Telehealth Facilitates Value-Based Care in Emergency Department Settings

Spurred by the COVID-19 pandemic, the health care industry is increasingly aware of benefits emergency physicians could contribute to value-based care. The use of emergency telehealth—to reduce the number of hospital admissions, readmissions, and missed outpatient follow-up appointments—will play an increasing role in the shift to value-based care paradigms. Although certain legal, regulatory, and reimbursement challenges remain, the COVID-19 outbreak should stimulate lawmakers and regulatory agencies to promulgate further measures that facilitate widespread adoption of telemedicine, which will inevitably extend into emergency care. Emergency physicians should play a leadership role in the development and implementation of coordinated care before, during, and after acute unscheduled care needs of patients. Coordinated care is a recognized role of emergency telehealth in the value chain. For emergency telehealth to be effective, it must be appropriately integrated into standard practice of emergency medicine.

Emerging and Innovative Technologies

To provide acute unscheduled care 24 hours per day and 7 days per week is the core mission of emergency medicine. Emergency telehealth is evolving in scope and complexity, no longer constraining care by the walls of the emergency department (ED). Current audio- and video-based communications will advance to support a complex interplay between enhanced video communication, remote patient monitoring, augmented reality, and machine learning. Many of these technologies already exist or are under development for near-term implementation. For those deploying or planning the deployment of emergency telehealth services, this chapter highlights near-term technologies and applications to be considered.

SP3.1.14 NELA; what happens after discharge?

Aims NELA has been instrumental at improving perioperative care and 30–day mortality following emergency laparotomy (EmLap); long-term outcomes and follow-up are less well reported. This study aims to establish the unscheduled and scheduled service use of EmLap patients after discharge. Methods This is a single-centre service evaluation. Patients were included if they had an EmLap recorded from 2016-2019 at our local institute and were alive on discharge. Outcomes were 30-day readmission rate and outpatient follow-up. Results 944 patients were included. 11.9% re-presented to the surgical department within 30-days; 58.0% of these needed readmissions. The most common causes for re-presentation (n = 112) were management of a wound issue (15.2%), ongoing pain without evidence of complication (10.7%) and ongoing intra-abdominal sepsis (9.8%). 1-year survival was 81.4%. Of these (n = 856); 74.3% were invited to outpatients; DNA rate was 8.8%, with only 67.8% of patients having a follow-up review. Median time to follow up was 9 weeks. Patients were more likely to be invited for outpatient review if they had a new stoma (OR 2.56, 95% CI 1.81 – 3.56), and less likely if adhesiolysis was the primary procedure (OR 0.55, 95% 0.39-0.76). Patients who failed to attend an appointment were significantly younger (median age 53 vs. 60 years, p = 0.0033) and from more deprived areas (average WIMD 673.6 vs 977.3, p = 0.002). Conclusion This study demonstrates higher levels of unscheduled care and lower levels of scheduled care than expected. Care standards should be extended beyond the 30-day milestone to fully appreciate the morbidity associated from EmLap.

EP.WE.231Emergency Presentations of Colorectal Cancer during the COVID-19 Era

Aims COVID-19 has reduced the ability to provide red flag investigations for colorectal patients. The aim of this study is to assess the number of emergency presentations of new colorectal malignancy during the COVID-19 era and if there is an increase in palliative cases. Methods A retrospective review of all patients presenting to unscheduled care with a new diagnosis of colorectal malignancy from 31st March 2020 - 25th January 2021 in a single UK Trust. An institutional data base and electronic care records were used to review patient demographics, management and curative intent. Data points for the same period in 2019-2020 were recorded for comparison. Results 45 patients diagnosed with new colorectal malignancy during an unscheduled admission to hospital within the study timeframe. 22% (10/45) presented in January 2021. 29 diagnosed during the same time interval 2019-2020. Median age at presentation was 77.5 and 79 respectively. 40% (18/45) of patients in 2020-2021 proceeded to emergency surgery, compared to 58% (17/29) in 2019-2020 (p = 0.12). 10.3% (3/29) of 2019-2020 patients were managed with colonic stenting. This increased in 2020-2021 to 17.8% (8/45) (p = 0.38). 77.8% (35/45) patients in 2020/2021 presented at a palliative stage of disease compared to 62.1% (18/29) in 2019-2020 (p = 0.15). Conclusions Overall the data has not shown a statistically significant difference in patients presenting as an emergency with new colorectal malignancy. However, there was a rise in admissions noted in January 2021; should this trend continue, alongside the persistent pressures of COVID-19 ongoing research is needed to assess the true impact.

Trends in emergency department use by older people during the COVID-19 pandemic

Purpose Reports suggest that many older people deferred seeking healthcare during the COVID-19 pandemic due to fear of contracting COVID-19. The aim of this study was to examine trends of emergency department (ED) use by older people during the first wave of the COVID-19 pandemic compared to previous years. Methods The study site is a 1000-bed university teaching hospital with annual ED new-patient attendance of > 50,000. All ED presentations of patients aged ≥ 70 years from March to August 2020, 2019 and 2018 inclusive (n = 13,989) were reviewed and compared for presenting complaint, Manchester Triage Score, and admission/discharge decision. Results There was a 16% reduction in presentations across the 6 months in 2020 compared to the average of 2018/2019. On average, 4 fewer people aged ≥ 70 years presented to the ED per day in 2020. Much of this was concentrated in March (33% fewer presentations) and April (31% fewer presentations), when the country was in ‘lockdown’, i.e. non-essential journeys were banned. There was a 20% reduction in patients presenting with stroke and cardiac complaints. In the 3 months following easing of restrictions, there was a 25% increase in falls and orthopaedic injuries when compared to 2018/2019. Conclusion This study demonstrates a significant decline in the number of older people presenting to the ED for unscheduled care, including for potentially time-dependent illnesses such as stroke or cardiac complaints. Given the possibility of further lockdowns, it is imperative that we consider enabling strategies to ensure older people access unscheduled care in a timely manner when necessary.

Applying the Synergy Model to inform the nursing model of care in an inpatient and an ambulatory care setting: The experience of two urban cancer institutions, Hamilton Health Sciences and Grand River Regional Cancer Centre

The incidence and prevalence of cancer continues to rise throughout Canada. Approximately one in two Canadians are expected to develop cancer at some point in their lives (Canadian Cancer Society, 2021). As the complexity and acuity of individuals with cancer increases, there is increased necessity to define the ideal nurse-to-patient ratio and patient caseload for nurses in specialized oncology settings. Two senior nurse leaders, faced with the need to determine the most appropriate model to inform the nursing model of care within their respective care areas, collaborated and decided to implement the Synergy Model. The Synergy Model is a professional practice model developed by the American Association of Critical Care Nurses (AACN). In the Synergy Model, nursing care reflects the integration of nurses’ knowledge, skills, attitudes, competencies, and experience to meet the needs of patients and families (Curley, 2007). This model provides a framework for matching nursing resources based on patient care needs and has been adapted in various care settings. The model, however, has not been applied in a surgical oncology inpatient unit or in an oncology ambulatory care setting. Using a quality improvement methodology, the Synergy Model was piloted in these new areas and found to be effective. The Synergy Model can be utilized to determine the need for additional nursing resources with specialized oncology nurses and appropriate skill mix of intraprofessional nursing teams. It can also be used to assess adult oncology patients who present to the ambulatory systemic care suite for unscheduled care related to symptomatic concerns.