ABSTRACT
Objective: Telehealth in the ED seems counterintuitive. However, COVID-19 surges have led to crowding and increases in patients leaving without being seen (LWBS). This study evaluated the impact of a novel virtual telehealth initiative (virtual telehealth rounding or VTR) in the ED on the prevalence of LWBS dispositions during the pandemic and its effect on mortality and patient safety. Method(s): We conducted a cross sectional study on adult patients presenting to a level 1 trauma and tertiary referral center who were triaged to the waiting room. The trial of VTR took place for 107 days in December 2021-April 2022 and was operational for 65 days (8-hours a day). The remaining 42 days without VTR served as a comparison group. During VTR patients were triaged per usual care on arrival to the ED. Those patients with triage acuity categories II to V who were triaged to the waiting room were then evaluated virtually by a remote clinician (advanced practice providers such as physician assistants, advanced nurse practitioners, and third year emergency medicine residents) after their initial screening examination using a secure virtual health platform in a private cubicle in the ED waiting room. Patients were then reevaluated at 1-2 hour intervals if necessary. ED paramedics were available onsite to take vital signs, transport patients, and communicate directly with the onsite nurses and ED physicians. Patients were evaluated virtually via an iPad by the virtual clinician and provided an initial assessment. They expedited care by ordering labs, radiography, changing the patient's triage category and determining early disposition according to usual clinical practice. Patients were then either left to wait in the waiting room, taken for radiography and/or blood work, or taken back to a room in the ED where they were seen by an onsite ED physician. The main outcome was the LWBS rate, including LWBS before and after triage, patients leaving against medical advice and elopements. Secondary patient outcomes included in-hospital mortality and improved patient safety via "great saves" defined as care that was urgently/emergently escalated by the virtual rounding provider. Result(s): There were 19,958 patients in the analysis, 6,953 (35%) were evaluated via VTR and 13,006 (65%) received standard of care. Mean patient age was 50 years (SD20), 48 (95% CI 48-49) in the VTR group and 50 (95% CI 50-51) in the standard group. Females were 49%, with 3,489 (50%) females in the VTR group and 6,204 (48%) in the standard care group. Overall acuity levels at triage were II 24%, III 54%, IV 22%, and V 1%. Mean triage levels were 2.95 (95% CI 2.94-2.97) in the VTR group and 3.07 (95% CI 3.06 - 3.09) in the standard group. The proportion of LWBS was 565 (8%) in the VTR group and 3,246 (25%) in the standard care group (p<0.001). Overall, 27 (0.1%) of patients did not survive to hospital discharge, 7 (0.1%) in the VTR group and 20 (0.2%) in the standard care group (p=0.421). VTR clinician documented "great saves" in 5% of their patient encounters. Conclusion(s): This novel approach to triage in the ED significantly reduced the proportion of patients with LWBS dispositions by 17%. Although in-hospital mortality was lower in the VTR group it was not statistically significant. Furthermore, VTR clinicians documented rapid escalations in care that may have otherwise been delayed or missed. This approach has the potential to improve patient care and provide relief from crowding. No, authors do not have interests to disclose Copyright © 2022
ABSTRACT
Learning Objectives: Evaluate the economic impact of the COVID-19 pandemic on the post graduate plans of the 2020 and 2021 graduating emergency medicine residency classes to aid in the future career guidance by emergency medicine faculty. Background(s): The strict lockdown measures in response to the COVID-19 pandemic had significant effects in all aspects of the economy and the healthcare industry, including a reduction in emergency department visits by 42%, according to the CDC. This decrease in volume continued throughout 2020 and 2021, causing many physician practice groups to re-evaluate their costs. Objective(s): We hypothesize that the COVID-19 pandemic caused economic impacts on the class of 2020 and 2021 emergency medicine residents in a variety of ways both economically and with changes to post graduate plans to include fellowship. Method(s): We created a survey-based study of the graduating classes of emergency medicine residents of all 17 programs in Florida sent via email through the Florida CORD consortium. Inclusion criteria were that the survey respondent must be from the graduating class of 2020 or 2021. Data was collected through an anonymous online survey platform. Result(s): We received a total of 33 responses, stratifying the data based on the graduating class year. In our small sample, 49% of responders indicated that COVID-19 did impact their post-graduate plans in some way. 50% of responders from the class of 2020 noted some level of reduction in their number of post-graduate shifts, with a total of 33% of responders from both classes. We found a statistically significant difference (p=0.054) in expenses reduction for the class of 2021 graduates (43% of responders) compared to the class of 2020 (8%), with a total of 33% of responders of all classes indicating a reduction. There was no significant difference regarding impact on fellowship plans. Conclusion(s): There seemed to be some impact on employment opportunities and post-graduate career plans, though the degree of this impact is somewhat limited by small sample size. Similar studies need to be repeated to observe any potential generalizable trends to further aid residency program leadership in career guidance for residents.