Nonemergent Conditions Research Articles

Reproductive health paradigms in times of COVID‐19

Ivonne Diaz Yamal, Chair, FIGO Committee for Reproductive Medicine, Endocrinology and Infertility. Ivonne Díaz Yamal is a Professor at University Militar Nueva Granada and Fundación Universitaria Sanitas, Bogota, Colombia. She is also the scientific director at Unidad de Fertilidad Procreación Medicamente Asistida, Bogota, Colombia. From 2016 to 2018, she served as president of FECOLSOG. She is also the chair for the Committee for Reproductive Medicine for FLASOG. Ivonne Díaz Yamal is the current chair of the FIGO Committee for Reproductive Medicine, Endocrinology and Infertility. For the past several months, we have witnessed one of the greatest global health challenges experienced by humankind. This unprecedented COVID-19 viral pandemic, characterized by its enigmatic nature and bewildering spread, respects no borders and has nearly paralyzed healthcare systems throughout the world. Indeed, in the absence of specific, proven medical interventions, healthcare systems have been overwhelmed, thus limiting their ability to treat patients with non-emergent medical conditions and those awaiting elective procedures. Although it is beyond the scope of this editorial to discuss what constitutes a necessary or elective procedure, this radical change in medical practice has had an enormous impact on discontinuation of fertility care services, especially the assisted reproductive technologies (ART). It is eminently clear that reducing or discontinuing elective procedures and essential ART treatments was crucial not only to enable hospitals and medical facilities to manage (or to treat) the explosive rise in SARS-CoV-2 patients, but also to reduce disease transmission vis-à-vis various mitigating strategies—especially individual isolation and social distancing, strategies utilized effectively in China and Italy. Thus, national authorities and local governmental regulations as well as guidelines published by several medical societies (the European Society of Human Reproduction and Embryology [ESHRE] and the American Society for Reproductive Medicine [ASRM]) have affirmed these recommendations.1-4 All have pointedly emphasized that social isolation and reduced social contact will slow the spread of the disease, reduce risk to medical staff, and conserve medical resources until better testing, tracking, treatments, and hopefully a vaccine become available. While it is recognized that the discontinuation of fertility services is necessary at present, it is essential that every effort be made to continue all reproductive health services to the extent possible. Women need ongoing access to safe and reliable contraception of their choice, management of sexually transmitted infections, and, when necessary, safe termination of pregnancy. It is also a concern that there have been reports of increased gender-based violence in some communities during lockdown. We need to be especially vigilant about this particular problem at this time. Important additional reproductive health considerations are the unknown effects of coronavirus infection on pregnant women and their fetuses, especially in the first trimester, in addition to the generally limited knowledge about the SARS-CoV-2 pathophysiology in pregnancy. The ability to cryopreserve embryos has enabled treatments in progress to be completed for many women and for emergency treatment for cancer patients to continue. For some older women and those with diminished ovarian reserve, treatment delay of a few months may theoretically cause harm in reducing their ultimate chances for a live birth. Additionally, the psychological toll of postponed treatment is a major health burden for those affected. However, the vast majority of infertile patients will not be significantly compromised by a few months’ delay in treatment. Nevertheless, infertility is a disease and fertility care should be considered as an essential medical service; thus, it is important to restart fertility and in vitro fertilization (IVF) treatments as soon as possible. Considerations for beginning IVF treatments should follow both governmental and local regulations as well as ASRM and ESHRE recommendations. First and foremost, restarting must depend on: the degree and prevalence of the disease burden in a given locality; the availability of personnel; personal protective equipment and other health resources; and the development of new patient treatment paradigms that ensure social distancing to maximize patient and personnel safety. Telehealth visits should be encouraged to reduce patient contact and appropriate changes should be made in laboratories to ensure social distancing and application of relevant viral precautions. All patients should be counseled about the possible risks of SARS-CoV-2 in pregnancy and be given the choice to either proceed or postpone treatment. To ensure safe practice and to minimize the risks related to SARS-COV-2 to our patients and staff, we must proceed cautiously as we resume treating patients. Future reproductive care will have to account for the ‘new normal,’ with acknowledgment that infertility care must evolve as we unravel this inscrutable disease.

