Unnecessary Transfers Research Articles

Telemedical Consultations in Palliative Care: Benefits through Knowledge Exchange and Intercollegiate Collaboration-Findings from the German oVID Project.

(1) Background: As the number of people receiving specialized palliative care (PC) continues to rise, there is a need to ensure the transfer of this expertise from university-based PC departments to primary care hospitals without such in-house access. The present study examines the potential of telemedicine to bridge these gaps. (2) Methods: This is a prospective multi-center feasibility trial. All physicians were appropriately pre-equipped and instructed to conduct telemedical consultations (TCs), which took place within fixed meetings or on-call appointments either related or unrelated to individual patients (allowing TCs also for educational and knowledge exchange purposes). (3) Results: An inquiry for participation was submitted to 11 hospitals, with 5 external hospitals actively cooperating. In the first study section, a total of 57 patient cases were included within 95 patient-related TCs during 80 meetings. Other university disciplines were involved in 21 meetings (26.2%). Therapy adjustments resulted following 25 of 71 affected TCs (35.2%). In 20 cases (21.1%), an on-site consultation at the university hospital was avoided, and in 12 cases (12.6%), a transfer was avoided. Overall, TCs were considered helpful in resolving issues for 97.9% of the cases (n = 93). Yet, technical problems arose in about one-third of all meetings for at least one physician (36.2%; n = 29). Besides, in the second study section, we also conducted 43 meetings between physicians for education and knowledge exchange only. (4) Conclusions: Telemedicine has the potential to transfer university expertise to external hospitals through simple means. It improves collaboration among physicians, may prevent unnecessary transfers or outpatient presentations, and is thus likely to lower costs.

Comparison of Tele-stroke transfer between intervention and non-intervention cases and 30-day outcome events (P8-5.018)

<h3>Objective:</h3> We sought to study patient characteristics and 90-day clinical outcomes among telestroke transfers and compared characteristics between the patients who received stroke interventions of tPA +/− thrombectomy versus who did not. <h3>Background:</h3> Telestroke programs are crucial in providing access to regional medical centers that may not have direct in-person neurology. Patients who get emergently transferred to an affiliated tertiary medical center after an acute telestroke evaluation may not end up requiring advanced tertiary care, which raises a question of potentially futile transfer. <h3>Design/Methods:</h3> We retrospectively analyzed 204 consecutive emergent telestroke transfers from affiliated 19 regional medical centers between October 3rd, 2021, to May 3rd, 2022. The primary outcome of interest was 90-day clinical outcome and 30-day readmission. Baseline patient characteristics were compared. <h3>Results:</h3> Among total 204 patients (mean age 64, female [51.0%]), 181 (88.7%) cases had initial transfer request to our ER and 126 (61.8%) cases were eventually admitted to the ICU. A total of 72 (35.3%) patients underwent an intervention. There was a significant difference in patients age (68 vs 62, <i>P</i>&lt;0.05), acuity of care (<i>i.e.</i>, ICU admission, 78% vs. 53%, <i>P</i>&lt;0.001), stroke diagnosis (ischemic stroke, 93% vs. 25%; hemorrhagic stroke 4% vs 43%; <i>P</i>&lt;0.001), neurosurgery consult (8.3% vs. 43.2%, <i>P</i>&lt;0.001), presenting NIHSS (13 vs 7, <i>P</i>&lt;0.001) in patients with or without intervention, respectively. The 90-day death outcome or 30-day readmission were similar between the two groups of intervention versus without intervention (<i>P</i>&gt;0.05). There were no differences in length of stay or death during index admission in these 2 groups (P&gt;0.05). Goals of care discussions prior to transfer were unclear for both groups, and majority of these two groups were labeled as full code (P&gt;0.05). <h3>Conclusions:</h3> There are patients that do not require interventions, yet require transfer after tele-stroke evaluations, requiring additional resources. Future studies are warranted to understand preventable and unnecessary transfers. <b>Disclosure:</b> Dr. Sivakumar has nothing to disclose. Dr. Ghasemi has nothing to disclose. Dr. Trivedi has nothing to disclose. Dr. Silver has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Various legal firms. Dr. Silver has received intellectual property interests from a discovery or technology relating to health care. Dr. Silver has received publishing royalties from a publication relating to health care. Dr. Silver has received publishing royalties from a publication relating to health care. Dr. Silver has received publishing royalties from a publication relating to health care. Dr. Silver has received personal compensation in the range of $500-$4,999 for serving as a Consultant with Women’s Health Initiative. Dr. Silver has received personal compensation in the range of $500-$4,999 for serving as a Consultant with Best Doctors, Inc./Teladoc, Inc.. Dr. Silver has a non-compensated relationship as a Consultant with ABPN that is relevant to AAN interests or activities. Dr. Silver has a non-compensated relationship as a Member, Regional Board of Directors with American Heart Association that is relevant to AAN interests or activities. Dr. Henninger has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Astrocyte Pharmaceuticals, Inc.. The institution of Dr. Henninger has received research support from DoD. The institution of Dr. Henninger has received research support from NIH. Dr. Kobayashi has nothing to disclose. Dr. Jun-O’Connell has nothing to disclose.

