Faculty Bibliography

BACKGROUND:The coronavirus disease (COVID)-19 pandemic quickly challenged New York City health care systems. Telemedicine has been suggested to manage acute complaints and divert patients from in-person care. OBJECTIVES/OBJECTIVE:The objective of this study was to describe and assess the impact of a rapidly scaled virtual urgent care platform during the COVID-19 pandemic. METHODS:This was a retrospective cohort study of all patients who presented to a virtual urgent care platform over 1 month during the COVID-19 pandemic surge. We described scaling our telemedicine urgent care capacity, described patient clinical characteristics, assessed for emergency department (ED) referrals, and analyzed postvisit surveys. RESULTS:During the study period, a total of 17,730 patients were seen via virtual urgent care; 454 (2.56%) were referred to an ED. The most frequent diagnoses were COVID-19 related or upper respiratory symptoms. Geospatial analysis indicated a wide catchment area. There were 251 providers onboarded to the platform; at peak, 62 providers supplied 364 h of coverage in 1 day. The average patient satisfaction score was 4.4/5. There were 2668 patients (15.05%) who responded to the postvisit survey; 1236 (49.35%) would have sought care in an ED (11.86%) or in-person urgent care (37.49%). CONCLUSIONS:A virtual urgent care platform was scaled to manage a volume of more than 800 patients a day across a large catchment area during the pandemic surge. About half of the patients would otherwise have presented to an ED or urgent care in person. Virtual urgent care is an option for appropriate patients while minimizing in-person visits during the COVID-19 pandemic.

BACKGROUND:Although dalbavancin's (DBV's) long half-life and one-time dosing strategy confer ideal administration in the ambulatory setting, the optimal role of DBV in the management of acute bacterial skin and skin structure infections (ABSSSIs) remains to be elucidated. OBJECTIVES/OBJECTIVE:The primary objective of this study was to compare treatment outcomes of ABSSSI between patients who received DBV in the emergency department (ED) as part of standard care versus patients who received DBV as part of a telehealth program. METHODS:This was a retrospective cohort study evaluating patients who received DBV at 3 urban EDs. The primary end point was the incidence of ABSSSI recurrence. Secondary outcomes included need for hospital admission and ED length of stay (LOS; in hours). RESULTS:A total of 65 ABSSSI treatment courses were included; 42 were included in the telehealth criteria (TC) cohort and 23 in the initial criteria (IC) cohort. There were 14% (6/42) infection recurrences in the TC cohort and 22% (5/23) in the IC cohort, with median time to recurrence being 4 and 14 days, respectively. Median ED LOS was significantly shorter in the TC (5 vs 25 hours, P < 0.05). Numerically fewer individuals in the TC cohort required inpatient admission (0 vs n = 2, 9%). Conclusion and Relevance: Our results suggest that patients may be safely administered DBV in an ED setting, with telehealth follow-up. Providing structured patient selection criteria is an effective method of assisting ED providers in selecting appropriate DBV candidates to limit potential recurrences and readmissions.

BACKGROUND:Outpatients receive observation services to determine the need for inpatient admission. These services are usually provided without the use of condition-specific protocols and in an unstructured manner, scattered throughout a hospital in areas typically designated for inpatient care. Emergency department observation units (EDOUs) use protocolized care to offer an efficient alternative with shorter lengths of stay, lower costs and higher patient satisfaction. EDOU growth is limited by existing policy barriers that prevent a "two-service" model of separate professional billing for both emergency and observation services. The majority of EDOUs use the "one-service" model, where a single composite professional fee is billed for both emergency and observation services. The financial implications of these models are not well understood. METHODS:We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recently available peer-reviewed literature, national survey and payer data. Using this simulation, we modeled annual staffing costs and payments for professional services under two common models of care in an EDOU. We also modeled cash flows over a continuous range of daily EDOU patient encounters to illustrate the dynamic relationship between costs and revenue over various staffing levels. RESULTS:We estimate the mean (±SD) annual net cash flow to be a net loss of $315,382 ±$89,635 in the one-service model and a net profit of $37,569 ±$359,583 in the two-service model. The two-service model is financially sustainable at daily billable encounters above 20 while in the one-service model, costs exceed revenue regardless of encounter count. Physician cost per hour and daily patient encounters had the most significant impact on model estimates. CONCLUSIONS:In the one-service model, EDOU staffing costs exceed payments at all levels of patient encounters, making a hospital subsidy necessary to create a financially sustainable practice. Professional groups seeking to staff and bill for both emergency and observation services are seldom able to do so due to EDOU size limitations and the regulatory hurdles that require setting up a separate professional group for each service. Policymakers and healthcare leaders should encourage universal adoption of EDOUs by removing restrictions and allowing the two-service model to be the standard billing option. These findings may inform planning and policy regarding observation services.

