Nonurgent Issues Research Articles

Identifying Preventable Emergency Admissions in Hospitals Using Machine Learning.

Overcrowding in EDs has been viewed globally as a chronic health challenge. It is directly related to the increased use of EDs for non-urgent issues, leading to increased complications, long waiting times, a higher death rate, or delayed intervention of those more acutely ill. This study aims to develop Machine Learning models to differentiate immediate medical needs from unnecessary ED visits. A Decision Tree, Random Forest, AdaBoost, and XGBoost models were built and evaluated on real-life data. XGBoost achieved the best accuracy and F1-score.

Hotline to Helpline: Reducing On-call Demands.

There is a growing societal trend in plastic surgery patients of viewing their medical care as a commodity product rather than as a healthcare service. Our four-provider private plastic surgery practice noticed this phenomenon through our patients' trend of overusing the emergency after-hours service call line. To affect this behavior, we designed a study educating patients on the emergency service call line's purpose and how to handle nonurgent issues independently. After a 6-month preintervention phase to categorize after-hours emergency calls, We improved preoperative patient education and implemented in-office protocols for quicker provider responses. Postintervention data were collected for another 6 months and compared statistically with the preintervention data. In the preinterventional period, we saw a total of 236 after-hours phone calls. The intervention led to a 22% significant reduction in total calls (P = 0.007). Calls were categorized as nonurgent, urgent, and emergent. While emergent calls remained unchanged (P = 0.56), nonurgent calls significantly decreased (P = 0.005). The most common nonurgent calls were regarding pain, routine postoperative concerns, and drain care, with the intervention resulting in a significant reduction of routine postoperative swelling/bruising/discomfort calls (P = 0.04) but not changing pain (P = 0.23) or drain-related calls (P = 0.78). We found that targeted preoperative patient education coupled with a real-time action board in the office, to ensure timely response to patient questions during office hours, can positively impact after-hours call use, and improve overall patient outcomes by catching urgent issues earlier.

Impacts of COVID-19 on Owner's Veterinary Healthcare Seeking Behavior for Dogs With Chronic Conditions: An Exploratory Mixed-Methods Study With a Convenience Sample.

This mixed-method study explored the impacts of the COVID-19 pandemic on owners' veterinary healthcare seeking, with particular focus on dogs with chronic conditions. A convenience sample of 719 UK dog owners completed an online survey (December 2020-January 2021). Differences in treatment provision and respondents' decisions to seek care across acute, preventative, chronic conditions and for end-of-life care were explored. Multivariable logistic regression models were used to identify factors associated with seeking care for any health issue compared to deciding against it, and urgency to seek care given symptom that could indicate chronic conditions. Open-ended questions were analyzed by thematic analysis. Significant (p-value < 0.05) differences in care seeking decisions were identified regarding access to veterinary care and the way treatment was provided across all health issues. The top reasons for not seeking care across all health issues were a lack of access to a veterinarian (30%, n = 56/187) and a reluctance for a dog to go to the clinic unaccompanied (20%, n = 38/187). Variables related to stronger dog-owner relationship, higher confidence in seeking care, perception of: benefits of veterinary care, dog's high susceptibility to illness and high severity of dog's condition, increased the odds of seeking, and urgency to seek, care. A dog's chronic illness diagnosis reduced the odds of seeking care during the pandemic, reportedly due to difficulties in accessing care for non-urgent issues. Qualitative analysis showed that limited access to routine consultations, delays in test results and restricted access to complementary treatments, led some owners of dogs with chronic conditions to believe that their dog's welfare had deteriorated during the pandemic. Pandemic control measures necessitated changes to how consultations were run. These changes were often viewed favorably, but dog-client separation during consultations were considered problematic, sometimes delaying veterinary advice-seeking, including for euthanasia. Separating owners from their dogs during veterinary consultations should be avoided wherever possible due to impacts on dogs, owners and healthcare seeking. Interventions to improve veterinary healthcare seeking could target attitudes toward benefits of seeking care, improve owners' self-efficacy and capitalize on the dog-owner bond. Such interventions should be implemented alongside interventions aimed at removing structural barriers to accessing healthcare.