Ellen R. Grass Lecture: Disparities in Access to Neurodiagnostic Testing

ABSTRACT Limited access to EEG services in rural areas creates health disparities in neurological care, including unnecessary transfers and delays in diagnosis and treatment. Rural facilities face several challenges to expanding EEG resources, including a lack of neurologists, technologists, EEG equipment, and adequate IT infrastructure. Potential solutions include investment in innovative technology, expansion of the workforce, and development of hub-and-spoke EEG networks. Bridging the EEG gap requires collaboration between academic and community practices to advance practical technologies, train competent personnel and develop cost-effective resource-sharing strategies.

Resilient Event-/Self-Triggering Leader-Following Consensus Control of Multiagent Systems Against DoS Attacks

This paper focuses on the problem of resilient leader-following consensus for multi-agent systems (MAS) against denial-of-service&#x00A0;(DoS) attacks. Two update strategies based on event/self-triggering are proposed for the control protocols to handle the leader-following consensus in unreliable shared networks. We first propose a dynamic event-triggered communication&#x00A0;(DETC) scheme to mitigate unnecessary information transfer through energy-limited and vulnerable networks. Continuous communication between agents can be avoided. DoS attacks are supposed to be aperiodic and asynchronous at different edges. The concept of valid DoS attack interval is introduced, and the frequency and duration of attacks are analyzed. The leader-following consensus can be achieved when there exist DoS attacks using the dynamic event-based control strategy. Then to avoid continuous event detection and save computation resources, a self-triggered communication&#x00A0;(STC) function is developed. The next triggering moment is predetermined with the latest received state information. And the Zeno behavior is eliminated for the feasibility of the event/self-triggering scheme. Finally, a simulation is provided to verify the effectiveness of the proposed update strategies and control protocols.

395 The “Hub-Spoke” Telemedicine Model in a Large Cohort of Stroke Patients

INTRODUCTION: Stroke is a leading cause of death and disability worldwide. According to the World Health Organization, stroke patients should be treated in dedicated stroke units. However, stroke units require multidisciplinary stroke expertise which is usually scarce in rural areas. METHODS: This is a retrospective single-center study encompassing patients suffering from strokes and receiving pre-hospital and in-hospital tele-stroke expertise based on a spoke/hub stroke network. Data from 38 hospital networks between December 2014 and January 2018 were collected. RESULTS: The study cohort consisted of 9702 patients. The majority were females (n = 3556, 55.3%) and the mean age was 67 (67 +16.7, 66.7 - 67.4, 26 -122). Of all patients, tissue plasminogen activator (tPA) was recommended in 1313 (16.3%) patients, and from these, 810 (61.7%) patients were actually given tPA. As for endovascular intervention, only 187 (2.3%) patients underwent mechanical thrombectomy at our institution. CONCLUSIONS: Tele-stroke networks have proven to be a pivotal development in the treatment of strokes, especially those that are remote. With the additional expertise and the shorter duration from onset to diagnosis to treatment, these networks have substantially improved patient care and decreased healthcare costs, avoiding unnecessary transfers from spoke hospitals to hub.