Recognition and Management of Emergent Spinal Pathology Among First-Line Providers.

Spinal emergencies require prompt identification, management, and surgical referral (if needed) from first-line providers. Diagnostic delays from a failure to recognize emergency conditions can lead to adverse patient outcomes. The objective of this study was to understand the proficiency with which first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This was a cross-sectional analysis of 143 internal medicine, family medicine, emergency care, and neurology questionnaires collected at a single-site academic center. Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Only 35.0% (n=50) of respondents felt "very prepared" to handle spinal emergencies. Bivariate analyses revealed interdepartmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (P<.0001), epidural abscess (P=.0002), and cervical myelopathy (P<.0001). Following pairwise comparisons of interdepartmental differences, emergency medicine statistically outperformed internal medicine (P=.0007) and neurology (P<.0001) on initial management of lumbar radiculopathy, while also having markedly higher success in identifying and managing epidural abscess with respect to family medicine (P<.0001). The likelihood of appropriate initial treatment of cervical myelopathy was significantly higher for neurology than for emergency medicine (P<.0001). A minority of first-line providers reported being very prepared to handle spinal emergencies. Disparities exist between first-line provider specialties regarding clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. Because appropriate handling of emergent spinal pathologies is essential to patient outcomes and optimal resource use, measures should be taken to further educate first-line providers regarding the spinal conditions they will be treating. [Orthopedics. 2020;43(4):e244-e250.].

Misallocation of Demand and the Persistent Non-emergent Use of the Emergency Department Post-Healthcare Reform

The US healthcare systems is struggling to keep pace with increasing demand, as the burden faced by providers and healthcare organizations expands. While care delivery models continue to evolve in the post-reform era, many barriers stemming from capacity constraints, regulation, shortages of manpower and, misallocation of resources persist. In this paper, we provide an analysis of unmet demand in the US system healthcare system. We contribute a deep dive of the literature to elucidate the reasons for which imbalanced and unmet demand, including the heavy use of the emergency department for non-emergent conditions, continues to burden healthcare organizations. We use these findings to motivate recommendations about how to address critical shortcomings in order to better address the needs of patients with both emergent and non-emergent conditions.

Testicular volume: correlation of ultrasonography, orchidometer and caliper measurements in children

BackgroundTesticular size assessment is an important and initial technique for the evaluation of gonadal function. Our study aims to determine the correlation between paediatric testicular volumes measured with the orchidometer, high-resolution ultrasonography (US) and intra-operative measurements using calipers.ResultsThis is a prospective observational study of 127 boys presenting to our institution with non-emergent scrotal conditions between January 2007 and October 2008. Volume estimates of both testes were measured using the Prader orchidometer. The patient was then sent to a radiologist who measured the testicular volumes using US, being blinded to the orchidometer estimates. At surgery, the testicular dimensions on the side of the pathology were obtained with a vernier caliper. The testicular volumes by US and caliper were calculated using the formula 0.71 × Length × Width × Height. The relationship between the measured volumes was determined using Pearson’s correlation statistic and Student’s t test. The level of significance for all analysis was set at p < 0.05. Their ages ranged from 18 days to 13 years (median 3 years). There was significant correlation between testicular volumes (for both sides, i.e. right and left) measured with the orchidometer and US (r = 0.544; 0.537, p < 0.001), significant correlation between testicular volumes measured with the orchidometer and caliper (r = 0.537; 0.638, p < 0.001) and also significant correlation between volumes measured by US and caliper (r = 0.382; 0.829, p < 0.01).ConclusionPrader orchidometer testicular volume estimates correlate significantly with US estimates in children. In resource-constrained settings, it could be used for an accurate and quick testicular volume assessment.

