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Expanding Diabetes Screening to Identify Undiagnosed Cases Among Emergency Department Patients

Lee, David C; Reddy, Harita; Koziatek, Christian A; Klein, Noah; Chitnis, Anup; Creary, Kashif; Francois, Gerard; Akindutire, Olumide; Femia, Robert; Caldwell, Reed
PMID: 37788038
ISSN: 1936-9018
CID: 5603282

Piloting a novel medical student virtual discharge counseling process in the time of the COVID-19 pandemic

Leybov, Victoria; Ross, Joshua; Smith, Silas W; Ciardiello, Amber; Maheshwari, Sana; Caspers, Christopher; Wittman, Ian; Kuhner, Christopher; Stark, Stephen; Conroy, Nancy
BACKGROUND:During the COVID-19 pandemic, we identified a gap in adequate discharge counseling for COVID-19 patients in the Emergency Department. This was due to high patient volumes and lack of patient education regarding a novel disease. Medical students were also restricted from clinical areas due to safety concerns, compromising their clinical experience. We piloted a novel program in which medical students served as virtual discharge counselors for COVID-19 patients via teleconference. We aimed to demonstrate an impact on patient care by examining the patient bounce back rate as well as assessing medical student education and experience. METHODS:This program was piloted in a tertiary care Emergency Department. Medical student volunteers served as virtual discharge counselors. Students were trained in discharge counseling with a standardized protocol and a discharge script. Eligible patients for virtual discharge counseling were 18 years old or greater with a diagnosis of confirmed or suspected COVID-19 and no impediment precluding them from participating in a telemedicine encounter. Counseling was provided via secure teleconference in the patient's preferred language. Counseling included diagnosis, supportive care with medication dosing, quarantine instructions, return precautions, follow up, and time to ask questions. Duration of counseling was recorded and medical students were anonymously surveyed regarding their experience. RESULTS:Over an 18-week period, 45 patients were counseled for a median of 20 min. The 72-hr ED revisit rate was 0%, versus 4.2% in similarly-matched, not counseled COVID-19 patients. 90% of medical students believed this project increased their confidence when speaking with patients while 80% indicated this was their first telemedicine experience. CONCLUSION/CONCLUSIONS:Our pilot discharge program provided patients with an extensive discharge counseling experience that would not otherwise be possible in an urban ED setting and demonstrated benefit to patient care. Medical students received a safe clinical experience that improved their communication skills.
PMID: 36627176
ISSN: 1758-1109
CID: 5434352

Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit

Cardinale, Stephanie; Saraon, Tajinderpal; Lodoe, Nawang; Alshehry, Abdullah; Raffoul, Melanie; Caspers, Christopher; Vider, Etty
OBJECTIVES/OBJECTIVE:Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). METHODS:This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. RESULTS:The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P < .00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P = .01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P = .01). CONCLUSION/CONCLUSIONS:The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected.
PMID: 35465767
ISSN: 1531-1937
CID: 5205422

A Tale of Two Institutions: COVID-19 Positive Rates in Asymptomatic Patients Pre-Screened for Spine Procedures and Surgeries in Los Angeles, California

Chen, Allen S; Brown, Matthew; Arekelyan, Anush; Wennemann, Sophie; Shamie, Nick; Holly, Langston; Liu, John C; Wang, Jeffrey C; Buser, Zorica
STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVES/OBJECTIVE:The coronavirus disease (COVID-19), caused by the severe respiratory syndrome coronavirus 2 (SARS-CoV-2), has created an unprecedented global public health emergency. The aim of the current study was to report on COVID-19 rates in an asymptomatic population prior to undergoing spine procedures or surgeries at two large Los Angeles healthcare systems. METHODS:Elective spine procedures and surgeries from May 1, 2020 to January 31, 2021 were included. Results from SARS-CoV-2 virus RT-PCR nasopharyngeal testing within 72 hours prior to elective spine procedures were recorded. Los Angeles County COVID-19 rates were calculated using data sets from Los Angeles County Department of Public Health. Chi-squared test and Stata/IC were used for statistical analysis. RESULTS:A total of 4,062 spine procedures and surgeries were scheduled during this time period. Of these, 4,043 procedures and surgeries were performed, with a total of 19 patients testing positive. Nine positive patients were from UCLA, and 10 from USC. The overall rate of positive tests was low at .47% and reflected similarities with Los Angeles County COVID-19 rates over time. CONCLUSIONS:The current study shows that pre-procedure COVID-19 testing rates remains very low, and follows similar patterns of community rates. While pre-procedure testing increases the safety of elective procedures, universal COVID-19 pre-screening adds an additional barrier to receiving care for patients and increases cost of delivering care. A combination of pre-screening, pre-procedure self-quarantine, and consideration of overall community COVID-19 positivity rates should be further studied.
PMID: 34870486
ISSN: 2192-5682
CID: 5187012

Use of a telehealth follow-up system to facilitate treatment and discharge of emergency department patients with severe cellulitis