The Role of Telemedicine in Prehospital Traumatic Hand Injury Evaluation

Unnecessary ED visits and transfers to hand clinics raise treatment costs and patient burden at trauma centers. In the present COVID-19 pandemic, needless transfers can increase patients' risk of viral exposure. Therefore, this review analyzes different aspects of the remote diagnosis and triage of traumatic hand injuries. The most common file was photography, with the most common devices being cell phone cameras. Treatment, triage, diagnosis, cost, and time outcomes were assessed, showing concordance between teleconsultation and face-to-face patient evaluations. We conclude that photography and video consultations are feasible surrogates for ED visits in patients with traumatic hand injuries. These technologies should be leveraged to decrease treatment costs and potentially decrease the time to definitive treatment after initial evaluation.

Process improvement using telemedicine consultation to prevent unnecessary interfacility transfers for low-severity blunt head trauma

ObjectiveMild traumatic brain injuries (MTBI) associated with intracranial haemorrhage are commonly transferred to tertiary care centres. Recent studies have shown that transfers for low-severity traumatic brain injuries may be unnecessary....

Nursing Home Residents' Use of Radiography in New Brunswick: A Case for Mobile Radiography?

Identifying ways to eliminate unnecessary transfer of nursing home (NH) residents to hospitals provides an opportunity to improve outcomes and use scarce healthcare resources more efficiently. This study's goal was to better understand where NH residents access X-ray (XR) and computed tomography (CT) scans and to determine if there was a case for mobile radiography policies in New Brunswick. A retrospective analysis of all the visits to the emergency department (ED) and outpatient imaging departments in two hospitals in Saint John, New Brunswick, in 2020, that involved XR or CT investigations was conducted. There were 521 visits by 311 unique NH residents and 920 investigations (688 XR and 232 CT scans). Most investigations were ordered in the ED (696 of 920; 75.6%; confidence interval: 72.8-78.3%). Of the NH residents who visited the ED and received either an XR or a CT scan, 33.2% received only XR imaging and were discharged back to the NH after a mean ED stay of 5.15 hours. The pattern of NH residents' use of the ED for their imaging needs supports the creation of mobile XR policies to deliver more safe and efficient care in a Canadian medium population urban centre.

Decoding Algorithms and HW Strategies to Mitigate Uncertainties in a PCM-Based Analog Encoder for Compressed Sensing

Analog In-Memory computing (AIMC) is a novel paradigm looking for solutions to prevent the unnecessary transfer of data by distributing computation within memory elements. One such operation is matrix-vector multiplication (MVM), a workhorse of many fields ranging from linear regression to Deep Learning. The same concept can be readily applied to the encoding stage in Compressed Sensing (CS) systems, where an MVM operation maps input signals into compressed measurements. With a focus on an encoder built on top of a Phase-Change Memory (PCM) AIMC platform, the effects of device non-idealities, namely programming spread and drift over time, are observed in terms of the reconstruction quality obtained for synthetic signals, sparse in the Discrete Cosine Transform (DCT) domain. PCM devices are simulated using statistical models summarizing the properties experimentally observed in an AIMC prototype, designed in a 90 nm STMicroelectronics technology. Different families of decoders are tested, and tradeoffs in terms of encoding energy are analyzed. Furthermore, the benefits of a hardware drift compensation strategy are also observed, highlighting its necessity to prevent the need for a complete reprogramming of the entire analog array. The results show &gt;30 dB average reconstruction quality for mid-range conductances and a suitably selected decoder right after programming. Additionally, the hardware drift compensation strategy enables robust performance even when different drift conditions are tested.

Reduce unnecessary transfers from clinics to EDs

A quality improvement project addresses a growing problem.

