Freestanding Emergency Departments Research Articles

Pharmacy services in a freestanding emergency department.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Effectiveness of ALTO® Program in Reducing Opioid Prescription Rates in Inspira Woodbury Freestanding Emergency Department (FSED)

Effectiveness of ALTO® Program in Reducing Opioid Prescription Rates in Inspira Woodbury Freestanding Emergency Department (FSED)

Nonresponse Bias against the Underserved in Emergency Department Patient Experience Surveys: A Cross-Sectional Analysis: Nonresponse to Patient Surveys

BackgroundPatient experience scores are used to assess emergency physicians, but only a small fraction of patients actually respond to patient experience surveys. No prior studies have determined patient characteristics that predict emergency department (ED) patient experience survey response. ObjectivesTo determine which patient characteristics are associated with ED patient experience survey response. MethodsThis was a cross-sectional analysis of a random sample of 2500 patients from our hospital system who were discharged from an ED between January 1 and June 30, 2022. Our hospital system has one hospital-based ED and two freestanding EDs, one of which is in an economically disadvantaged area. For each randomly selected patient, we used chart review to gather the following data points: ED visited, patient age, gender, race, preferred language, primary residence, time of arrival, marital status, health insurance, and emergency severity index for that visit. We used multivariable logistic regression to determine which of those variables were associated with patient experience survey response. ResultsAmong 2500 patients sent surveys, 207 (8.3%) responded. Those with the lowest response rates were from a freestanding ED in an economically disadvantaged area (5.9%), were uninsured (4.9%), or were homeless (2.1%). On multivariable analysis, adjusted odds ratios for survey response for those characteristics were as follows: 0.54 (95% CI 0.33-0.84), 0.56 (95% CI 0.34-0.90), and 0.30 (95% CI 0.02-1.44), respectively. ConclusionMultiple markers of lower socioeconomic status were associated with decreased patient experience survey response rates, suggestive of nonresponse bias against these individuals.

Toward Standardization and High Reliability: Improved Sepsis Screening in Emergency Department Triage Across an Academic Health System

Sepsis is a life-threatening emergency, and early recognition and treatment in the emergency department (ED) is critical to improving outcomes. The authors implemented an interdisciplinary quality improvement (QI) project to standardize sepsis screening workflow across an academic health system consisting of a large tertiary care urban hospital, one freestanding ED, and two small rural affiliate hospitals (RA-1 and RA-2). The research team used the Institute for Healthcare Improvement Model for Improvement framework, consisting of iterative Plan-Do-Study-Act (PDSA) cycles. The primary outcome was rates of screening for sepsis at each site. Secondary outcomes included sepsis mortality and Centers for Medicare & Medicaid Services (CMS) sepsis bundle (SEP-1) compliance at our main medical center. Primary outcome was assessed using electronic dashboards extracting the ratio of ED encounters with electronic health record (EHR)-documented sepsis screening per total ED encounters. The SEP-1 bundle was assessed as percent compliance, and mortality was calculated as average observed to expected (O:E). Averages were compared from preintervention to after initiating improvements using two-tailed t-tests. This QI project took place from December 2022 to December 2023 across four EDs that experience around 138,000 visits annually. A standardized workflow was established at ED triage with an EHR-based question and an associated nurse and physician defined response. Preintervention (October 2022 to November 2022) triage rates for sepsis were 1.7% (163/9,560), 25.3% (523/2,068), 11.0% (360/3,272), and 36.5% (915/2,506) at our main hospital, freestanding ED, RA-1, and RA-2, respectively. After four PDSA cycles, triage rates rose to 91.9% (4,927/5,360), 97.5% (1,032/1,059), 99.0% (1,845/1,863), and 97.4% (1,328/1,363), respectively (p < 0.005). Sepsis triage rates rose most slowly at the large academic medical center, where progressive PDSA cycles were needed to achieve > 90% screening for sepsis. Mean O:E mortality was 0.99 for the 9 months of available data preintervention and 0.83 in the 17 months postintervention (p = 0.07). CMS sepsis bundle compliance was 28.4% for the 15 months preintervention and 40.5% in the 17 months postintervention, (p = 0.14). An interdisciplinary QI project leveraged EHR optimization to integrate with human workflows over four PDSA cycles to achieve standardized and improved screening for sepsis in the ED. This resulted in lower sepsis mortality and increased sepsis bundle compliance, though results were not statistically significant.