Are There Nationwide Socioeconomic and Demographic Disparities in the Use of Outpatient Orthopaedic Services?

Although disparities in the use of healthcare services in the United States have been well-documented, information examining sociodemographic disparities in the use of healthcare services (for example, office-based and emergency department [ED] care) for nonemergent musculoskeletal conditions is limited. This study was designed to answer two important questions: (1) Are there identifiable nationwide sociodemographic disparities in the use of either office-based orthopaedic care or ED care for common, nonemergent musculoskeletal conditions? (2) Is there a meaningful difference in expenditures associated with these same conditions when care is provided in the office rather than the ED? This study analyzed data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS). The MEPS is a nationally representative database administered by the Agency for Healthcare Research and Quality that tracks patient interactions with the healthcare system and expenditures associated with each visit, making it an ideal data source for our study. Differences in the use of office-based and ED care were assessed across different socioeconomic and demographic groups. Healthcare expenditures associated with office-based and ED care were tabulated for each of the musculoskeletal conditions included in this study. The MEPS database defines expenditures as direct payments, including out-of-pocket payments and payments from insurances. In all, 63,514 participants were included in our study. Fifty-one percent (32,177 of 63,514) of patients were aged 35 to 64 years and 29% were older than 65 years (18,445 of 63,514). Women comprised 58% (37,031 of 63,514) of our population, while men comprised 42% (26,483 of 63,514). Our study was limited to the following eight categories of common, nonemergent musculoskeletal conditions: osteoarthritis (40%, 25,200 of 63,514), joint derangement (0.5%, 285 of 63,514), other joint conditions (43%, 27,499 of 63,514), muscle or ligament conditions (6%, 3726 of 63,514), bone or cartilage conditions (8%, 5035 of 63,514), foot conditions (1%, 585 of 63,514), fractures (7%, 4189 of 63,514), and sprains or strains (18%, 11,387 of 63,514). Multivariable logistic regression was used to ascertain which demographic, socioeconomic, and health-related factors were independently associated with differences in the use of office-based orthopaedic services and ED care for musculoskeletal conditions. Furthermore, expenditures over the course of our study period for each of our musculoskeletal categories were calculated per visit in both the outpatient and the ED settings, and adjusted for inflation. After controlling for covariates like age, gender, region, insurance status, income, education level, and self-reported health status, we found substantially lower use of outpatient musculoskeletal care among patients who were Hispanic (odds ratio 0.79 [95% confidence interval 0.72 to 0.86]; p < 0.001), non-Hispanic black (OR 0.77 [95% CI 0.70 to 0.84]; p < 0.001), lesser-educated (OR 0.72 [95% CI 0.65 to 0.81]; p < 0.001), lower-income (OR 0.80 [95% CI 0.73 to 0.88]; p < 0.001), and nonprivately-insured (OR 0.85 [95% CI 0.79 to 0.91]; p < 0.001). Public insurance status (OR 1.30 [95% CI 1.17 to 1.44]; p < 0.001), lower income (OR 1.53 [95% CI 1.28 to 1.82]; p < 0.001), and lesser education status (OR 1.35 [95% CI 1.14 to 1.60]; p = 0.001) were also associated with greater use of musculoskeletal care in the ED. Healthcare expenditures associated with care for musculoskeletal conditions was substantially greater in the ED than in the office-based orthopaedic setting. There are substantial sociodemographic disparities in the use of office-based orthopaedic care and ED care for common, nonemergent musculoskeletal conditions. Because of the lower expenditures associated with office-based orthopaedic care, orthopaedic surgeons should make a concerted effort to improve access to outpatient care for these populations. This may be achieved through collaboration with policymakers, greater initiatives to provide care specific to minority populations, and targeted efforts to improve healthcare literacy. Level III, therapeutic study.

Geospatial and Clinical Factors Associated with Frequent Emergency Department Use at a Washington DC Safety Net Hospital.

