Impact of Emergency Department Tele‐intake on Left Without Being Seen and Throughput Metrics

Abstract

Objectives 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. Methods 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. Results 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%). Conclusions 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.

Rapid response to COVID-19: health informatics support for outbreak management in an academic health system

“…15 Telemedicine can be used to set emergency medicine to triage patients, decrease the rate of discharge without complete treatment and proper follow-up, and reduce the number of in person visits and subsequent risk of transmission of infection. [12][13] An additional application is in early symptom identification and triaging as a mitigation strategy for potential delays in access to healthcare. 30 This was previously observed in Wuhan, China during the initial outbreak of COVID-19 when 89% of patients were not hospitalized until at least 5 days into their illness.…”

“…11 Technology-based tools can effectively support institutions during a pandemic by facilitating the immediate widespread distribution of information, tracking transmission in real time, creating virtual venues for meetings and day-to-day operations, and, perhaps most importantly, offering telemedicine visits for patients. [12][13][14][15][16] During the Ebola outbreak in 2014, attention was brought to the use of the EHR as a potential public health tool. 17 Unfortunately, despite the recent Ebola epidemic, the infrastructure for outbreak management was not present in many US health systems and their EHR applications.…”

Rapid development of telehealth capabilities within pediatric patient portal infrastructure for COVID-19 care: barriers, solutions, results

“…After launching our remote enrollment method, weekly pediatric patient portal enrollments experienced a roughly 10-fold increase for ages 0-12 years and 1.2-fold increase for ages [13][14][15][16][17] years. Weekly telehealth visits increased by roughly 200-fold for ages 0-12 years and 90-fold for ages 13-17 years.…”

Less social emergency departments: implementation of workplace contact reduction during COVID-19

“…Other shifts have been staggered through the day to minimise the number of healthcare workers in the ED at any given time as well as congregation during handoffs or breaks. We worked with consult services to maximise the use of in-hospital telemedicine 5 6 consults for management decisions thereby reducing excess personnel in the ED. Non-essential personnel such as volunteers and research assistants were recalled and attempts made to repurpose their roles into department needs that could be managed virtually.…”