Mapping spiritual care in small and critical access hospitals in a faith-based US Health system

Little is known about spiritual care in small hospitals and critical access hospitals (CAHs), essential sources of health care in rural areas of the US. Using interview-administered surveys with spiritual care providers, we examined spiritual care services in 19 facilities, including seven small hospitals, nine CAHs, and three freestanding emergency departments, in one religiously-owned healthcare system. We identified four groups of facilities based on intensity/frequency of chaplain availability. A central finding was the variation in spiritual care services provided in these diverse facilities. Of the 16 hospitals in the sample, 11 of them (69%) offered spiritual care from professional chaplains at least three days per week. Support for staff was an important priority in all the facilities. Needs identified include virtual training and support for the spiritual care providers in these settings. Future research should replicate this study in a representative sample of hospitals that serve the rural US population.

Emergency Department-Based Medication for Opioid Use Disorder Program: Addressing Gaps in Linkages to Care.

Background Emergency department (ED)-based medication for opioid use disorder (MOUD) has been shown to be effective in providing ease of access and successful treatment rates for patients with opioid use disorder (OUD). This study examined the social determinants of health (SDOH) of patients entering an ED-based MOUD program through individual and focus group surveys. SDOHmay impact treatment retention for current and future patients. Methods A survey of all patients entering our MOUD program at two hospital-based EDs and two free-standing EDs was conducted from January to March 2022.Addiction care coordinators (ACCs) used standardized screening tools to enroll patients into the MOUD program, and trained research coordinators used a standardized form, using previously validated survey questions,to examine the role of SDOH.Focused group surveys were also collected. The survey measured patients' perspectives of the program and solicited feedback on SDOH and program barriers. Results Of the 60 OUD patients inducted into the ED-based MOUD program during our survey period, 19 (32%) participated in an individual or focus group interview. Of these, 16 patients (27%) completed all survey questions. The mean age was 42 years old, 94% identified as Caucasian, and 65% were males. Over 94% of subjects found the ACCs helpful in providing follow-up care.Nearly 40% experienced transportation and financial issues.The vast majority found the MOUD program beneficial in coping with withdrawal symptoms, dealing with their addiction, and supporting recovery. Conclusion OUD patients found the ACCs and the MOUD program helpful for their transition to the treatment stage. The MOUD program can improve some patients' reluctance to engage with a healthcare system by addressing barriers related to transportation to appointments and financial issues.

Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation.

Protocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing. We performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0h if they had a hs-cTnI<4ng/L and at 1h if the initial value were 4ng/L and the 1-h value ≤7ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay. Among 32,450 included patients, an AP had no significant differences in cost (+$89, CI: -$714, $893 hospital cost, +$362, CI: -$414, $1138 health system cost) or ED length of stay (+46, CI: -28, 120min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (-37min, CI: -62, 12min) and reduced health system cost (-$112, CI: -$250, $25). Overall, the implementation of AP using hs-cTn does not result in higher costs.

Who do freestanding emergency departments treat? Comparing Texas hospitals to satellite and independent freestanding departments in 2021 and 2022.

The objective was to describe characteristics of emergency department visits to Texas satellite and independent freestanding emergency departments (FrEDs) relative to hospital emergency departments (EDs). The study used all 2021-2022 hospital and FrED discharges from the publicly available Texas Emergency Department Public Use Data Files (PUDF). We conducted a descriptive analysis, comparing patient and visit characteristics at satellite and independent FrEDs and hospital EDs using chi-square tests. We characterized the top 20 diagnoses and procedures ranked by volume, treatment intensity, and potentially avoidable ED use. Discharge data from 2021 to 2022 were combined for the analysis, and ED data at critical access hospitals were excluded. Our sample consisted of 21,605,421 ED visits, 76% occurring at hospitals, 12% at satellite FrEDs, and 12% at independent FrEDs. Compared with hospitals and satellite FrEDs, patients to independent FrEDs were younger, healthier, more likely covered by private insurance, and less likely to be identified as non-Hispanic Black or Hispanic. Visits at satellite and independent FrEDs were more likely to be of moderate and low intensity and potentially avoidable. Our results underscore the need to address potentially avoidable utilization of emergency services.