Koziatek, Christian; Klein, Noah; Mohan, Sanjay; Lakdawala, Viraj; Swartz, Jordan; Femia, Robert; Press, Robert; Caspers, Christopher
INTRODUCTION/BACKGROUND:Novel long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with cellulitis who require intravenous antibiotics. Telehealth systems have shown success in remote management of dermatologic conditions; we implemented a telehealth follow-up program for patients diagnosed with cellulitis in the ED, treated with single-dose dalbavancin, and discharged. METHODS:This was a prospective, multi-center observational study. Patients were included based on clinical criteria and ability to complete follow-up using a smartphone and enroll in an online care portal. We examined the rate of successful telehealth follow-up at 24- and 72-hour intervals from discharge. We also examined the ED return rate within 14 days, reviewed any visits to determine cause of return, and for admission. RESULTS:55 patients were enrolled. 54/55 patients completed at least one telehealth follow up encounter (98.2%). 13 patients (23.6%) had a return ED visit within 14 days; no patients required admission for worsening cellulitis. Patient engagement in the telehealth program decreased over time; there was an approximately 11% decrease in engagement between the 24 and 72-hour follow-up call, and a 15% decrease in engagement between the 24 and 72-hour image upload. Patients over 65 had a lower rate of image upload (31%) than younger patients (80.6%). DISCUSSION/CONCLUSIONS:A telehealth follow-up system for discharged emergency department patients with cellulitis demonstrated high rates of engagement. In these patients who -may have otherwise required admission for intravenous antibiotics, telehealth-facilitated outpatient management resulted in a low ED return rate and no inpatient admissions for cellulitis.
PMID: 32081554
ISSN: 1532-8171
CID: 4313372

Virtual Urgent Care Quality and Safety in the Time of Coronavirus

Smith, Silas W; Tiu, Janelle; Caspers, Christopher G; Lakdawala, Viraj S; Koziatek, Christian A; Swartz, Jordan L; Lee, David C; Jamin, Catherine T; Femia, Robert J; Haines, Elizabeth J
BACKGROUND:Telemedicine use rapidly increased during the COVID-19 pandemic. This study assessed quality aspects of rapid expansion of a virtual urgent care (VUC) telehealth system and the effects of a secondary telephonic screening initiative during the pandemic. METHODS:A retrospective cohort analysis was performed in a single health care network of VUC patients from March 1, 2020, through April 20, 2020. Researchers abstracted demographic data, comorbidities, VUC return visits, emergency department (ED) referrals and ED visits, dispositions, intubations, and deaths. The team also reviewed incomplete visits. For comparison, the study evaluated outcomes of non-admission dispositions from the ED: return visits with and without admission and deaths. We separately analyzed the effects of enhanced callback system targeting higher-risk patients with COVID-like illness during the last two weeks of the study period. RESULTS:A total of 18,278 unique adult patients completed 22,413 VUC visits. Separately, 718 patient-scheduled visits were incomplete; the majority were no-shows. The study found that 50.9% of all patients and 74.1% of patients aged 60 years or older had comorbidities. Of VUC visits, 6.8% had a subsequent VUC encounter within 72 hours; 1.8% had a subsequent ED visit. Of patients with enhanced follow-up, 4.3% were referred for ED evaluation. Mortality was 0.20% overall; 0.21% initially and 0.16% with enhanced follow-up (p = 0.59). Males and black patients were significantly overrepresented in decedents. CONCLUSION/CONCLUSIONS:Appropriately deployed VUC services can provide a pragmatic strategy to care for large numbers of patients. Ongoing surveillance of operational, technical, and clinical factors is critical for patient quality and safety with this modality.
PMID: 33358323
ISSN: 1938-131x
CID: 4731212

Implementation of the Surviving Sepsis Campaign one-hour bundle in a short stay unit: A quality improvement project

Gripp, Lauren; Raffoul, Melanie; Milner, Kerry A
OBJECTIVE:To improve timely sepsis care by implementing the 2018 Surviving Sepsis Campaign one-hour interventions. DESIGN/METHODS:Ten-month prospective quality improvement project. SETTING/METHODS:A 38-bed short stay unit within an 800-bed hospital in New York City. PARTICIPANTS/METHODS:Patients admitted to the short stay unit who screened positive for sepsis. INTERVENTION/METHODS:A sepsis implementation tool was created from the 2018 Surviving Sepsis Campaign guidelines. Sepsis champions delivered education on sepsis recognition, treatment, and management, and the sepsis implementation tool to the healthcare staff. PROCESS AND OUTCOME MEASURES/UNASSIGNED:Time to first lactate, blood cultures × 2, antibiotic administration, length of stay and mortality were tracked weekly for five months. RESULTS:From May 6, 2019 to October 1, 2019, 32 patients were diagnosed with sepsis. Initial lactate and blood cultures were completed on every patient within 1one-hour of sepsis diagnosis. Administration of antibiotics within one-hour reached 100% after week four and was sustained. CONCLUSION/CONCLUSIONS:Use of a registered nurse-initiated sepsis implementation tool in a short stay unit led to the completion of blood cultures, initial lactate, and antibiotic administration within one-hour. Key factors to support this practice improvement were increasing registered nurse, physician and physician assistant sepsis knowledge, registered nurse and physician/physician assistant early collaboration, increased staffing and intravenous access equipment.
PMID: 33358134
ISSN: 1532-4036
CID: 4762252

Assessing the Impact of a Rapidly Scaled Virtual Urgent Care in New York City During the COVID-19 Pandemic

Koziatek, Christian A; Rubin, Ada; Lakdawala, Viraj; Lee, David C; Swartz, Jordan; Auld, Elizabeth; Smith, Silas W; Reddy, Harita; Jamin, Catherine; Testa, Paul; Femia, Robert; Caspers, Christopher
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.
PMID: 32737005
ISSN: 0736-4679
CID: 4552202

In Reply to Fyfe and Douglass

Raffoul, Melanie; Bartlett-Esquilant, Gillian; Phillips, Robert L
PMID: 32097146
ISSN: 1938-808x
CID: 4324262

Dalbavancin Use in the Emergency Department Setting

Patel, Mitulkumar; Smalley, Samantha; Dubrovskaya, Yanina; Siegfried, Justin; Caspers, Christopher; Pham, Vinh; Press, Robert A; Papadopoulos, John
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.
PMID: 31155916
ISSN: 1542-6270
CID: 3922282