We examined clinical and geospatial factors associated with frequent emergency department (ED) use and identified neighborhood ED "hotspots" over a two-year period (2014-16). Emergency department patients were classified into three categories: (1) infrequent users (&lt;3 ED visits); (2) semi-frequent users (3 or more visits in a year); and (3) persistent users (3 or more visits in both years). Persistent users were more likely to be female, aged 45-64, and have insurance compared with infrequent and semi-frequent users. Thirty percent of persistent users had both a mental and chronic health condition. Persistent and semi-frequent users were no more likely than infrequent users to use the ED for non-emergent conditions, but were more likely to use the ED for primary care treatable and preventable conditions. Emergency department hotspots were located closer to federally qualified health centers, closer to the main ED, had higher rates of mental health and other chronic conditions.

Staff and clinic protection during COVID pandemic

The impact of novel coronavirus pandemic (COVID-19) on the healthcare system has been devastating and the medical fraternity is facing challenges to tackle this catastrophic outbreak. With regard to dermatology practice, we review various outbreak response measures to be followed by the dermatology staff at clinic in constrained environment. Preventive measures like social distancing, hand hygiene practices and protective measures such as introduction of personal protective equipment (PPE) for staff, standardization of clinical guidelines and continuing medical services via teleconsultation are recommended. Physical consultation has been limited to emergency-based services. Although teledermatology would never replace physical consultation, it might serve as an adjunctive role in providing adequate services to the non-emergent conditions and minimizes the risk of exposure of both doctors and patients. Non-urgent visits of the patients are being discouraged and elective dermatology procedures are being postponed. Dermatologists should also recognize and educate health care workers about primary cutaneous features of COVID-19 as well possible dermatological side effects arising from prolonged usage of PPE and hand hygiene practices. Limited office-based and in-patient services with a parallel increase in teledermatology consultations will allow effective dermatologic care and services to the public while ensuring minimum transmission of the virus.

Screening for hypertension: an elevated office blood pressure measurement is valuable, adding an automated one is even better.

Previous studies have examined the relevance of hypertension (HTN) screening in walk-in clinics. So far, no valid algorithm has been proposed on how to integrate HTN screening in this context. The aim of our study was to assess, in a walk-in clinic setting, the HTN screening strategy for performing an automated office blood pressure (AOBP) measurement following an initially high office blood pressure (OBP) measurement. Included participants were adults with nonemergent medical conditions and an initial walk-in clinic OBP between systolic 140 and/or diastolic 90 mmHg and systolic 180 and/or diastolic 110 mmHg. AOBP was performed with patients unattended. The 24-h ambulatory blood pressure measurement (ABPM) was used as the diagnostic threshold. Fifty participants were included in the study. The overall HTN prevalence as confirmed by the 24-h ABPM was 46% [95% confidence interval (CI): 32.19-59.81]. After an elevated OBP, AOBP over diagnostic thresholds occurred in 32 patients and were confirmed by ABPM in 20 participants, leading to a 62.5% positive predictive value (95% CI: 51.5-72.3%). Measurements under the AOBP diagnostic threshold occurred in 18 patients and were confirmed by ABPM in 15 participants, leading to a negative predictive value of 83.3% (95% CI: 62.3-93.8%). In a walk-in clinic, an elevated OBP is a useful screening tool due its ability to recognize nearly one in two patients as actually hypertensive. Adding an AOBP makes it possible to specify what course of action to take. This ultimately results in better targeting of patients for an ABPM referral.

Urgent Care Centers and the Demand for Non-Emergent Emergency Department Visits

Urgent care centers (UCCs) are a cost-efficient substitute to the emergency department (ED) for non-emergent conditions, but no study has identified their impact on ED demand. We address this gap using a novel strategy that exploits daily UCC operating times in a differencing framework. After UCCs close each day, local non-emergent ED visits increase by 1.43 percent (over the adjusted mean rate of 70.58 percent) in areas with multiple UCCs. This effect occurs only among the privately insured population, the target customers of UCCs. Our results suggest that UCCs are successfully substituting for EDs in the treatment of non-emergent conditions.