Individual Attributes and Environmental Conditions of Registered Nurses Working in Freestanding Emergency Departments in the United States: A Descriptive Exploratory Study

IntroductionFreestanding emergency departments (FSEDs) are emergency facilities not connected to inpatient services. The percentage of FSEDs of all EDs grew from 1% in 2001 to 12% in 2017, making FSEDs a substantial subset of US emergency care. The purpose of this study was to describe the individual attributes and environmental conditions of registered nurses working in FSEDs in the US. MethodsA quantitative descriptive exploratory design with cross-sectional survey methodology. ResultsA total of 364 emergency nurses responded to the survey. Most reported their FSED was open 24 hours/day (99.5%), with board-certified emergency physicians onsite (91.5%) and a mean of 3.6 RNs working per shift. Resources immediately available in more than 50% of FSEDs included laboratory and imaging services, and in fewer than 30% of FSEDs included behavioral health care, MRI, obstetric care, orthopedic care, neurologic care, and surgical consult care. Respiratory therapy was reported by 39.6% of respondents as being immediately available. A significant minority of respondents expressed concerns about adequacy of resources and training and the effect on patient care in both survey (30% of respondents) and open-ended questions (42.5% of respondents). DiscussionThe practice environment of emergency nurses in FSEDs was reported as having positive elements; however, a substantial subpopulation reported serious concerns. FSEDs adhere to some of the standards put forward by the American College of Emergency Physicians, with notable exceptions in the areas of staffing RNs, staffing ancillary staff, and availability of some resources.

Association between physician resource utilization, throughput, and patient experience in the emergency department

Background and Importance: Emergency department (ED) care is complex, involving multifaceted factors such as patient volume, provider experience, throughput metrics, and patient-provider interactions. While some studies have explored relationships between these parameters, there is still much to understand about the nuances in ED care. Objective: Our study aimed to analyze the statistical relationships between admission rates, Press Ganey (PG) scores, and various throughput/resource utilization variables in the ED. These variables include imaging and lab ordering rates, door-to-doctor (D2D) success rate, disposition times for specific patient acuities, and elopement or discharge against medical advice (AMA) rates. Design: A retrospective cohort study was conducted using data from eight emergency facilities within the Valley Health System. Settings and Participants: Data from six community hospital EDs and two freestanding emergency departments (FEDs) in the Valley Health System, spanning August 1, 2020, to July 31, 2021, were examined. The analysis involved 99 physicians and approximately 200,000 adult patients. Outcome Measures and Analysis: Correlations between admission rates, PG scores, and various ED metrics were examined using the Jamovi software. Separate analyses were conducted based on facility type using ANOVAs. Main Results: Our findings revealed several significant correlations. There was a positive correlation between lab ordering and admission rates, while D2D success rates showed a negative correlation with admission rates. Additionally, there was a positive association between D2D success rates and quick dispositioning of lower acuity patients. Patient satisfaction (PG score) was negatively correlated with admission, AMA, and D2D success rates, whereas it positively correlated with lab ordering rates. Conclusion: This study identifies significant relationships among ED throughput, resource utilization, and patient satisfaction metrics. These findings can guide further research to understand the patient experience better, optimize resource utilization, and improve overall ED efficiency.