Ocular and Systemic Complications of COVID-19: Impact on Patients and Healthcare

There is increasing information available about the effects of the SARS-CoV-2 virus on the systemic and ocular health of patients, as well as the effects of delayed health care. This mini-review summarizes the potential complications and treatments of COVID-19. Systemic findings include respiratory illness, risk of thromboembolic events, and neurologic findings. Some patients may develop persistent symptoms even after the infection resolves. Effective treatment options include glucocorticoids, antivirals, interleukin-6 antagonists, monoclonal antibodies, Janus kinase inhibitors and vaccines. Potential ocular findings of COVID-19 include conjunctivitis, cranial nerve palsies, and microvascular changes in the retina; most symptoms resolved over time. During the lockdown periods, teleophthalmology was utilized to triage non-urgent issues; patients who did present to emergency departments tended to have more severe disease with worse visual prognoses. While transient delays in outpatient ophthalmic care may be tolerated in some patients, others experienced significant vision loss with interruptions in treatments. Resumption of ophthalmic care as soon as possible may help mitigate the effects of delayed care due to the pandemic.

Patient satisfaction with telephone care assessment among patients with non-urgent prehospital emergency care issues: A cross-sectional study

BackgroundTelephone care assessment (TCA) by a nurse have shown to reduce the number of emergency department (ED) visits and emergency medical services missions (EMS). The present study aimed to describe satisfaction among patients with non-urgent prehospital medical issues that were transferred to TCA instead of receiving EMS. These results could provide a basis for developing the telephone services and emergency care pathways. MethodsThis cross-sectional study included 765 patients with non-urgent issues that were transferred to a telephone care assessment, after a risk and urgency assessment by an emergency medical communications operator. One week later, patient satisfaction was evaluated in a structured telephone interview with randomized patients. Results127 telephone interviews were completed.Most patients (70.9–85.0%) were highly satisfied with the telephone care assessment. In particular,patients who were unsure of the urgency of their own health condition and the need for EMS, were highly satisfied (95.3%). Patients that received EMS after the telephone care assessment were more satisfied than those that received telephone guidance or those directed to other health care services (91.4% vs. 65.5% vs. 67.9%, p = 0.002). ConclusionPatients with non-urgent prehospital emergency issues were mainly satisfied with telephone care assessment. In considering ways to reduce the increasing load on emergency medical services, a telephone care assessment could be a good option, without reducing patient satisfaction.

Telehealth Sustainability in a Neurosurgery Department During the COVID-19 Pandemic

BackgroundThe COVID-19 pandemic has shifted the dynamics of health care and neurosurgical practice. Elective surgeries were suspended for 8 weeks in Kentucky. Our objective was to determine if telehealth (TH) visits could be sustained as an alternative to in-person visits.MethodsDeidentified data on TH usage, in-person clinic visits, and inpatient and neurosurgical case volumes from March 2, 2020 to June 26, 2020 were obtained for retrospective analysis.ResultsTH use increased soon after the case suspension started and then decreased to little usage. The number of in-person visits were significantly lower during elective case suspension compared with when cases were resumed. Twenty-five percent of all visits during the suspension were conducted using TH. Thirty-nine percent of TH-visit patients were new patients, 11% were preoperative, 10% were postoperative, and 39% were other existing patients. Forty-eight percent of TH visits resulted in a later in-person clinic visit. After the suspension, in-person visits rebounded to 98% of the prepandemic numbers and TH visits were low.ConclusionsTH visits were challenging due to the need for in-person physical examinations in neurosurgery. TH temporarily accommodated patient needs during the pandemic but could not totally replace in-person visits and was not sustained after 3.5 months of use. Video TH visits worked well for nonurgent issues, such as minor visual examinations. Our findings could help guide the implementation of TH should similar circumstances arise again.

