ABSTRACT
Study Objectives: The COVID-19 pandemic imposed both constraints and opportunities for innovation in emergency care delivery. Visits to the emergency department (ED) plunged by as much as 42% in the US, resulting in excess morbidity and mortality due to patients deferring or avoiding emergency care. With the declaration of a public health emergency, payors such as Medicare authorized emergency physicians (EPs) to bill for evaluation and management services delivered through telehealth—potentially allowing EPs to project emergency care beyond the four walls of the physical ED. If adopted, the provision of emergency care via telehealth could expand the reach of emergency medicine, not only during a pandemic but also more broadly, and especially as aging populations choose to receive more care at home. Such expansion of emergency care could benefit from perspectives of EPs in terms of the motivations, barriers, and necessary capabilities. Thus, our objectives were to survey and profile EPs to better understand the potential for telehealth in emergency care delivery. Methods: In collaboration with ACEP and the Emergency Medicine Practice Resource Network (EMPRN), we designed a survey instrument comprising of 5 main questions that provided ranked choice selections. The survey was sent electronically to a group of EMPRN volunteers representing EPs from diverse geographic, age, and practice levels. Results: The survey was sent to a total number of 765 participants, of which a total of 140 (18%) responded. In terms of motivations, respondents identified early engagement with the option to escalate care to the ED if necessary (77% ranked as very important or somewhat important). Respondents also identified the opportunity to quickly address non-life-threatening complaints that may not have needed an ED visit (76% ranked as very important or somewhat important). The top two identified barriers ranked as very significant or somewhat significant were the inability to obtain an adequate evaluation of the patient (76%) and a lack of support personnel in patients’ homes to assist with virtual visits (64%). A related series of responses ranked the needed capabilities necessary for supportive personnel to address barriers to telehealth use. (Table 1). Conclusions: This survey is a mechanism to begin understanding EPs’ perceptions and what they would need to feel comfortable to safely provide telehealth services in the ED. The results revealed that EPs recognize certain opportunities in terms of the potential future of telehealth in emergency care delivery. However, specific barriers were identified. This survey suggests that the ability to escalate care and obtain adequate telehealth exams with presenters and diagnostic support will be important for EPs to feel safe delivering telehealth services. [Formula presented]
ABSTRACT
Study Objectives: Approximately 10-30% of older patients in the emergency department (ED) exhibit delirium, which goes unrecognized by up to 75% of providers. Delirium is linked to increased lengths of stay, in-hospital falls, cognitive decline, and mortality, yet in a recent national survey of ACEP members, only 14% reported having a protocol addressing delirium in the ED. We conducted a feasibility pilot of a delirium toolkit developed to improve screening and management of delirium in the ED. Methods: Supported by a monthly workgroup, four EDs used the toolkit to develop and implement distinct quality improvement (QI) initiatives contextually appropriate to their ED (sites represented a range of ED environments). QI initiatives included delirium screening (using the CAM, bCAM, and/or DTS instruments) as well as delirium management strategies. Toolkit feasibility testing included assessment of implementation speed, protocol adherence, and qualitative feedback. Sites implemented and reported on process metrics for their QI initiatives from July – November 2020. Results: Findings reflect data from three sites (the fourth site did not contribute quantitative data). Over 73% of ED staff received delirium protocol training across sites in the first month of implementation, and staff participation in additional monthly trainings continued at a lower intensity over time. A total of 7,107 delirium screenings were conducted (representing 43% of older adults visiting the three EDs during the study period) and 4.5% of delirium screenings were positive. Over time, the monthly number and proportion of older adults screened for delirium trended slightly downwards, while the proportion of positive delirium screenings trended upwards. The sites provided 1,460 instances of delirium management activities (some patients received more than one). These activities were grouped into over a dozen different categories, with documenting an updated diagnosis or disposition being most common (300 instances), followed by orientation (239 instances) and hydration/nutrition interventions (196 instances). Conclusion: All pilot sites leveraged the ED-Delirium Toolkit to develop QI initiatives, with three of the four sites contributing data demonstrating successful implementation. These delirium QI initiatives were seen as complementary activities to the concurrent pandemic priorities given the recognition of delirium as both a presenting symptom as well as a common complication of COVID-19. ED nurses may have been able to improve targeted screening of patients over time based on the increasing positivity rate and declining proportion and number of screenings conducted. Given the number of staff trained and scale of delirium management activities, use of the toolkit increased awareness of and interventions for addressing delirium in the ED.