TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study).
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ABSTRACT:
SUBMITTER: Mohr NM
PROVIDER: S-EPMC8008221 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Telemedicine connects emergency departments (ED) with resources necessary for patient care; its use has not been characterized nationally, or even regionally. Our primary objective was to describe the prevalence of telemedicine use in New England EDs and the clinical applications of use. Secondarily, we aimed to determine if telemedicine use was associated with consultant availability and to identify ED characteristics associated with telemedicine use.We analyzed data from the National Emergency Department Inventory-New England survey, which assessed basic ED characteristics in 2014. The survey queried directors of every ED (n=195) in the six New England states (excluding federal hospitals and college infirmaries). Descriptive statistics characterized ED telemedicine use; multivariable logistic regression identified independent predictors of use.Of the 169 responding EDs (87% response rate), 82 (49%) reported using telemedicine. Telemedicine EDs were more likely to be rural (18% of users vs. 7% of non-users, p=0.03); less likely to be academic (1% of users vs. 11% of non-users, p=0.01); and less likely to have 24/7 access to neurology (p<0.001), neurosurgery (p<0.001), orthopedics (p=0.01), plastic surgery (p=0.01), psychiatry (p<0.001), and hand surgery (p<0.001) consultants. Neuro/stroke (68%), pediatrics (11%), psychiatry (11%), and trauma (10%) were the most commonly reported applications. On multivariable analysis, telemedicine was more likely in rural EDs (odds ratio [OR] 4.39, 95% confidence interval [CI] 1.30-14.86), and less likely in EDs with 24/7 neurologist availability (OR 0.21, 95% CI [0.09-0.49]), and annual volume <20,000 (OR 0.24, 95% CI [0.08-0.68]).Telemedicine is commonly used in New England EDs. In 2014, use was more common among rural EDs and EDs with limited neurology consultant availability. In contrast, telemedicine use was less common among very low-volume EDs.
| S-EPMC5654874 | biostudies-other
Project description:Background:Sepsis is a life-threatening syndrome and a leading cause of morbidity and mortality representing significant financial burden on the health-care system. Early identification and intervention is crucial to maximizing positive outcomes. We studied a quality improvement initiative with the aim of reviewing the initial management of patients with sepsis in Canadian community emergency departments, to identify areas for improving the delivery of sepsis care. We present a retrospective, multicenter, observational study during 2011 to 2015 in the community setting. Methods:We collected data on baseline characteristics, clinical management metrics (triage-to-physician-assessment time, triage-to-lactate-drawn time, triage-to-antibiotic time, and volume of fluids administered within the first 6 hours of triage), and outcomes (intensive care unit [ICU] admission, in-hospital mortality) from a regional database. Results:A total of 2056 patients were analyzed. The median triage-to-physician-assessment time was 50 minutes (interquartile range [IQR]: 25-104), triage-to-lactate-drawn time was 50 minutes (IQR: 63-94), and triage-to-antibiotics time was 129 minutes (IQR: 70-221). The median total amount of fluid administered within 6 hours of triage was 2.0 L (IQR: 1.5-3.0). The ICU admission rate was 36% and in-hospital mortality was 25%. We also observed a higher ICU admission rate (51% vs 24%) and in-hospital mortality (44% vs 14%) in those with higher lactate concentration (?4 vs ?2 mmol/L), independent of other sepsis-related parameters. Conclusion:Time-to-physician-assessment, time-to-lactate-drawn, time-to-antibiotics, and fluid resuscitation in community emergency departments could be improved. Future quality improvement interventions are required to optimize management of patients with sepsis. Elevated lactate concentration was also independently associated with ICU admission rate and in-hospital mortality rate.
| S-EPMC7175053 | biostudies-literature
Project description:INTRODUCTION:The receipt of remote clinical care for children via telecommunications (pediatric telemedicine) appears to improve access to and quality of care in U.S. emergency departments (EDs), but the actual prevalence and characteristics of pediatric telemedicine receipt remain unclear. We determined the prevalence and current applications of pediatric telemedicine in U.S. EDs, focusing on EDs that received telemedicine from clinicians at other facilities. METHODS:We surveyed all 5,375 U.S. EDs to characterize emergency care in 2016. We then randomly surveyed 130 (39%) of the 337 EDs who reported receiving pediatric telemedicine. The second survey was administered by phone to ED directors primarily. It confirmed that the ED received pediatric telemedicine services in 2017 and asked about ED staffing and the nature, purpose, and concerns with pediatric telemedicine implementation. RESULTS:The first survey (4,507/5,375, 84% response) showed that 337 (8%) EDs reported receiving pediatric telemedicine. Among the randomly sampled EDs completing the second survey (107/130, 82% response), 96 (90%) confirmed 2016 use and 89 (83%) confirmed 2017 use. Reasons for discontinuation included technical and scheduling concerns. Almost all who confirmed their pediatric telemedicine use in 2017 also reported 24/7 availability (98%). The most widely reported use was for patient placement and transfer coordination (80%). Many EDs (39%) reported no challenges with implementing pediatric telemedicine and described its utility. However, the most frequently reported challenges were process concerns (30%), such as concerns about slowing or interrupting providers' work flow and technological concerns (14%). CONCLUSION:Few EDs receive telemedicine for the delivery of pediatric emergency care nationally. Among EDs that do use telemedicine for pediatric care, many report process concerns. Addressing these barriers through focused education or interventions may support EDs in further developing and optimizing this technological adjunct to pediatric emergency care.
