain and incidental pain were significantly associated with time to reach stable pain control ( P ≤ 0.05). Patients with neuropathic or incidental pain used significantly more modalities to achieve stable pain control ( P < 0.01). Patients with neuropathic pain, incidental pain, as well as the presence of psychological distress or addiction, required a higher final mean morphine equivalent daily dose (MEDD) ( P < 0.001). A comparison of the rESS with the ESS demonstrated the ineffectiveness of the ESS prognostic staging system for predicting achievement of stable pain control. These findings confirm the study hypothesis, suggesting that the rESS appears to have good predictive value and a moderate to high inter-rater reliability. We suggest the rESS should prove to be a useful tool in clinical practice, and in the comparison of cancer pain populations in research studies.