Which interventions are effective at decreasing or increasing emergency department attendances or hospital admissions from long-term care facilities? A systematic review

ObjectiveUK long-term care facility residents account for 185 000 emergency hospital admissions each year. Avoidance of unnecessary hospital transfers benefits residents, reduces demand on the healthcare systems but is difficult...

The Utah Pediatric Trauma Network, a statewide pediatric trauma collaborative can safely help nonpediatric hospitals admit children with mild traumatic brain injury.

Created in 2019, the Utah Pediatric Trauma Network (UPTN) is a transparent noncompetitive collaboration of all hospitals in Utah with the purpose of improving pediatric trauma care. The UPTN implements evidence-based guidelines based on hospital resources and capabilities with quarterly review of data collected in a network-specific database. The first initiative was to help triage the care of traumatic brain injury (TBI) to prevent unnecessary transfers while ensuring appropriate care. The purpose of this study was to review the effectiveness of this network wide guideline. The UPTN REDCap database was retrospectively reviewed between January 2019 and December 2021. Comparisons were made between the pediatric trauma center (PED1) and nonpediatric hospitals (non-PED1) in admissions of children with very mild, mild, or complicated mild TBI. Of the total 3,315 cases reviewed, 294 were admitted to a non-PED1 hospital and 1,061 to the PED1 hospital with very mild/mild/complicated mild TBI. Overall, kids treated at non-PED1 were older (mean, 14.9 vs. 7.7 years; p = 0.00001) and more likely to be 14 years or older (37% vs. 24%, p < 0.00001) compared with those at PED1. Increased admissions occurred post-UPTN at non-PED1 hospitals compared with pre-UPTN (43% vs. 14%, p < 0.00001). Children admitted to non-PED1 hospitals post-UPTN were younger (9.1 vs. 15.7 years, p = 0.002) with more kids younger than 14 years (67% vs. 38%, p = 0.014) compared with pre-UPTN. Two kids required next-day transfer to a higher-level center (1 to PED1), and none required surgery or neurosurgical evaluation. The mean length of stay was 21.8 hours (interquartile range, 11.9-25.4). Concomitantly, less children with very mild TBI were admitted to PED1 post-UPTN (6% vs. 27%, p < 0.00001) and more with complicated mild TBI (63% vs. 50%, p = 0.00003) than 2019. Implementation of TBI guidelines across the UPTN successfully allowed nonpediatric hospitals to safely admit children with very mild, mild, or complicated mild TBI. In addition, admitted kids were more like those treated at the PED1 hospital. Prognostic/Epidemiological; Level IV.

EasyTBSA as a method for calculating total body surface area burned: a validation study

BackgroundCurrent methods of burn estimation can lead to incorrect estimates of the total body surface area (TBSA) burned, especially among injured children. Inaccurate estimation of burn size can impact initial...

Inter-hospital cardiorespiratory telemonitoring of newborns and infants: a wellworking example of a hub and spoke network

BackgroundPatients who experience cardiorespiratory events usually have to be moved to specialized centers to perform cardiorespiratory studies. To avoid the transfer of these patients to specialized centers, a network has been created based on an interchange system, where the recordings were uploaded in unspecialized centers (spokes) and downloaded by the Sleep Disorders Breathing (SDB) Center (hub) to be analyzed.MethodsThe inter-hospital network was established in November 2008. Initially only 3 non-tertiary hospitals in the Tuscany Region joined the network. Currently, 12 Tuscany hospitals are included.ResultsFrom November 2008 to December 2020, 625 recordings were collected belonging to 422 infants.No recurrent life-threatening episode or infant death occurred in the study population and none of the infants needed to be readmitted or be moved to a tertiary center, except infants who underwent home monitoring.The discharge diagnoses belong to the following categories: apnoea, respiratory problem of the newborn, syncope, gastroesophageal reflux, altered consciousness, transient loss of consciousness and cyanosis.ConclusionsThis study shows that the inter-hospital network is an efficient system that allows accurate and safe management of infants at risk for apnoea, bradycardia, and hypoxemia to remain in unspecialized centers, avoiding unnecessary transfers of patients and over – hospitalizations.