The Impact of Private Insurance Access on Nonurgent Inflammatory Bowel Disease-Related Emergency Department Use

Abstract Background Inflammatory bowel disease (IBD)-related Emergency Department (ED) visits are a costly component to current healthcare expenditures. Patients who are discharged directly from the ED for nonurgent issues (aka “treat and release” ED visits) present an opportunity for quality improvement. Purpose To determine the impact of private insurance on IBD-related treat and release ED visits. The secondary outcome was cost per IBD-related ED visit. Methodology A retrospective cohort study was performed on the 2006 Nationwide Emergency Department Sample (NEDS). Comparisons were made between patients with access to private insurance vs those without. Multivariable survey-weighted logistic and linear regression models with clustering by hospital were created for the primary and secondary outcomes, respectively. Results In total, 19,324 patient encounters were included in the stratified analytic sample. Of these, 9272 (47.98%) patients reported private insurance as their primary payment method. An additional 10,052 (52.02%) patients reported an alternative payment form. The private insurance group was statistically younger, less likely to reside in an urban setting and had more representation within the highest income quartile. The OR of a treat and release ED visit was 1.47 (95% confidence interval 1.34–1.62) for no private insurance compared to private insurance. On average, the cost per ED visit of patients without private insurance was $214.80 ± 48.48, P &amp;lt; 0.001 less than those with private insurance. Conclusions Lack of private insurance is an important predictor of IBD-related treat and release ED visits.

A randomized controlled trial of a novel artificial-intelligence based smartphone application to optimize the management of cancer-related pain.

76 Background: Cancer pain affects 70-90% of advanced malignancy patients, resulting in impaired quality of life and increased healthcare utilization. Novel care delivery models are needed to optimize care for patients dealing with cancer-related pain in between clinic visits. ePAL is a smartphone application(app) that regularly monitors pain and uses artificial intelligence(AI) to differentiate urgent from non-urgent issues to intercede in real time. The purpose of this randomized controlled trial was to determine ePAL's impact on pain severity, attitudes toward cancer treatment, and healthcare utilization in patients with cancer pain. Methods: MGH Palliative Care Clinic Patients with pain from metastatic, solid-organ cancer (n=112) were recruited and randomized to either a control group (n=56) that received usual care or an intervention group (n=56) that used the ePAL app in addition to usual care for 8 weeks. The app assessed pain 3 times/week and questionnaires about pain (BPI), attitudes towards cancer treatment(BQ-II), and general anxiety(GAD-7) were given at 0, 4, and 8 weeks. A repeated measures mixed model approach assessed how outcome measures changed over time. Models controlled for baseline differences at enrollment and random slopes in addition to baseline depression score, age and sex(alpha=0.05). Results: Pain severity (BPI) and negative attitudes toward cancer pain treatment (BQ-II) decreased significantly for those using the app compared to controls(coeff. -0.09, 95% CI: -0.17, -0.007, p=0.034 and coeff. -0.037, 95% CI: -0.072, -0.001, p=0.042 respectively). Anxiety scores increased for those using ePAL compared to controls (coeff. 0.21, 95% CI: 0.039, 0.37, p=0.015). Over 8-weeks, ePAL users had 40% fewer inpatient hospital admissions compared to controls (n=15 vs. n=25, p=0.048). Conclusions: To our knowledge, this is the first mobile app to utilize AI and clinical algorithms to significantly decrease pain and reduce overall inpatient hospitalizations in patients with cancer-related pain. Clinical trial information: NCT02069743.