| S-EPMC6822676 | biostudies-literature
Project description:STUDY OBJECTIVE:Interhospital transfers are costly to patients and to the health care system. The use of telemedicine may enable more efficient systems by decreasing transfers or diverting transfers from crowded referral emergency departments (EDs) to alternative appropriate facilities. Our primary objective is to describe the prevalence of telemedicine for transfer coordination among US EDs, the ways in which it is used, and characteristics of EDs that use telemedicine for transfer coordination. METHODS:We used the 2016 National Emergency Department Inventory-USA survey to identify telemedicine-using EDs. We then surveyed all EDs using telemedicine for transfer coordination and a sample of EDs using telemedicine for other clinical applications. We used a multivariable logistic regression model to identify characteristics independently associated with use of telemedicine for transfer coordination. RESULTS:Of the 5,375 EDs open in 2016, 4,507 responded to National Emergency Department Inventory-USA (84%). Only 146 EDs used telemedicine for transfer coordination; of these, 79 (54%) used telemedicine to assist with clinical care for local admission, 117 (80%) to assist with care before transfer, and 92 (63%) for arranging transfer to a different hospital. Among telemedicine-using EDs, lower ED annual visit volume (odds ratio 5.87, 95% CI 2.79 to 12.36) was independently associated with use of telemedicine for transfer coordination. CONCLUSION:Although telemedicine has potential to improve efficiency of regional emergency care systems, it is infrequently used for coordination of transfer between EDs. When used, it is most often to assist with clinical care before transfer.
| S-EPMC7252127 | biostudies-literature
Project description:BackgroundDifferences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described.ObjectivesWe aimed to (1) quantify the prevalence of HPS versus EDPS cases and outcomes; (2) compare HPS versus EDPS characteristics at presentation; (3) compare HPS versus EDPS in process and patient outcomes; and (4) estimate risk differences in patient outcomes attributable to initial resuscitation disparities.DesignRetrospective consecutive-sample cohort.SettingNine hospitals from October 1, 2014, to March 31, 2016.PatientsAll hospitalized patients with sepsis or septic shock, as defined by simultaneous (1) infection, (2) ?2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and (3) ?1 acute organ dysfunction criterion. EDPS met inclusion criteria while physically in the emergency department (ED). HPS met the criteria after leaving the ED.MeasurementsWe assessed overall HPS versus EDPS contributions to case prevalence and outcomes, and then compared group differences. Process outcomes included 3-hour bundle compliance and discrete bundle elements (eg, time to antibiotics). The primary patient outcome was hospital mortality.ResultsOf 11,182 sepsis hospitalizations, 2,509 (22.4%) were hospital-presenting. HPS contributed 785 (35%) sepsis mortalities. HPS had more frequent heart failure (OR: 1.31, CI: 1.18-1.47), renal failure (OR: 1.62, CI: 1.38-1.91), gastrointestinal source of infection (OR: 1.84, CI: 1.48-2.29), euthermia (OR: 1.45, CI: 1.10-1.92), hypotension (OR: 1.85, CI: 1.65-2.08), or impaired gas exchange (OR: 2.46, CI: 1.43-4.24). HPS were admitted less often from skilled nursing facilities (OR: 0.44, CI: 0.32-0.60), had chronic obstructive pulmonary disease (OR: 0.53, CI: 0.36-0.78), tachypnea (OR: 0.76, CI: 0.58-0.98), or acute kidney injury (OR: 0.82, CI: 0.68-0.97). In a propensity-matched cohort (n = 3,844), HPS patients had less than half the odds of 3-hour bundle compliant care (17.0% vs 30.3%, OR: 0.47, CI: 0.40-0.57) or antibiotics within three hours (66.2% vs 83.8%, OR: 0.38, CI: 0.32-0.44) vs EDPS. HPS was associated with higher mortality (31.2% vs 19.3%, OR: 1.90, CI: 1.64-2.20); 23.3% of this association was attributable to differences in initial resuscitation (resuscitation-adjusted OR: 1.69, CI: 1.43-2.00).ConclusionsHPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences.