Development of an artificial intelligence model for triage in a military emergency department: Focusing on abdominal pain in soldiers

BackgroundIn military settings, determining whether a patient with abdominal pain requires emergency care can be challenging due to the absence or inexperience of medical staff. Misjudging the severity of abdominal pain can lead to delayed treatment or unnecessary transfers, both of which consume valuable resources. Therefore, our aim was to develop an artificial intelligence model capable of classifying the urgency of abdominal pain cases, taking into account patient characteristics. MethodsWe collected structured and unstructured data from patients with abdominal pain visiting South Korean military hospital emergency rooms between January 2015 and 2020. After excluding patients with missing values, 20,432 patients were enrolled. Structured data consisted of age, sex, vital signs, past medical history, and symptoms, while unstructured data included preprocessed free text descriptions of chief complaints and present illness. Patients were divided into training, validation, and test datasets in an 8:1:1 ratio. Using structured data, we developed four conventional machine learning models and a novel mixed model, which combined one of the best performing machine learning models with emergency medical knowledge. And we also created a deep learning model using both structured and unstructured data. ResultsXgboost demonstrated the highest performance among the six models, with an area under the precision-recall curve (AUPRC) score of 0.61. The other five models achieved AUPRC scores as follows: logistic regression (0.24), decision tree (0.22), multi-layer perceptron (0.21), deep neural network (0.58), and mixed model (0.58). ConclusionThis study is the first to develop an AI model for identifying emergency cases of abdominal pain in a military setting. With more balanced and better-structured datasets, clinically significant AI model could be developed based on the findings of this study.

PISA-DMA: Processing-in-Memory Instruction Set Architecture Using DMA

Processing-in-memory (PIM) has attracted attention to overcome the memory bandwidth limitation, especially for computing memory-intensive DNN applications. Most PIM approaches use the CPU’s memory requests to deliver instructions and operands to the PIM engines, making a core busy and incurring unnecessary data transfer, thus, resulting in significant offloading overhead. DMA can resolve the issue by transferring a high volume of successive data without intervening CPU and polluting the memory hierarchy, thus perfectly fitting the PIM concept. However, the small computing resources of DRAM-based PIM devices allow us to transfer only small amounts of data at one DMA transaction and require a large number of descriptors, thus still incurring significant offloading overhead. This paper introduces PIM Instruction Set Architecture (ISA) using a DMA descriptor called PISA-DMA to express a PIM opcode and operand in a single descriptor. Our ISA makes PIM programming intuitive by thinking of committing one PIM instruction as completing one DMA transaction and representing a sequence of PIM instructions using the DMA descriptor list. Also, PISA-DMA minimizes the offloading overhead while guaranteeing compatibility with commercial platforms. Our PISA-DMA eliminates the opcode offloading overhead and achieves 1.25x, 1.31x, and 1.29x speedup over the baseline PIM at the sequence length of 128 with the BERT, RoBERTa, and GPT-2 models, respectively, in ONNX runtime with real machines. Also, we study how our proposed PISA affects performance in compiler optimization and show that the operator fusion of matrix-matrix multiplication and element-wise addition achieved 1.04x speedup, a similar performance gain using conventional ISAs.

Nursing Home Use of a Resident and Family Decision Guide to Reduce Hospital Readmissions: A Quality Improvement Project