Urgent Care Center and Emergency Department Utilization for Non-Emergent Health Conditions: Analysis of Managed Care Beneficiaries.

The objective was to identify predictors of utilization for urgent care centers (UCCs), emergency departments (EDs), or for both services for non-emergent health conditions among beneficiaries from a managed care organization (MCO) who resided within a 10-mile radius of UCCs. A cross-sectional design was used to analyze 2016 administrative claims data from an MCO that contracted with a UCC with 12 locations (n = 20,107). Outcome variables were number of visits to UCC, ED, or both. The MCO used the New York University ED algorithm to identify non-emergent health conditions. The Behavioral Model of Health Care Utilization was used as a conceptual framework to identify predictors in the model; age, sex, race/ethnicity, distance to UCC from residence, type of insurance, primary care physician visits, inpatient admissions, chronic conditions, morbid obesity, and smoking behavior. Generalized linear models were used to analyze the association between outcomes and predictors. About 22.7% were UCC users, 66.8% were ED users, and 10.5% used both. African Americans (incident rate ratio [IRR] = 0.95; 95% confidence interval [CI]: 0.91-0.98] were less likely to use UCCs and more likely to use the ED (IRR = 1.10; 95% CI: 1.07-1.13). Beneficiaries with multiple chronic conditions were more likely to use the ED than UCCs. Distance was not a predictor of UCC or ED usage. Utilization of UCC was low for non-emergent health conditions. African Americans and individuals with multiple chronic conditions preferred the ED to UCC for non-emergent health conditions. This study implies that MCO beneficiaries, especially the African American population, need to be informed about UCC locations and services provided.

163 Preliminary Findings and Acceptability of a Clinician-Driven Emergency Department Geriatric Consult Service

Geriatric patients present complex challenges for emergency medicine providers (EMP). These patients more frequently display atypical signs and symptoms of serious pathology as well as non-specific chief complaints, both of which increase hospitalization and mortality. Furthermore, many geriatric patients who present to the emergency department (ED) are subsequently admitted for non-emergent conditions such as worsening neurocognitive disorders, functional decline, caregiver burden and other social challenges. These hospitalizations are not without significant adverse health consequences. Our study seeks to evaluate the acceptability and possible benefits of a geriatric consult service (CS) for older patients seen in the ED. Consults were conducted at a medium size, urban, academic medical center with approximately 60,000 annual visits. Geriatric consult requests were made at the discretion of EMP via the electronic medical record. Geriatricians, geriatric fellows or geriatric physician assistants evaluated these patients in the ED and discussed recommendations directly with the EMP. Over a 6-month period, the CS received 55 consults with an average age of 79.4 years (51% female). Most of these patients lived alone (45.5%) while only 12.7% were from nursing or assisted living facilities. For ambulatory patients, 45% had a fall directly related to the ED visit. The most common reason for consultation was for discharge planning (78.2%) with specific medical management questions as the second most common reason for consult (27.3%). The CS made medication recommendations in 58.2% of all patients seen. For patients not admitted, 57% were evaluated for and offered home services and 74% had outpatient follow-up services arranged. Of all patients seen, 45% were discharged from the ED with the remainder being admitted. The length of stay (LOS) for patients over 65 years of age admitted to the medicine service after CS recommendations in the ED was 4.0 days, compared to a LOS of 4.83 days for those patients not seen by the CS. Of patients seen by the CS and discharged home, 20% returned to the ED and 12% were admitted within 30 days. For all geriatric patients admitted to the general medicine service over the same period of time, the readmission rate was 16.2% Our CS was a well-received and feasible new clinical service for older patients seen in the ED. The CS primarily saw, independent, community-dwelling older patients. Nearly half of patients seen had suffered a fall. The most common reasons for consultation was for discharge planning, suggesting EMPs recognize the importance of outpatient management in this patient population. Of geriatric patients admitted, those seen by the CS had a shorter LOS compared to patients not seen by the CS. Having confirmed the feasibility of an ED geriatric consult service our future research will focus on a prospective evaluation of this CS looking at specific patient and health care system outcomes.

