Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth, Philadelphia, PA.
JeffConnect Program and National Academic Center for Telehealth, Thomas Jefferson University, Philadelphia, PA.
Acad Emerg Med. 2020 Feb;27(2):139-147. doi: 10.1111/acem.13890. Epub 2019 Dec 26.
More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures.
We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program.
Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%).
Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.
目的：每年有超过 200 万名患者前往美国急诊部（ED）就诊，但由于护理开始延迟，其中有 200 多万人离开时未得到治疗（LWBS）。我们评估了在就诊时使用远程接诊是否会降低 LWBS 率和 ED 吞吐量指标。
方法：我们在一家城市社区医院进行了一项前后对照研究。干预措施是在每天上午 11 点至下午 6 点、每周 7 天使用远程接诊医生对患者进行分诊。远程接诊医生进行分诊病史和体格检查，记录检查结果，并在病历中开出处方。我们使用国家质量论坛框架的访问、提供者体验和护理效果评估领域来评估该方案的影响。主要结果是 24 小时 LWBS 率。次要结果是总门到提供者和门到处置时间、未治疗完成（LWTC）、未经医嘱离开（AMA）、未治疗（LWOT）和医生体验。我们将远程接诊期的 6 个月与前一年同期（2017 年 10 月 1 日至 2017 年 4 月 1 日与 2016 年）进行比较。此外，我们对我们的医生进行了一项调查，以评估他们对该计划的体验。
结果：在前后两个时期，ED 总容量相似（19892 名患者与 19646 名患者）。24 小时 LWBS 率从 2.30%（95%置信区间[CI] = 2.0%至 2.5%）降至 1.69%（95% CI = 1.51%至 1.87%；p < 0.001）。总的门到提供者时间缩短（中位数= 19 [四分位距[IQR] = 9 至 38]分钟与 16.2 [IQR = 7.8 至 34.3]分钟；p < 0.001），但所有患者的 ED 住院时间（所有患者的门到门时间定义）略有增加（中位数= 184 [IQR = 100 至 292]分钟与 184.3 [IQR = 104.4 至 300]分钟；p < 0.001）。门到出院时间增加（中位数= 146 [IQR = 83 至 231]分钟与 148 [IQR = 88.2 至 233.6]分钟；p < 0.001），门到入院时间增加（中位数= 330 [IQR = 253 至 432]分钟与 357.6 [IQR = 260.3 至 514.5]分钟；p < 0.001）。我们看到 LWTC 增加（0.59% [95% CI = 0.49%至 0.70%]与 1.1% [95% CI = 0.9%至 1.2%]；p < 0.001），但 AMA 没有变化（1.4% [95% CI = 1.2%至 1.6%]与 1.6% [95% CI = 1.4%至 1.78%]；p = 0.21）或 LWOT（4.3% [95% CI = 4.1%至 4.6%]与 4.4% [95% CI = 4.1%至 4.7%]；p = 0.7）。远程接诊医生认为远程接诊增加了价值（12/15，80%），并使他们能够有效地解决医疗问题（14/15，95%），但只有（10/15，67%）认为它与面对面分诊一样好。在接受调查的医生中，大多数人同意以下说法：远程接诊不会干扰治疗（19/22，86%），有助于补充治疗（19/21，90%），并给患者带来更好的体验（19/22，86%）。
结论：在城市社区医院 ED 中提供远程接诊可降低 LWBS 和到提供者的时间，但增加了 LWTC 率，对 LWOT 没有影响。
