Emergency Department Patient Navigator Program Demonstrates Reduction in Emergency Department Return Visits and Increase in Follow-up Appointment Adherence.

BACKGROUND: An estimated 56% of emergency department (ED) visits are avoidable. One motivation for return visits is patients' perception of poor access to timely outpatient care. Efforts to facilitate access may help reduce preventable ED visits. We aimed to analyze whether an ED patient navigator (PN) program improved adherence with outpatient appointments and reduced ED return visits. METHODS: We performed a retrospective analysis of patients evaluated and discharged from two EDs from October 2016 to December 2019. Using propensity score matching, an intervention case group was matched against two control groups - patients similar to the case group who presented either (1) pre-PN intervention or (2) post-PN intervention and did not receive intervention. The four outcomes included 72-h return ED visits, 30-day return ED visits, overall ED utilization, as well as the intervention group's adherence rates to PN-scheduled outpatient appointments. From 482,896 charts, propensity matching led to a total of 14,295 patients in each group. RESULTS: PN intervention decreased both acute and subacute ED return visits. Compared to both pre-PN and post-PN controls, navigated patients had a decrease in 72-h and 30-day return visits from 2% to 1% and 7% to 4% (p < 0.001) respectively. Navigated patients also had outpatient appointment adherence rates of 74-80% compared to the estimated national average of 25-56%. While there was no difference in mean ED utilization between the intervention group and pre-PN control group, mean ED utilization was found to be higher in the intervention group compared to the post-PN control group with 0.62 visits compared to 0.38 mean visits (p < 0.001). CONCLUSIONS: By facilitating access to post-ED care, PNs may reduce avoidable ED utilization and improve outpatient follow-up adherence. While overall ED utilization did not change, this may be due to the overall vulnerability of the navigated group which is the goal PN intervention group.

MyEDCare: Evaluation of a Smartphone-Based Emergency Department Discharge Process.

BACKGROUND: Poor comprehension and low compliance with post-ED (emergency department) care plans increase the risk of unscheduled ED return visits and adverse outcomes. Despite the growth of personal health records to support transitions of care, technological innovation's focus on the ED discharge process has been limited. Recent literature suggests that digital communication incorporated into post-ED care can improve patient satisfaction and care quality. OBJECTIVES: We evaluated the feasibility of utilizing MyEDCare, a text message and smartphone-based electronic ED discharge process at two urban EDs. METHODS: MyEDCare sends text messages to patients' smartphones at the time of discharge, containing a hyperlink to a Health Insurance Portability and Accountability Act (HIPAA)-compliant website, to deliver patient-specific ED discharge instructions. Content includes information on therapeutics, new medications, outpatient care scheduling, return precautions, as well as results of laboratory and radiological diagnostic testing performed in the ED. Three text messages are sent to patients: at the time of ED discharge with the nurse assistance for initial access of content, as well as 2 and 29 days after ED discharge. MyEDCare was piloted in a 9-month pilot period in 2019 at two urban EDs in an academic medical center. We evaluated ED return visits, ED staff satisfaction, and patient satisfaction using ED Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS) patient satisfaction scores. RESULTS: MyEDCare enrolled 27,713 patients discharged from the two EDs, accounting for 43% of treat-and-release ED patients. Of the treat-and-release patients, 27% completed MyEDCare discharge process, accessing the online content at the time of ED discharge. Patients discharged via MyEDCare had fewer 72-hour, 9-day, and 30-day unscheduled return ED visits and reported higher satisfaction related to nursing care. CONCLUSION: EDs and urgent care facilities may consider developing a HIPAA-compliant, text message, and smartphone-based discharge process, including the transmission of test results, to improve patient-centered outcomes.

Utilizing Telemedicine in a Novel Approach to COVID-19 Management and Patient Experience in the Emergency Department.