This article presents a quality improvement project involving the first organizational-level test of the effectiveness of a new U.S. Centers for Medicare and Medicaid Services (CMS) endorsed Decision Guide, Go to the Hospital or Stay Here? A Decision Guide for Residents, Families, Friends, and Caregivers. This Decision Guide can enhance resident and family knowledge about nursing home (NH) capabilities and is intended to reduce nursing home resident and family insistence on potentially unnecessary resident transfers and hospital readmissions. The SQUIRE 2.0 guidelines were the framework for this project. A quality improvement project was conducted in 16 NHs in the southeastern United States to evaluate the effect of the resident and family Decision Guide on hospital readmission rates. Prior to implementation, the investigators provided an online orientation to the project followed by onsite training of nursing home personnel. The NHs then distributed and reviewed the Guide with residents and their family members. NH staff entered data related to readmissions and resident and family responses to the Guide into a secure portion of the project website. NH staff recorded data for three months before Guide implementation and for three months after Guide distribution. Three of the nursing homes lost their upper management team soon after study initiation and were unable to continue. A fourth did not provide complete data. In the 12 remaining facilities, the three-month mean number of readmissions dropped from 27 pre-intervention to 18.58, a 31.2% decrease. Participating facilities reported the Guide was very well received by residents and their families. The facilities’ personnel reported that most residents and family members were unaware of the scope of services provided by the nursing home, an information gap filled by the Decision Guide. They found that implementing this Guide in nursing homes was cost-effective, easy to use, and could substantially reduce readmissions. The results of this quality improvement project demonstrated a significant decrease in hospital readmission rates underscoring its potential for quality improvement in NH care and avoidance of burdensome hospital transfers.

Measuring the impact of a “Virtual Pediatric Trauma Center” (VPTC) model of care using telemedicine for acutely injured children versus the standard of care: study protocol for a prospective stepped-wedge trial

BackgroundThe current standard of care in the treatment of children with physical trauma presenting to non-designated pediatric trauma centers is consultation with a pediatric trauma center by telephone. This includes contacting a pediatric trauma specialist and transferring any child with a potentially serious injury to a regionalized level I pediatric trauma center. This approach to care frequently results in medically unnecessary transfers and may place undue burdens on families. A newer model of care, the “Virtual Pediatric Trauma Center” (VPTC), uses telemedicine to make the expertise of a level I pediatric trauma center virtually available to any hospital. While the use of the VPTC model of care is increasing, there have been no studies comparing the VPTC to standard care of injured children at non-designated trauma centers with respect to patient- and family-centered outcomes. The goal of this study is to compare the current standard of care to the VPTC with respect to family-centered outcomes developed by parents and community advisory boards.MethodsWe will use a stepped-wedge trial design to enroll children with physical trauma presenting to ten hospitals, including level II, level III, and non-designated trauma centers. The primary outcome measures are parent/family experience of care and distress 3 days following injury. Secondary aims include 30-day healthcare utilization, parent/family out-of-pocket costs at 3 days and 30 days after injury, transfer rates, and parent/family distress 30 days following injury. We expect at least 380 parents/families of children will be eligible for the study following an emergency department physician’s request for a level I pediatric trauma center consultation. We will evaluate parent/family experience of care and distress using previously validated instruments, healthcare utilization by family recollection and medical record abstraction, and out-of-pocket costs using standard economic analyses.DiscussionWe expect that the findings from this study will inform other level I pediatric trauma centers and non-pediatric trauma centers on how to improve their systems of care for injured children. The results will help to optimize communication, confidence, and shared decision-making between parents/families and clinical staff from both the transferring and receiving hospitals.Trial registrationClinicalTrials.gov Identifier: NCT04469036. Registered July 13, 2020 before start of inclusion.

BARRIERS AND FACILITATORS FOR ECONSULT: IMPROVING ACCESS TO SPECIALIST ADVICE IN LONG-TERM CARE

Abstract Long-term care (LTC) residents continue to receive most of their specialist care outside of the home. These visits present significant risks and burdens for residents. Such risks can be mitigated by eConsult, which facilitates timely, resident-specific, and practical recommendations between primary care providers (PCPs) and specialists to support clinical decision making, reduce unnecessary transfers, and positively impact resident care and quality of life. During focus groups in LTC homes where eConsult is used, PCPs, senior leadership, and a nurse champion recognized eConsult as having great value for residents, especially those with challenges travelling outside of the home. However, they also described LTC homes as under resourced, with minimal IT infrastructure and coupled with time constraints present barriers to eConsult adoption in LTC. Enabling factors (engaging clinician champions, establishing delegates, integration into existing workflows) similarly identified as supporting eConsult implementation more broadly were discussed.

Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients

BackgroundPrevious work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers. MethodsStatewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles. ResultsMedicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage. ConclusionsIn the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.