The effect of primary care visits on other health care utilization: A randomized controlled trial of cash incentives offered to low income, uninsured adults in Virginia

We conducted a randomized controlled trial, enrolling low-income uninsured adults in Virginia (United States), to determine whether cash incentives are effective at encouraging a primary care provider (PCP) visit, and at lowering utilization and costs. Subjects were randomized to four groups: untreated controls, and one of three incentive arms with incentives of $0, $25, or $50 for visiting a PCP within six months of group assignment. We used the exogenous variation generated by the experiment to obtain causal evidence on the effects of a PCP visit. We observed modest reductions in non-urgent emergency department visits and increased outpatient visits, but no reductions in overall costs. These findings in utilization are consistent with the expectation that PCPs offer an alternative to the emergency department for non-emergent conditions. Total costs did not decline because any savings from avoiding the emergency department were offset by increased outpatient utilization.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P55. Recognition and management of emergent versus nonemergent spinal pathology amongst first-line providers

BACKGROUND CONTEXT Spinal pathology, particularly spinal emergencies, require prompt identification, management, and surgical referral (if needed) from first-line providers. As such, diagnostic delays from the failure to recognize emergency conditions lead to adverse patient outcomes. In addition, even with nonemergent pathologies, the failure to provide adequate care can result in suboptimal patient outcomes and unnecessary resource utilization. PURPOSE We sought to understand the proficiency with which different types of first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This may aid in tailoring education resources for first-line providers. STUDY DESIGN/SETTING Cross-sectional analysis of collected single-site data. PATIENT SAMPLE A total of 143 internal medicine, family medicine, emergency care, and neurology providers. OUTCOME MEASURES Inter-departmental differences in management of spinal pathology, familiarity, and preparedness for the diagnosis of spinal emergencies. METHODS A pilot survey was distributed to physicians, physician assistants, and nurse practitioners via the REDCap data collection tool. Chi square, Fisher's Exact, and Kruskal–Wallis tests were utilized, as appropriate. RESULTS Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Bivariate analyses revealed inter-departmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (p CONCLUSIONS Disparities exist between the first-line provider specialties with regard to clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. As appropriate recognition and management of emergent spinal pathologies is essential to patient outcomes and optimal resource utilization, it is necessary that measures be taken educationally to ensure first-line providers are familiar and proficient with the established standard of care for the spinal conditions they will be treating.

Reasons for Nonurgent Emergency Department Use by Elders

When systems designed only for true emergencies experience overuse for nonemergent conditions, the result is long wait times and overcrowding. These

Patient Factors Associated With the Decision to Transfer Adult Patients From a Pediatric Emergency Department for Definitive Care.

Adults presenting to pediatric emergency departments are transferred to general emergency departments in proportions between 20% and 60%. How illness severity is related to the decision to transfer is poorly understood. We compared the proportion of adults with emergent and nonemergent conditions with respect to their final disposition. We also determined characteristics associated with transfer. We conducted a retrospective review of the electronic medical record and identified all patients 25 years and older presenting to a large urban freestanding pediatric emergency department from 2008 to 2013. We collected demographic and clinical information and used a preexisting algorithm to classify visits as emergent or nonemergent. We created a multivariate logistical regression model to determine independent variables associated with transfer. Among 246,694 encounters, 1182 (0.5%) patients were older than 25 years. We excluded 402 (34%) because they were not categorized. Of the 780 categorized, 32% had an emergent and 68% had a nonemergent condition. Only 22% were transferred. Compared with nonurgent patients, the proportion transferred was twice as high for emergent patients (36% vs 15%), but even for emergent patients, most (63%) were retained for definitive care and/or disposition. Emergent diagnosis, age 45 to 64 years, and higher triage acuity were independently associated with the decision to transfer. Regardless of illness severity, a minority of adult patients were transferred away for definitive care. Factors independently associated with transfer were emergent condition, higher triage acuity, and older age.

