Practical alternative to hospitalization for emergency department patients (PATH): A feasibility study.

OBJECTIVE: We sought to determine the feasibility of the Practical Alternative to Hospitalization (PATH) program, an intervention that offers ED clinicians an outpatient care pathway for patients initially designated for inpatient admission or observation. METHODS: We evaluated a novel care delivery model that was piloted at a tertiary academic medical center in December 2019. An advanced practice provider screened patients designated for inpatient admission or observation and identified eligible participants. Outpatient services were customized for each patient but primarily included care coordination and monitoring through telemedicine and home health services. The primary feasibility outcome was the proportion of eligible patients who were enrolled in the program, as well as patient outcomes after discharge including return ED visits and averted ED boarding time. RESULTS: A total of 199 patients were designated for inpatient admission or observation during PATH program hours. Of 52 eligible patients, 30 (58%) were enrolled. The mean participant age was 62.5 years (SD 17.5), and 25 (83%) had non-Hispanic Black race/ethnicity. The most common disease conditions were chest pain, heart failure, and hyperglycemia. 4 (13%) enrolled patients returned to an ED within 30 days. We estimate that ED boarding time was reduced by 8.2 h (SD 8.1) per patient. CONCLUSION: Emergency physicians and patients were willing to use a novel service that provided an alternative disposition to hospitalization. IMPLICATIONS: alternative payment models that seek to reduce hospital utilization and cost may consider strengthening systems to monitor and coordinate care for patients after ED discharge.

4.5-gram monofilament sensation beneath both first metatarsal heads indicates protective foot sensation in diabetic patients.

BACKGROUND: Loss of protective plantar foot sensation is the major cause of diabetic foot ulcerations and ultimate limb loss. Identification of patients without protective sensation can reduce the risk of unrecognized foot injury. The current recommended screening protocol requires 10-g monofilament testing of ten foot sites with use of a forced-choice paradigm. The objective of the present study was to determine whether testing of fewer than ten sites could provide accuracy comparable with that obtained by testing all ten sites. METHODS: A cross-sectional comparative study of plantar sensory levels in diabetic subjects with and without plantar ulceration was conducted in a tertiary-care teaching hospital setting. We examined forty-seven diabetic subjects with a history of foot ulceration and forty-five diabetic subjects with no history of foot ulceration. Plantar sensory threshold values at five sites on the sole of each foot were measured with a quasi-continuous range of applied forces, and receiver operating characteristic analysis techniques were applied. RESULTS: Screening on the basis of only the maximum force threshold for the left and right first metatarsal head sites provided comparable or better performance at high levels of sensitivity than did either the mean or the maximum force threshold across all ten sites. A sensory threshold of 4.5 g for both the left and right first metatarsal head sites predicted the risk of ulceration with a sensitivity of 100% and a specificity of 67%. CONCLUSIONS: Testing of diabetic patients for protective sensation may be simplified to testing under both first metatarsal heads with a 4.5-g monofilament. If a patient cannot sense the application of a 4.5-g monofilament under either first metatarsal head, he or she probably has lost protective sensation and should be considered to be at risk for undetected injury.

Accuracy of a custom-designed activity monitor: implications for diabetic foot ulcer healing.

The relationship between repetitive trauma and propensity for ulceration and ulcer healing is unknown in part because of the lack of accurate information on activity level. The Step Activity Monitor (SAM) is a newly designed accelerometer to record activity level, but its accuracy is questionable. The purpose of this study was to determine the accuracy of the SAM under varying footwear and walking surface conditions. Ten healthy subjects consented to walk over 530 m of flat ground and up and down two flights of stairs, while wearing an athletic shoe or a fiberglass total contact cast (TCC). The accelerometer, programmed for a subject's cadence and leg motion, was secured to the distal, lateral aspect of the right lower leg. Two observers using hand-held digital counters followed the subject and recorded steps taken with the right leg on all walking surfaces. With the use of a repeated measures analysis of variance (ANOVA), the SAM and hand-held digital counters similarly recorded steps taken, regardless of walking surface condition. While the SAM was highly accurate (94 to 96 percent), the percent error was greater (p = 0.007) for the stair-climbing condition with the use of the TCC because of two subjects using a step-to-gait pattern. Overall, the SAM is an accurate accelerometer that will accurately record activity level, even with the application of a TCC. However, its accuracy may vary with deviations from a normal gait pattern.