Background: The COVID-19 crisis has highlighted telemedicine as a care delivery tool uniquely suited for a disaster pandemic. Introduction: With support from emergency department (ED) leadership, our institution rapidly deployed telemedicine in a novel approach to large-scale ED infectious disease management at NewYork-Presbyterian/Weill Cornell Medical Center (NYP/WCMC) and NewYork-Presbyterian/Lower Manhattan Hospital (NYP/LMH). Materials and Methods: Nineteen telemedicine carts were placed in COVID-19 isolation rooms to conserve personal protective equipment (PPE) and mitigate infectious risk for patients and providers by decreasing in-person exposures. Results: The teleisolation carts were used for 261 COVID-19 patient interactions from March to May 2020, with 79% of overall use in March. Our urban academic site (NYP/WCMC) had 173 of these cases, and the urban community hospital (NYP/LMH) had 88. This initiative increased provider/patient communication and attention to staff safety, improved palliative care and patient support services, lowered PPE consumption, and streamlined clinical workflows. The carts also increased patient comfort and reduced the psychological toll of isolation. Discussion: Deploying customized placement strategies in these two EDs maximized cart availability for isolation patients and demonstrates the utility of telemedicine in various ED settings. Conclusions: The successful introduction of this program in both academic and urban community hospitals suggests that widespread adoption of similar initiatives could improve safe ED evaluation of potentially infectious patients. In the longer term, our experience underscores the critical role of telemedicine in disaster preparedness planning, as building these capabilities in advance allows for the agile scaling needed to manage unforeseen catastrophic scenarios.

Crisis clinical pathway for COVID-19.

The pandemic of COVID-19 has been particularly severe in the New York City area, which has had one of the highest concentrations of cases in the USA. In March 2020, the EDs of New York-Presbyterian Hospital, a 10-hospital health system in the region, began to experience a rapid surge in patients with COVID-19 symptoms. Emergency physicians were faced with a disease that they knew little about that quickly overwhelmed resources. A significant amount of attention has been placed on the problem of limited supply of ventilators and intensive care beds for critically ill patients in the setting of the ongoing global pandemic. Relatively less has been given to the issue that precedes it: the demand on resources posed by patients who are not yet critically ill but are unwell enough to seek care in the ED. We describe here how at one institution, a cross-campus ED physician working group produced a care pathway to guide clinicians and ensure the fair and effective allocation of resources in the setting of the developing public health crisis. This 'crisis clinical pathway' focused on using clinical evaluation for medical decision making and maximising benefit to patients throughout the system.

Conscious Proning: An Introduction of a Proning Protocol for Nonintubated, Awake, Hypoxic Emergency Department COVID-19 Patients.

The novel coronavirus, or COVID-19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi-institutional (New York-Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID-19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID-19 cases with respiratory symptoms.

Quality improvement initiative increases total paracentesis and early paracentesis rates in hospitalised cirrhotics with ascites.

OBJECTIVE: Early paracentesis (EP) for rapid diagnosis of spontaneous bacterial peritonitis is considered best practice in the care of admitted patients with cirrhosis and ascites, but inpatient paracentesis is frequently not performed or delayed. We developed a quality improvement (QI) initiative aimed at increasing the proportion of admitted patients with cirrhosis who undergo paracentesis and EP. DESIGN: Pre-post study of a QI initiative. SETTING: A tertiary care hospital in a major metropolitan area. PATIENTS: Hospitalised patients with cirrhosis and ascites. INTERVENTIONS: We targeted care providers in the emergency department (ED) by raising awareness of the importance of EP, developing criteria to identify patients at highest risk of SBP who were prioritised for EP by ED providers and restructuring the ED environment to enable timely paracentesis. RESULTS: 76 patients meeting inclusion criteria were admitted during the postintervention 9-month study period. Of these, 91% (69/76) underwent paracentesis during admission versus 71 % (77/109) preintervention (p=0.001). 81% (56/69) underwent EP within 12 hours of presentation or after a predefined acceptable reason for delay versus 48% (37/77) preintervention (p=0.001). There were no significant differences in in-hospital mortality or length of stay before and after intervention. CONCLUSION: A multidisciplinary QI intervention targeting care in the ED successfully increased the proportion of patients with cirrhosis and ascites undergoing diagnostic paracentesis during admission and EP within 12 hours of presentation.