The Public's Knowledge of Anatomy as a Primer for Medical Education

Undergraduate anatomical content of medical curricula is vast and must be learnt over multiple years before students can apply this knowledge in clinical practice. On graduation medical students, and allied health professionals are deemed competent in their anatomical knowledge and communication of this. We have previously shown the level of anatomical knowledge in the public is varied (Taylor, 2017). There is an assumed uniform level of knowledge of patients by medical professionals, and this may have an impact on the success of communication between patients and medical professionals, particularly those who have a reduced knowledge of anatomy. We have undertaken a further survey of the anatomical knowledge of the general public to emphasise the existence of the varied level of knowledge. We utilized public engagement events to offer the opportunity for members of the public to complete a questionnaire. Participants were asked to place 20 structures onto a blank map of the body, they then recorded their age, gender, highest academic qualification, whether they worked in healthcare and if they had visited a healthcare professional in the last 7 days. Questionnaires were scored independently by 2 anatomists and responses categorized to examine statistical differences between groups for age, gender, working healthcare, highest academic qualification and whether they had undertaken a visit to a healthcare professional in the last 7 days. Statistical significance between groups were determined by ANOVA using Graphpad Prism 5. This study was approved by Lancaster University's FHM Research Ethics Committee. Our respondents (n=109) were aged between 6–90 years, with a mean age of 36 years. Our results demonstrated 100% of participants correctly identified the anatomical location of the brain, with 89% and 88% correctly identifying the location of the biceps and cornea. Interestingly, triceps was only answered correctly by 66% of the participants and both hamstrings and quadriceps being correctly answered by 57% of respondents. The triceps were often labelled in the forearm and the hamstrings and quadriceps were often confused. The abdominal organs were consistently poorly answered, with adrenals, spleen, gallbladder and pancreas, scoring only 14%, 17%, 24% and 27% correct respectively. The only abdominal organ that was correctly placed by over 50% of respondents was the kidneys; 59%, all other abdominal structures scored under 50%. There was no statistical significance in the number of correct answers when comparing between males and females (p=0.086), across age groups (p=0.052), highest academic qualification (p=0.080) and whether an individual had visited a healthcare professional in the last week (p=0.097). Individuals who worked in healthcare scored significantly better than those who did not (p=0.007).Our results add further evidence to the varied knowledge of the general public. A basic level of anatomical knowledge of the public may help them correctly seek medical advice for urgent and non‐urgent issues relating to their body, specifically abdominal issues where respondents scored weakest. The findings of this study emphasize the possible mismatch in anatomical knowledge between clinicians and patients. Students should be aware of this in order to ensure effective communication.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Hospital text paging communication as a surgical quality improvement initiative

BackgroundStudies on medicine wards have shown that numeric pages can be disruptive of workflow and patient care. We created a quality improvement program among surgical ward nurses and residents and hypothesized that a text-based, urgency-stratified initiative would improve communication at no detriment to patient care. MethodsSurgery residents recorded preintervention data for 1 mo including number of total pages, text pages, and numeric pages received from surgical floors. Nurses and residents completed surveys to assess preintervention satisfaction with communication, responsiveness, and workflow. Nurses were then instructed to use text paging for nonurgent issues. Paging data were again recorded for 1 mo, surveys repeated, and patient safety and satisfaction data collected. Primary endpoints evaluated included patient safety and satisfaction data. Secondary endpoints included communication satisfaction of nurses and residents. ResultsAfter text paging implementation, 40.1% of nonurgent pages sent from nurses to resident physicians were alphanumeric texts versus only 17.9% before implementation (P < 0.0001). There was a 19.5% reduction in the number of nonurgent numeric pages sent (P < 0.0001). Overall, 70% of nurses responded postintervention that text paging was the preferred method of contacting a physician and that the text paging initiative improved efficiency. After implementation, 62% of nurses thought that overall communication with clinicians improved. In addition, there was no change in patient safety issues or patient satisfaction. ConclusionsOur text paging initiative for all nonurgent pages from nurses to residents improved physician–nurse workflow and communication on the surgical ward with no decrease in patient satisfaction or safety.