Allergic reaction is a common clinical picture in the Emergency Department (ED). Most allergic reactions are from food or drugs. A detailed history is an integral aspect of determining the causative agent of an allergy. Galactose-alpha-1,3-galactose (alpha-gal) allergy is a tick-acquired red meat allergy that causes delayed-onset allergic reaction or anaphylaxis due to molecular mimicry. Alpha-gal allergy may not be widely known as a cause of allergic reactions. Lack of universal awareness of this phenomenon in the ED and Urgent Care setting could lead to misdiagnosis, or delayed diagnosis. Subsequently, lack of proper instruction to avoid red meat could put patients at risk for future attacks with morbidity or mortality. We report three cases of allergic reaction presumed from red meat consumption secondary to alpha-gal allergy.

Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.

Early palliative care consultation ha the potential to provide comfort to patients and families, and decrease costs and length of stay.

OBJECTIVE: The emergency department (ED) of NYU Langone Medical Center was destroyed by Hurricane Sandy, contributing to a public health disaster in New York City. We evaluated hospital-based acute care provided through the establishment of an urgent care center with an associated ED-run observation service (EDOS) that operated in the absence of an ED during this disaster. METHODS: We conducted a retrospective cohort study of all patients placed in an EDOS following a visit to an urgent care center during the 18 months of ED closure. We reviewed diagnoses, clinical protocols, selection criteria, and performance metrics. RESULTS: Of 55,723 urgent care center visits, 15,498 patients were hospitalized, and 3167 of all hospitalized patients (20.4%) were placed in the EDOS. A total of 2660 EDOS patients (84%) were discharged from the EDOS. The 8 most frequently utilized clinical protocols accounted for 76% of the EDOS volume. CONCLUSIONS: A diverse group of patients presenting to an urgent care center following the destruction of an ED by natural disaster can be cared for in an EDOS, regardless of association with a physical ED. An urgent care center with an associated EDOS can be implemented to provide patient care in a disaster situation. This may be useful when existing ED or hospital resources are compromised. (Disaster Med Public Health Preparedness. 2016;page 1 of 6).

The 2013 American College of Cardiology (ACC) and American Heart Association (AHA) practice guidelines for the treatment of blood cholesterol significantly changed the paradigm of how providers should prescribe statin therapy, especially for older adults. While the evidence supports statin therapy for older adults with cardiovascular disease for secondary prevention and with high cardiovascular risk for primary prevention, the evidence is lacking for older adults without major cardiovascular risk aside from age. The unclear evidence base for older adults must be considered along with the potential harms of statin therapy when incorporating the 2013 ACC/AHA practice guidelines for considering statin treatment, particularly for primary prevention for older adults.

BACKGROUND:The incidence of obesity is on the rise in the United States and worldwide. Complications following panniculectomy are higher for super obese patients, often requiring readmission and additional interventions. In this study, the authors compare the outcomes of patients who underwent primary closure of their resection wounds to the outcomes of patients who underwent initial open wound management with a negative-pressure dressing. METHODS:The records of all patients who underwent panniculectomy between 2007 and 2012 were reviewed. Of 14 patients with a body mass index greater than 50, nine underwent primary closure and five were treated with open wound management. A retrospective chart review was performed. RESULTS:There were no statistically significant differences in age or preoperative comorbidities, but body mass index was higher for the open wound management group (66.4 versus 58.9, p = 0.039). There were no statistically significant differences in mean operative time, resection weight, estimated blood loss, or hospital length of stay. The primary closure group had a 44 percent readmission rate and a 33 percent reoperation rate for wound complications. The open wound management group had no wound-related readmissions or secondary procedures for débridement. CONCLUSIONS:Open wound management in the massive panniculectomy patient reduces hospital readmission and secondary operations. This case series provides reasons to support the consideration of open wound management following massive panniculectomy in the super morbidly obese patient population.

BACKGROUND:This study focuses on the impact of preoperative narcotic medication use on outcomes of surgical treatment of migraine headaches. METHODS:A retrospective comparative review was conducted with patients undergoing migraine surgery. Data gathered included demographic information, baseline migraine headache characteristics, migraine surgery sites, postoperative migraine headache characteristics 1 year or more following surgery, and preoperative migraine medication use. Patients were grouped based on preoperative narcotic medication use. The narcotic users were subdivided into low and high narcotic user groups. Preoperative migraine characteristics were comparable between groups and the outcomes of migraine surgery were compared between the groups. RESULTS:Outcomes in 90 narcotic users were compared with those for 112 patients not using narcotic medications preoperatively. Narcotic users showed statistically significantly less reduction in frequency, severity, and duration of migraine headaches after surgery. Narcotic users had clinical improvement in 66.7 percent of patients and elimination in 18.9 percent versus 86.6 and 36.6 percent, respectively, in the nonnarcotic group. The group that consumed narcotics had significantly lower rates of improvement in all migraine indices. CONCLUSIONS:Previous studies have discouraged the routine use of narcotic medications in the management of migraine medications. The authors' study demonstrates that narcotic medication use before migraine headache surgery may predispose patients to worse outcomes postoperatively. Because pain cannot be objectively documented, the question remains of whether this failure to improve the pain was indeed a suboptimal response to surgery or the need for narcotic substances. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.