Abstract TP47: When Folks Stroke at a Freestand: Building Successful Stroke Workflows for Freestanding Emergency Departments

Background: Services offered at freestanding emergency departments (FSED) vary and often have inconsistent clinical education and workflow standardization. Delivery of clinical education and implementation of hospital-based emergency department (ED) workflows to FSEDs contributes to a successful system of care. All sites in a mostly rural region are held to PSC standards with 24/7 ED physician coverage from a local, contracted group. All sites have 24/7 neurology provider coverage from an internal Neurohospitalist group that responds to stroke alerts in person or via telestroke. Nursing, radiology, and pharmacy leadership across the region participate in regional stroke and quality committees. Methods: Clinical education for FSED staff aligns with hospital-based EDs but includes competencies related to lack of ancillary services at the FSEDs. NIHSS certification is required and renewed every two years. Quarterly stroke education posters team are at all sites and new hire training is standardized. Availability of thrombolytics is maintained by pharmacy even though they are not on site at FSEDs. Volume and accuracy of 2022 stroke alert activations were reviewed as were door to CT first slice times, total thrombolytic cases, and median D2N times. FSED data was compared to local hospital-based ED outcomes and national stroke standards. Results: There were 27 total FSED stroke alert activations in 2022; 13 had a final coded stroke diagnosis. This 48% accuracy rate is above the range of 35-40% across the region’s hospital-based EDs and meets national standards for alert accuracy. Median door to CT time was 20 minutes and is among the best for the region though slightly longer than national standards. There were 5 FSED thrombolytic cases with a median D2N time of 55 minutes—below the 60-minute national recommendation for treatment time. Conclusion: Providing clinical education and standardizing workflows in the FSEDs resulted in stroke metrics aligning with (or exceeding) regional and national standards. leading to a positive impact patient care when stroke patients present for emergent evaluation and treatment at a FSED.

Freestanding Emergency Departments: Opportunities, Challenges, and Implications for Emergency Care Delivery in the Middle East: A review

Freestanding Emergency Departments (FSEDs) have become increasingly important in healthcare, especially in rural and hospital-consolidated areas. This review evaluates their impact on emergency care, focusing on patient satisfaction, the work environment for healthcare professionals, and their potential to reduce overcrowding in hospital-based emergency departments (H-EDs). It acknowledges the challenges in these areas, particularly in ensuring standardized, high-quality care. The review advocates for state-level legislation to establish uniform standards for FSEDs, incorporating criteria from the American College of Emergency Physicians (ACEP). It also addresses the need for FSEDs in underserved areas, noting their current tendency to be located in more affluent regions. Additionally, the review highlights the necessity for increased price transparency to differentiate FSEDs from other acute care options and to avoid contributing to higher healthcare costs. By addressing these issues and implementing recommended changes, FSEDs can enhance healthcare access while maintaining quality and efficiency in emergency care delivery.

Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital

We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study. We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate. Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure. We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

Remote triage practices in general surgery patients from freestanding emergency departments: A 6-year analysis

BackgroundFreestanding emergency departments have risen in popularity as a means to expand access to care. Although some evaluation of freestanding emergency department utility in specific patient populations exists, management of surgical patients via remote triage and disposition has not been previously described. We report our experience with remote triage to discharge home, level I trauma center, or community hospital admission for general surgery patients who present to an affiliated freestanding emergency department. MethodsA retrospective cohort study of patients presenting to freestanding emergency departments requiring surgical consultation between 2016 and 2021 was conducted. Outcomes included disposition, length of stay, surgical intervention, 30-day mortality, and readmission. Undertriage and overtriage rates were calculated and defined as the following: (1) discharge undertriage—discharge home with 30-day emergency department visit/readmission; 2) transfer undertriage—transfers to community hospital requiring transfer to trauma center; and (3) overtriage—admissions <24 hours without surgery. ResultsOf 1,105 patients, 15% were discharged home, 27% were transferred to trauma centers, and 58% were transferred to community hospitals. Patients admitted to trauma centers were older and had higher acuity pathology, whereas patients admitted to community hospitals had higher operative rates with shorter lengths of stay, operating room time, 30-day readmission, and mortality. Transfer undertriage was 0.9% (n = 6), with only 1 patient requiring transfer from a community hospital to a trauma center for disease acuity. Discharge undertriage was 12% (n = 20) due to worsening or persistent pathology. Overtriage was 5.5% (n = 52), with most having a partial small bowel obstruction or ambiguous diagnostic imaging requiring observation. ConclusionRemote surgery triage at freestanding emergency departments, without an in-person examination, demonstrated both low undertriage and overtriage rates, reflecting appropriate triage practices.