Effect of Home-Call on Otolaryngology Resident Education: A Pilot Study

To inform institutional policies regarding call encounters through an evaluation of the effect of home-call on academic experience and fatigue among surgical residents. This study conducted an assessment of the nature of resident call encounters premidnight and postmidnight and a comparative analysis of sleep deprivation and efficiency in residents during home-call and off call. All Otolaryngology-Head and Neck Surgery residents (n = 9) at single Canadian institution were asked to establish the time and nature of call encounters during home-call. Residents completed the Stanford Sleepiness Scale precall and postcall to measure sleepiness and wore an Actigraph device to measure sleep efficiency to establish fatigue in the setting of home-call as compared with residents off call. Home-call and off call patterns were studied using a random computer-generated selection of days for participants in both study groups. Analysis was conducted from December 1, 2013 to December 30, 2014. Residents received on average 7 pages per night, of which 78.5% of pages were for nonurgent issues. On an average, change in sleep deprivation scores postcall was 3.0 points higher (95% CI: 2.48-3.57, p < 0.0001) in residents who were qualified for a postcall day compared with residents who did not qualify for a postcall day and residents off call according to the Stanford Sleepiness Scale. Postcall sleep deprivation was significantly associated with number of encounters managed after midnight, regardless of management through telephone or in-hospital (p = 0.01). The Actigraph device identified a significant decrease in sleep efficiency in residents who were qualified for a postcall day compared with residents off call (mean = -31.1; 95% CI: -38.9, -23.4; p < 0.001). This is the first study to evaluate surgical residents' home-call experience. We identified a high proportion of nonurgent encounters that residents managed on call and increased postcall fatigue associated with postmidnight telephone encounters. This study highlights the detrimental effects of frequent sleep interruptions because of encounters on call and suggests the need for institutional guidelines to help minimize these interruptions.

Parents' willingness to have their child receive care by physician assistants in a pediatric emergency department

To determine the willingness of parents of children visiting a pediatric emergency department to have a physician assistant (PA) assess and treat their child and the waiting time reduction sufficient for them to choose to receive treatment by a PA rather than wait for a physician. After describing the training and scope of practice of PAs, we asked caregivers of children triaged as urgent to nonurgent if they would be willing to have their child assessed and treated by a PA on that visit: definitely, maybe, or never. We also asked the minimum amount of waiting time reduction they would want to see before choosing to receive treatment by a PA rather than wait for a physician. We approached 320 eligible subjects, and 273 (85.3%) consented to participate. Regarding whether they would be willing to have their child receive treatment by a PA, 140 (51.3%) respondents answered definitely, 107 (39.2%) said maybe, and 26 (9.2%) said never. Most respondents (64.1%) would choose to have their child seen by a PA instead of waiting for a physician if the waiting time reduction were at least 60 minutes (median 60 minutes [interquartile range 60 minutes]). Respondents' perception of the severity of their child's condition was associated with unwillingness to receive treatment by a PA, whereas child's age, presenting complaint, and actual waiting time were not. Only a small minority of parents of children visiting a pediatric emergency department for urgent to nonurgent issues are unwilling to have their child treated by PAs.

The use of smartphones in general and internal medicine units: A boon or a bane to the promotion of interprofessional collaboration?

Effective communication and coordination are critical components for improving collaborative care delivery among different healthcare providers who work in mobile and time-pressured environments. Increasingly, healthcare providers are exploring alternative communication technologies to help bridge the temporal and spatial issues that are often inherent in the clinical communication conundrum. Our study examined perceptions of General Internal Medicine (GIM) staff on the usage of Smartphone devices and a Webpaging system, which were implemented on the inpatient GIM units at two teaching hospitals in North America. An exploratory case study approach was employed and in-depth interviews with 31 clinicians were conducted. This data-set serves as a subset and prelude to a larger research study that examined and compared the impacts of different types of communication technologies used in five teaching hospitals. Findings from our study indicate that the use of Smartphone technology was well received among clinicians. Specifically, healthcare professionals valued the use of emails when communicating nonurgent issues and the availability of the phone function that enabled access to clinicians especially in urgent situations. Dissatisfaction, however, was expressed over the suitability of these smartphone features in different communication contexts as well as discrepancies between clinicians over the appropriate use of the communication modes. Future interventions in communication technology should take into considerations how communication mediums and situational contexts (e.g. urgent and nonurgent patient issues) impact interprofessional interactions.