Clinical Mimics: An Emergency Medicine–Focused Review of Syncope Mimics

BackgroundSyncope is an event that causes a transient loss of consciousness (LOC) secondary to global cerebral hypoperfusion. The transient nature of the event can make diagnosis in the emergency department (ED) difficult, as symptoms have often resolved by time of initial presentation. The symptoms and presentation of syncope are similar to many other conditions, which can lead to difficulty in establishing a diagnosis in the ED. ObjectiveThis review evaluates patients presenting with a history concerning for possible syncope, mimics of syncope, and approach to managing syncope mimics. DiscussionSyncope is caused by transient LOC secondary to global cerebral hypoperfusion. Many conditions can present similarly to syncope, making diagnosis in the ED difficult. Some of the most emergent conditions include seizures, stroke, metabolic disorders, and head trauma. Other nonemergent conditions include cataplexy, pseudosyncope, or deconditioning. Many laboratory studies and imaging can be nondiagnostic during ED evaluation. For patients presenting with apparent syncope, immediate treatment should focus on identifying and treating life-threatening conditions. History and physical examination can help guide further diagnostic evaluation and management. ConclusionsPatients with apparent syncope should be evaluated for potential immediate life-threatening conditions. A thorough history and physical examination can aid in distinguishing syncope from common mimics and help identify and subsequently treat life-threatening conditions.

Antimicrobial Prescribing Rates Comparing On-Site Visits with Two Types of Virtual Care Visits Across a Large Integrated Healthcare System

BackgroundIn 2014, Carolinas Healthcare System (CHS) implemented virtual visits and Electronic visits (eVisits) as an alternative to on-site visits to provide novel and convenient ways for patients to access care for non-emergent conditions. With virtual visits, patients have a face-to-face consultation with a provider by logging onto any device equipped with a camera. eVisits offer a lower tech alternative that allow patients to email their health concerns through a series of health-related questions. Providers respond via email with recommendations. No face-to-face interaction is included with eVisits. This study aimed to compare prescribing rates across these care delivery options.MethodsWe identified 2,478 virtual visits, 269 eVisits and 655,329 on-site visits between Jan 2014 to Feb 2017 where there was any diagnosis of bronchitis, sinusitis, non-suppurative otitis media and upper respiratory infection. Antimicrobial prescribing rates were standardized to per 100 visits (reported as a %) for each indication. Prescribing rates are reported for each visit type and indication. Chi square tests were used to compare rates across the visit types.ResultsAcross all visit types and indications, on-site visits had the highest rate of antimicrobial prescribing and eVisits the lowest (onsite: 55.0; virtual: 51.3; eVisit 33.8; P < 0.001). Sinusitis was the most frequent indication for which an antimicrobial was prescribed, with on-site visits (86.6%), virtual (72.9%) and eVisits(57.8%) showing significantly different rates (P < 0.001). For upper respiratory infections, where an antimicrobial is not indicated, 34.5% of on-site, 11.0% of virtual and 2.0% of eVisits received an antimicrobial prescription (P < 0.001).ConclusionThe mechanism of care delivery significantly impacts whether or not an antimicrobial is prescribed for specific diagnoses where a prescription may not be indicated. eVisits had the lowest rates of inappropriate prescribing for URI while on-site care showed significantly higher antimicrobial prescriptions. Further investigation is needed into the underlying causes of prescribing rate variances and how these care delivery options may affect efforts to reduce inappropriate utilization of antimicrobials.Disclosures All authors: No reported disclosures.

Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions?