Ventricular Tachycardia.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of ventricular tachycardia (VT) that is refractory to single dose anti-arrhythmic management. Electrical storm, defined as three or more episodes of sustained VT, ventricular fibrillation, or appropriate shocks from an implantable cardioverter defibrillator within 24 hours,1 has a mortality rate up to 14% in the first 48 hours.2 Ventricular tachycardia may present in a heterogenous fashion, not only with stable versus unstable clinical presentations, but also with different electrocardiographic morphologies and etiologies.1 Understanding how to rapidly diagnose, treat, and utilize second or third-line treatments is vital in the setting of refractory ventricular tachycardia rather than relying on the success of first-line agents. Appreciation for what medications are readily available in your crash cart and medication dispensing cabinet is critical for timely management for refractory ventricular tachycardia. At the conclusion of the simulation session, learners will be able to: 1) identify the different etiologies of VT, including structural heart disease, acute ischemia, and acquired or congenital QT syndrome; 2) describe confounding factors of VT, such as electrolyte abnormalities and sympathetic surge; 3) describe how to troubleshoot an unsuccessful synchronized cardioversion, including checking equipment connections, increasing delivered energy, and changing pad placement; 4) compare and contrast treatments of VT based on suspected underlying etiology; 5) describe reasons to activate the cardiac catheterization lab other than occlusive myocardial infarction; and 6) identify appropriate disposition of the patient to the cardiac catheterization lab. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of VT. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form3 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Twelve learners completed a feedback form. This session received 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated 5 scores. The lowest average score was 6.67 for "Before the simulation, the instructor set the stage for an engaging learning experience." The highest average score was 7 for "The instructor helped me see how to improve or how to sustain good performance." The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Excellent care and debrief." Specific scores are available upon request. This is a cost-effective method for reviewing VT diagnosis and management. The case may be modified for appropriate audiences, such as describing what medications may be readily available in a free-standing emergency department or pre-hospital setting. Medical simulation, ventricular tachycardia, cardiac emergencies, dysrhythmias, cardiology, emergency medicine.

Computed Tomography Utilization for Patients Presenting with Chest Pain

IntroductionComputed tomography (CT) is routinely used in the emergency department (ED) due to its ease of access and its ability to rapidly rule in or out many serious conditions. Freestanding emergency departments (FSEDs) have become increasingly used as an alternative to hospital-based emergency departments (HBEDs). The objective of this study was to investigate if the utilization rate of CT differs between FSEDs and HBEDs for chest pain. MethodsA retrospective evaluation of patients presenting to 17 EDs within a large integrated healthcare system between May 1, 2019 – April 30, 2021 with a chief complaint chest pain. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation. Multiple logistic regression was used to assess the effect of facility on CT utilization for chest pain. ResultsThere were 67,084 patient encounters included in the study. Patients were predominately female (55%), white (61%), and insured through Medicare/Medicaid (59%). After controlling for predictive variables which included Charlson Comorbidity Index, ESI, age, sex, and race, patients who presented to FSEDs with chest pain were less likely to have a CT than those who presented to a HBED (AOR = 0.85, CI (0.81–0.90). ConclusionCT scans of the chest are utilized less frequently at FSEDs compared to HBEDs for patient presenting with chest pain.

Randomized Controlled Study in the Use of Aromatherapy for Pain Reduction and to Reduce Opioid Use in the Emergency Department

IntroductionThis study aimed to evaluate the effects of aromatherapy on emergency department patients' perception of pain and its ability to reduce the use of opioids in an emergency department. MethodsThis randomized, controlled, single-blinded study was conducted in a suburban/rural freestanding emergency department with a therapeutic group, sham group, and control group. ResultsA total of 230 patients, 171 females and 59 males, completed the study. Of those who received the therapeutic agent, an average reduction in pain of 1.04 points on the pain scale was reported, whereas the sham group averaged 0.38 and the control group 0.23. There was a statistically significant reduction of pain scores in the therapeutic group. A total of 13 received opioid pain medication during their visit. Of these, the therapeutic group averaged a total of 2.67 morphine milligram equivalents for their visit compared with 3.63 in the sham group and 4.36 in the control group; however, statistical significance was not achieved. DiscussionThis study supported what other studies have found, indicating that aromatherapy is effective in reducing pain. A difference between the placebo effect and a true therapeutic effect was seen by using a control group apart from the sham and therapeutic groups. Despite the small effect size (0.3), implementation of aromatherapy into standard practice may be practical considering the anxiolytic effects that have been shown in other studies. Aromatherapy with essential oils should be considered as another tool to use in a multimodal approach in the treatment of pain in the emergency department setting.