A Profile of Nonurgent Emergency Department Use in an Urban Pediatric Hospital

This study was designed to develop a descriptive profile of parents and caregivers who bring their children to the emergency department (ED) for nonurgent issues and to explore the reasons for presenting to an urban hospital pediatric ED for nonurgent conditions. Such work is necessary to develop effective interventions. A total of 106 parents/caregivers whose child was triaged with a nonemergent/urgent condition completed a 15- to 20-minute computerized survey (English and Spanish) in an urban pediatric ED. Most respondents described themselves as Latino (76%) and foreign born (62%). About one half (49%) reported having an annual income of less than $20,000, and 43% of respondents did not have health insurance for themselves. Almost all (95%) of the index children had a primary care physician and health insurance. Despite being triaged as nonurgent, more than one half (63%) described their child's condition as "very" or "extremely" urgent. About one half of the respondents reported not receiving basic information on childhood illnesses from their child's physician. Reasons for nonurgent visits seemed to revolve around issues of convenience and perception of quality of care. Interventions should focus on health literacy and ensure that parents are provided relevant and accurate education on pediatric illnesses and common safety concerns; by increasing parental education on pediatric health, parents may be better able to assess acuity of their child's health issues.

E-mail communication in paediatrics: Ethical and clinical considerations

E-mail has become a commonplace 'procedure' in medical practice because it is efficient and inexpensive. However, there are potential misuses and abuses of this form of written communication, with clinical and ethical implications.Common uses of e-mail in paediatics include general communication with colleagues in a professional setting; electronic formal consultation, in which patient confidentiality is paramount; electronic 'curb-side' consultation, which may be perceived as a formal consultation; electronic discussion groups, which lack peer review; communication with current patients or their parents, which should be limited to simple, nonurgent issues; and communication with individuals seeking medical advice who are not patients, which is generally ill-advised.The present practice point offers a few practical suggestions including e-mail etiquette, security measures to ensure confidentiality, development of an e-mail policy for patients and parents, and separation of personal from professional e-mail.

Improving resident work environment: Evaluation of a novel cooperative program

Background. Improving the resident work environment is a major concern for surgery faculty. This study evaluated the ability of a cooperative program with nurses and interns to decrease the number of nonurgent pages and consistently generate a 4-hour block of time at night without nonurgent pages. Methods. Multiple discussions with interns and with nurses on 2 nursing floors identified ways to improve nurse/resident communication. These included use of a notebook by nurses to record nonurgent issues and having on-call interns check with the night nurses after night shift report. For the week before and after institution of the program, interns logged each page received. Pretest and posttest data were compared by use of t testing. Result. Interns logged fewer pages after intervention compared with preintervention (P <.01). In addition, the interns had a 4-hour block of time on call nights without pages more frequently during the posttest period (100% vs 25%, P <.01). The percent of necessary calls increased from 50% to 70% during day shifts (P <.01). Conclusions. A cooperative program that focused on decreasing nonurgent pages and maximizing efficient communication led to a decrease in the number of nonurgent pages received by interns and increased the number of call nights in which a 4-hour block of sleep or study time was generated, thereby improving residents' work environment. (Surgery 2003;134:158-63.)

Doctors who are using e-mail with their patients: a qualitative exploration.

BackgroundDespite the potential for rapid, asynchronous, documentable communication, the use of e-mail for physician-patient communication has not been widely adopted.ObjectiveTo survey physicians currently using e-mail with their patients daily to understand their experiences.MethodsIn-depth phone interviews of 45 physicians currently using e-mail with patients were audio taped and transcribed verbatim. Two investigators independently qualitatively coded comments. Differences were adjudicated by group consensus.ResultsAlmost all of the 642 comments from these physicians who currently use e-mail with patients daily could be grouped into 1 of 4 broad domains: (1) e-mail access and content, (2) effects of e-mail on the doctor-patient relationship, (3) managing clinical issues by e-mail, and (4) integrating e-mail into office processes. The most consistent theme was that e-mail communication enhances chronic-disease management. Many physicians also reported improved continuity of care and increased flexibility in responding to nonurgent issues. Integration of e-mail into daily workflow, such as utilization of office personnel, appears to be a significant area of concern for many of the physicians. For other issues, such as content, efficiency of e-mail, and confidentiality, there were diverging experiences and opinions. Physicians appear to be selective in choosing which patients they will communicate with via e-mail, but the criteria for selection is unclear.ConclusionsThese physician respondents did perceive benefits to e-mail with a select group of patients. Several areas, such as identifying clinical situations where e-mail communication is effective, incorporating e-mail into office flow, and being reimbursed for online medical care/communication, need to be addressed before this mode of communication diffuses into most practices.