To examine the contributions of individual- and neighborhood-level spatial access to care to the utilization of emergency departments (EDs) for preventable conditions through implementation of novel local spatial access measures. Emergency department admissions data are from four HealthLNK member hospitals in Chicago from 2007 to 2011. Primary care physician office and clinic locations were obtained from the American Medical Association and the City of Chicago. Multilevel logit regression was used to model the relationship between individual- and neighborhood-level attributes and preventable ED use. Emergency department admissions data were classified based on the primary diagnosis for each encounter. Spatial access to care indices were generated in ArcGIS, and values were extracted at each ZIP code centroid to match patients' ZIP codes. Beyond sociodemographic factors such as gender and race, patients living in medically underserved areas (MUAs) and areas with lower spatial access to primary care clinics had higher odds of preventable ED use. Preventable ED use can be associated with sociodemographic characteristics, as well as spatial access to primary care services. This study reveals potential for using local measures of spatial accessibility for preventable ED analyses.

Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments

IntroductionEmergency medical services (EMS) agencies transport a significant majority of patients with low acuity and non-emergent conditions to local emergency departments (ED), affecting the entire emergency care system’s capacity and performance. Opportunities exist for alternative models that integrate technology, telehealth, and more appropriately aligned patient navigation. While a limited number of programs have evolved recently, no empirical evidence exists for their efficacy. This research describes the development and comparative effectiveness of one large urban program.MethodsThe Houston Fire Department initiated the Emergency Telehealth and Navigation (ETHAN) program in 2014. ETHAN combines telehealth, social services, and alternative transportation to navigate primary care-related patients away from the ED where possible. Using a case-control study design, we describe the program and compare differences in effectiveness measures relative to the control group.ResultsDuring the first 12 months, 5,570 patients participated in the telehealth-enabled program, which were compared against the same size control group. We found a 56% absolute reduction in ambulance transports to the ED with the intervention compared to the control group (18% vs. 74%, P<.001). EMS productivity (median time from EMS notification to unit back in service) was 44 minutes faster for the ETHAN group (39 vs. 83 minutes, median). There were no statistically significant differences in mortality or patient satisfaction.ConclusionWe found that mobile technology-driven delivery models are effective at reducing unnecessary ED ambulance transports and increasing EMS unit productivity. This provides support for broader EMS mobile integrated health programs in other regions.

INTERVENTIONS TO MANAGE RESIDUAL LIMB ULCERATION DUE TO PROSTHETIC USE IN INDIVIDUALS WITH LOWER EXTREMITY AMPUTATION: A SYSTEMATIC REVIEW OF THE LITERATURE.

Patients with lower extremity amputation (LEA) experience 65% more dermatologic issues than non-amputees, and skin problems are experienced by ≈75% of LEA patients who use prostheses. Continuously referring LEA patients to a dermatologist for every stump related skin condition may be impractical. Thus, physical rehabilitation professionals should be prepared to recognize and manage common non-emergent skin conditions in this population. The purpose of this study was to determine the quantity, quality, and strength of available evidence supporting treatment methods for prosthesis-related residual limb (RL) ulcers. Systematic literature review with evidence grading and synthesis of empirical evidence statements (EES) was employed. Three EESs were formulated describing ulcer etiology, conditions in which prosthetic continuance is practical, circumstances likely requiring prosthetic discontinuance, and the consideration of additional medical or surgical interventions. Continued prosthetic use is a viable option to manage minor or early-stage ulcerated residual limbs in compliant patients lacking multiple comorbidities. Prosthetic discontinuance is also a viable method of residual limb ulcer healing and may be favored in the presence of severe acute ulcerations, chronic heavy smoking, intractable pain, rapid volume and weight change, history of chronic ulceration, systemic infections, or advanced dysvascular etiology. Surgery or other interventions may also be necessary in such cases to achieve restored prosthetic ambulation. A short bout of prosthetic discontinuance with a staged re-introduction plan is another viable option that may be warranted in patients with ulceration due to poor RL volume management. High-quality prospective research with larger samples is needed to determine the most appropriate course of treatment when a person with LEA develops an RL ulcer that is associated with prosthetic use.