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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

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

Decreasing stroke alerts in the emergency department: A lesson in resource utilization [Meeting Abstract]

De, Witt D; Muckey, E; Di, Miceli E; Ishida, K; Rossan-Raghunath, N; Femia, R; Wu, T
Background: Stroke code activations are a valuable tool in providing prompt care to stroke patients who may be eligible for treatments such as tPA and endovascular interventions. However, stroke codes involve the immediate attention of many members of the healthcare team and significant hospital resources. The National Institutes of Health Stroke Scale (NIHSS) is commonly used to evaluate stroke severity; however, even patients with an NIHSS score of zero can have ongoing neurologic symptoms and disability. Confusion over the goals of stroke codes and the appropriate situations for their use may contribute to unnecessary activations.
Objective(s): The purpose of this analysis was to evaluate the frequency of stroke code activations in situations where activating a stroke code provides little potential benefit in terms of therapeutic options over a non-emergent neurology consult.
Method(s): We reviewed the records for all emergency department (ED) stroke code activations over the first five months of 2018, looking specifically at cases with an NIHSS score of zero. Within this pool, we identified cases where the patient was documented as being asymptomatic during initial ED evaluation as their symptoms had resolved (transient ischemic attack), as well as those who had been symptomatic for over 24 hours and were outside the therapeutic window. These patients were not eligible for emergent therapeutic intervention. Thus, these were cases in which a stroke code activation was avoidable.
Result(s): Of the 120 stroke codes with an NIHSS of zero, 39 (32.5%) involved patients whose symptoms had completely resolved prior to arrival. Another three cases involved patients who had been symptomatic for over 24 hours and were outside the therapeutic window. Thus, of the stroke code activations with an NIHSS of zero in this time period, 42 (35%) were avoidable as these patients would not have been considered candidates for emergent treatment.
Conclusion(s): Clarification and reinforcement of appropriate criteria for stroke code activation have the potential to reduce overutilization of resources in situations unlikely to affect acute therapeutic management. Addressing this would allow for a reduction in the burden on healthcare professionals and ED resources
ISSN: 1936-9018
CID: 4119142

Improving critical care documentation and coding using an online teaching module [Meeting Abstract]

Hartstein, G; Habboushe, J; Muckey, E; Wu, T; Goldberg, W; Femia, R
Background: Emergency medicine professional reimbursement-in particular, the Evaluation and Management levels-is based on Medicare's rules defining the complexity of care. Services are only reimbursable if they are properly recorded. Therefore detailed documentation is essential for optimal compensation. Critical care follows a different set of rules than other Evaluation and Management levels and a lack of clinician awareness of these rules leads to incomplete documentation and under billing. Objectives: The goal of this study is to: 1. Identify gaps in critical care documentation knowledge among emergency physicians. 2. Determine if these gaps can be filled via a selfadministered online training module. 3. Determine whether improvement in knowledge can improve documentation and enhance reimbursement. Methods: Critical care charts were examined in an urban tertiary care center with approximately 68,000 ED visits per year. Pre-intervention, 1.2% of charts were coded as "critical care"; less than the national average of 2.5%. Physicians completed a pre-module assessment, followed by a 15-minute online educational module, followed by a post-module assessment. Critical care rates were measured during the months preceding and following module completion. Results: 1. Gaps in knowledge were defined when average correct pre-assessment response was < 75%, revealing deficiencies in specific aspects of critical care documentation, which may be reflected in the critical care rate. 2. Post-module assessments had an overall higher correct response rate (65.9% to 84.8%, p<0.001). Specifically for knowledge gap questions, the correct response rate increased from 53% to 86.5% (p<0.001). 3. After all clinicians completed the teaching module, ED critical care rates increased from 1.4% (Nov-Dec, 2015) to 3.22% (Mar-Apr, 2016), an increase of 129% that trended towards statistical significance (p=0.058). This extrapolates to an annual increase in reimbursement of $103,900, based on the ED's specific average collection rates. Conclusions: The training module was able to identify and correct gaps in critical care knowledge, likely leading to an increase in proper charting and coding and a subsequent increase in revenue. Additionally, the effectiveness of a short, easily distributed teaching module carries broad implications for future physician education initiatives
ISSN: 1936-9018
CID: 3261662

Emergency Department concussion revisits: Chart review of the evaluation and discharge plans of post-traumatic headache patients [Letter]

Minen, Mia; Shome, Ashna; Femia, Robert; Balcer, Laura; Grudzen, Corita; Gavin, Nicholas P
PMID: 27908509
ISSN: 1532-8171
CID: 2329482


Fermia, Robert; Wilkins, Christine; Rodriguez, Danielle; Read, Kevin B; Gavin, Nicholas; Caspers, Christopher; Jamin, Catherine
Early palliative care consultation ha the potential to provide comfort to patients and families, and decrease costs and length of stay.
PMID: 30571866
ISSN: 2374-4030
CID: 3663862

Bridging the Gap: Financial Counseling in the ED

Gavin, Nicholas; McAleer, Sean; Asfour, Leena; Testa, Paul; Femia, Robert
PMID: 29897182
ISSN: 0735-0732
CID: 3658562

A novel approach to documentation: Telescribes [Meeting Abstract]

Worthing, J; Gulati, R; Habboushe, J; Femia, R; Wu, T
Background: The work of ED physicians is complex, with increasing patient volumes, rapidly changing EHRs, and growing documentation regulations. Medical scribes aim to address these problems, workflow efficiency, job satisfaction, and increase reimbursements. Despite the advantages, facilities remain resistant to adopting a scribe program for several reasons, including cost, addition of ED personnel, and incorporation new roles within an established workflow. Looking to minimize challenges, we propose modified telescribes utilizing a pre-established, qualified volunteer program. Workflow consists of providers connecting to telescribes via audio/video from secure mobile devices. Proper consent is obtained and telescribes document patient interactions in real time. Providers reap benefits of note drafting and volunteers gain valuable education only obtainable through collaboration with ED providers. Objectives: Assess physician, hospital volunteer, and patient receptiveness to scribes and telescribes. Methods: A survey was sent to 88 attendings (RR=29%) and 59 residents (RR=39%) employing yes/ no, multiple choice, and Likert scale questions to assess receptivity to scribes and telescribes; no supplemental information. A second survey evaluated hospital volunteers' desire to participate (n=50; RR=44%). A third survey (n=12) gauged patient responses to both scribes and telescribes services using a likert scale after a brief explanation of the services. Results: Of providers surveyed, 84% never used a traditional scribe or telescribe, while 85% indicated a desire to work with them. Furthermore, 95% agreed that learning to use a scribe would benefit them in the future and 75% agreed to adjust workflow to accommodate a scribe. Despite willingness to use a traditional scribe, 45% indicated they would not use the telescribe service (free-text rationales related to inconvenience). Secondly, 95% hospital volunteer respondents were interested in the scribe position. Finally, a patient survey showed zero were uncomfortable with presence of a scribe and 16% and 25% were uncomfortable with an audio or video scribe, respectively. Conclusion: Our results indicate patients and providers are more comfortable with a traditional scribe model and implementation of a telescribe model requires addressing workflow and privacy concerns of provider and patient
ISSN: 1936-9018
CID: 2977222

Observation Services Linked With an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster

Caspers, Christopher; Smith, Silas W; Seth, Rishi; Femia, Robert; Goldfrank, Lewis R
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).
PMID: 27087398
ISSN: 1938-744x
CID: 2079872