Virtual triage from freestanding emergency departments: a propensity score-weighted analysis of short-term outcomes in emergency general surgery.

Freestanding emergency departments (FSEDs) have generated improved hospital metrics, including decreased ED wait times and increased patient selection. Patient outcomes and process safety have not been evaluated. This study investigates the safety of FSED virtual triage in the emergency general surgery (EGS) patient population. A retrospective review evaluated all adult EGS patients admitted to a community hospital between January 2016 and December 2021 who either presented at a FSED and received virtual evaluation from a surgical team (fEGS) or presented at the community hospital emergency department and received in-person evaluation from the same surgical group (cEGS). Patients' demographics, acute care utilization history, and clinical characteristics at the onset of the index visit were used to build a propensity score model and stabilized Inverse Probability of Treatment Weights (IPTW) were used to create a weighted sample. Multivariable regression models were then employed to the weighted sample to evaluate the treatment effect of virtual triage compared to in-person evaluation on short-term outcomes, including length of stay (LOS) and 30-day readmission and mortality. Variables which occurred during the index visit (such as surgery duration and type of surgery) were adjusted for in the multivariable analyses. Of 1962 patients, 631 (32.2%) were initially evaluated virtually (fEGS) and 1331 (67.8%) underwent an in-person evaluation (cEGS). Baseline characteristics demonstrated significant differences between the cohorts in gender, race, payer status, BMI, and CCI score. Baseline risks were well balanced in the IPTW-weighted sample (SD range 0.002-0.18). Multivariable analysis found no significant differences between the balanced cohorts in 30-day readmission, 30-day mortality, and LOS (p > 0.05 for all). Patients who undergo virtual triage have similar outcomes to those who undergo in-person triage for EGS diagnoses. Virtual triage at FSED for these EGS patients may be an efficient and safe means for initial evaluation.

Modeling the value of an emergency department influenza vaccination program

BackgroundSeasonal influenza continues to present a significant annual burden as the vaccination rate in the United States is 51.8%. Emergency Department (ED) based influenza programs have been successfully implemented and improve vaccine uptake, reduce incidence and costs, and improve outcomes. ObjectiveTo develop a predictive model to assess preventable influenza cases, hospitalizations, fatalities, and incremental cost avoidance based on the unvaccinated population. MethodsA retrospective cohort of ED encounters limited to Medicare and Medicaid populations was performed across 14 tertiary care hospital EDs and six freestanding EDs for 2020. The total number of unvaccinated individuals was identified to determine the potential impact of an ED vaccination campaign. The average cost and loss per inpatient stay was identified from prior industry Medicare benchmark data and was utilized to extrapolate Medicaid losses. Results from published cost-effectiveness studies identified the vaccination thresholds to prevent one additional case of influenza, one additional hospitalization, and one additional fatality. ResultsA total of 39,463 unvaccinated individuals were identified, with 14,064 classified as Medicare, and 25,379 classified as Medicaid. Assuming a 95% target outreach, 90% medical eligibility, and 70% acceptance rate, 414 influenza cases would be prevented (266 Medicaid, 148 Medicare), 28 hospitalizations would be prevented (18 Medicaid, 10 Medicare), and eight deaths would be prevented (5 Medicaid, 3 Medicare). Accordingly, a reduction in admissions would prevent $409,360 in total inpatient medical costs and $36,232 in losses to healthcare systems. ConclusionAn ED-based influenza vaccination program would have a measurable impact on patient influenza disease burden and associated medical expenditures.

Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study.

The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response. To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response. We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability. Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns. Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.