| S-EPMC6625440 | biostudies-literature
Project description:BackgroundApproximately 2 million children are hospitalized each year in the United States, with more than three-quarters of non-elective hospitalizations admitted through emergency departments (EDs). Direct admission, defined as admission to hospital without first receiving care in the hospital's ED, may offer benefits for patients and healthcare systems in quality, timeliness, and experience of care. While ED utilization patterns are well studied, there is a paucity of research comparing the effectiveness of direct and ED admissions. The overall aim of this project is to compare the effectiveness of a standardized direct admission approach to admission beginning in the ED for hospitalized children.Methods/designWe will conduct a stepped wedge cluster randomized controlled trial at 3 structurally and geographically diverse hospitals. A total of 70 primary and urgent care practice sites in the hospitals' catchment areas will be randomized to a time point when they will begin participation in the multi-stakeholder informed direct admission program. This crossover will be unidirectional and occur at 4 time points, 6 months apart, over a 24-month implementation period. Our primary outcome will be the timeliness of clinical care provision. Secondary outcomes include (i) parent-reported experience of care, (ii) unanticipated transfer to the intensive care unit within 6?h of hospital admission, and (iii) rapid response calls within 6?h of hospital admission. We anticipate that 190 children and adolescents will be directly admitted, with 1506 admitted through EDs. Analyses will compare the effectiveness of direct admission to admission through the ED and will evaluate the causal effect of implementing a direct admission program using linear regression with random effects for referring practice clusters and time period fixed effects. We will further examine the heterogeneity of treatment effects based on hypotheses specified a priori. In addition, we will conduct a mixed-methods process evaluation to assess reach, effectiveness, adoption, implementation, and maintenance of our direct admission intervention.DiscussionOur study represents the first randomized controlled trial to compare the effectiveness of direct admission to admission through the ED for pediatric patients. Our scientific approach, pairing a stepped wedge design with a multi-level assessment of barriers to and facilitators of implementation, will generate valuable data about how positive findings can be reproduced across other healthcare systems.Trial registrationClinicalTrials.gov NCT04192799 . Registered on December 10, 2019).
| S-EPMC7706271 | biostudies-literature
Project description:We aimed to describe diagnosed acute coronary syndrome (ACS) and its care management and outcomes in emergency departments (EDs) and to determine related cardiovascular risk factors (CVRFs). We conducted a cross sectional multicenter study that included 1173 adults admitted to EDs for acute chest pain (ACP) in 2015 at 14 sites in Tunisia. Data included patients' baseline characteristics, diagnosis, treatment and output. ACS represented 49.7% of non-traumatic chest pain [95% CI: 46.7-52.6]; 74.2% of ACS cases were unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI). Males represented 67.4% of patients with ACS (p?<?0.001). The median age was 60?years (IQR 52-70). Emergency medical service transportation was used in 11.9% of cases. The median duration between chest pain onset and ED arrival was two hours (Inter quartile ranges (IQR) 2-4?h). The age-standardized prevalence rate was 69.9/100,000 PY; the rate was 96.24 in men and 43.7 in women. In the multivariable analysis, CVRFs related to ST segment elevation myocardial infarction were age correlated to sex and active smoking. CVRFs related to UA/NSTEMI were age correlated to sex, familial and personal vascular history and type 2 diabetes. We reported 27 cases of major adverse cardiovascular events (20.0%) in patients with STEMI and 36 in patients with UA/NSTEMI (9.1%). Half of the patients consulting EDs with ACP had ACS. Emergency medical service transportation calls were rare. Management delays were acceptable. The risk of developing an UA/NSTEMI was equal to the number of CVRFs +?1. To improve patient outcomes, it is necessary to increase adherence to international management guidelines.
| S-EPMC6276213 | biostudies-other
Project description:BackgroundSepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians.ObjectiveOur aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock.MethodsWe conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign's 3-hour and 6-hour sepsis bundles were evaluated.ResultsIn total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item "Administration of fluids when hypotension" (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item "Remeasurement of lactate" (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046).ConclusionsAdditional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management.
| S-EPMC6350091 | biostudies-literature
Project description:BACKGROUND:Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. METHODS AND FINDINGS:Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n?=?863) at six, and 67% (n?=?810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. CONCLUSIONS:SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions. TRIAL REGISTRATION:Current Controlled Trials ISRCTN 93681536.
| S-EPMC4070907 | biostudies-literature
Project description:BackgroundPenicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients.MethodsPatients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days).ResultsBetween 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39-20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45-3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27-.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09-23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94-11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36-.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26-.72]) in the delabeled group compared with the group who retained their allergy label.ConclusionsThis health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.
| S-EPMC8326579 | biostudies-literature