WHAT IS THE NEW DEVELOPMENT?
An urban medical center is combining telemedicine with the provider in triage model to perform medical screening examinations (MSEs) on ED patients, improving ED operations, efficiency, and patient care.1 This type of program can help address the nearly 15% increase in ED visits between 2006 and 2014, a trend that may have accelerated with increased access to health insurance under the Affordable Care Act.2 The 145.6 million ED visits in 2016 represent a 5.6% increase since 2014, according to the CDC.2,3 Under the Emergency Medicine Treatment and Labor Act (EMTALA), every patient who presents to an ED must receive an MSE to determine whether the patient has an emergency medical condition as defined by law.4 The impetus for EMTALA was an epidemic of patient transfers that were widely seen as inappropriate and dangerous for patients, including pregnant women in labor who were turned away from EDs.
One approach to meet EMTALA's requirements for the MSE is the provider in triage model. A physician assistant (PA) or NP obtains an accurate patient history and performs a focused physical examination. The PA or NP also directs the performance of point-of-care testing, corroborates the patient history with the triage nurse and emergency medical services (EMS), and orders laboratory and radiologic examinations in conjunction with patient triage, all before the patient is evaluated by an attending physician.
WHY IS IT CONSIDERED TO BE AN ADVANCE OR IMPROVEMENT?
Combining telemedicine with the provider in triage model allows additional flexibility in clinician staffing, letting a clinician be in multiple locations at one time to promptly perform MSEs as patients arrive at the ED. Without a timely MSE, time-sensitive diagnostic and treatment decisions can be delayed, or patients may leave without appropriate screening or initiation of care, which can result in patient and provider dissatisfaction and poor health-related outcomes.3-5
Literature suggests that PAs and NPs in triage can improve ED operations and efficiency, as well as improve patient care.1 The performance of an MSE provides almost immediate door-to-diagnostic evaluation, which we feel improves patient safety, and this is particularly true for patients arriving to the ED by ambulance. An MSE provides an additional level of safety at times of surges in EMS arrivals, ensuring that care continues to be initiated expeditiously and limiting any triage bottleneck that can accompany surges in arrivals.
WHAT DO PAS MOST NEED TO KNOW ABOUT THIS NEW DEVELOPMENT?
The New York-Presbyterian/Weill Cornell Medicine Department of Emergency Medicine staffs two hospitals in the New York City area: New York-Presbyterian/Weill Cornell Medicine (NYP/WCM) and New York-Presbyterian/Lower Manhattan Hospital (NYP/LMH). NYH/WCM is a quaternary-care, urban academic medical center with more than 90,000 total annual ED visits. The ED is a certified trauma, stroke, ST-segment elevation myocardial infarction (STEMI), and burn center and receives referrals from local and regional hospitals. The NYP/LMH ED sees about 50,000 ED visits annually and serves a community hospital population of southern Manhattan in New York City. The two institutions are staffed by a single faculty practice comprising 100 attending physicians, 30 PAs, and 5 NPs.
NYP has been actively promoting telemedicine adoption on an enterprise-wide level. Like many other institutions, NYP/WCM initiated a provider in triage model for ambulatory patients. PAs and NPs in ambulatory triage have been well-integrated into our ED operations to improve patient care and efficiency. Performance of a thorough MSE by a PA or NP has dramatically shortened the door-to-diagnostic evaluation times for ED patients.
To increase the efficiency of patient care, our ED instituted a novel program in 2018 in which a PA or NP, using a video-conferencing platform available at the NYP/WCM and NYP/LMH hospitals, performed telemedicine MSEs (teleMSEs) for patients arriving by ambulance. One PA or NP can observe two ambulance arrival areas simultaneously, and rapidly switch between them to interact with patients, RNs, and EMS.
In this program, the triage nurse, the patient, and EMS have a video interaction with the PA or NP through a HIPAA-secure video conferencing unit physically located at a remote centralized location. The PA or NP receives and documents pertinent on-scene information from EMS as well as any prehospital intervention. A virtual physical examination by visual inspection or assisted by the triage nurse or EMS is performed in full view of a high-definition camera remotely controlled by the PA or NP. The PA or NP documents this interaction in the electronic medical record and may enter orders such as laboratory tests, point-of-care testing, and ECGs before the patient is transported to the treatment area. For higher-acuity patients, such as those with stroke, STEMI, sepsis, or trauma, the PA or NP can rapidly place orders and activate the alert that triggers treatment pathways and communicates with care teams through the departments.
At our institution, the teleMSE consists of four elements:
- Video interaction with the triage nurse, patient, and EMS staff
- History (chief complaint, brief history of present illness consisting of one to three elements of the review of systems)
- Vital signs and visual or assisted physical examination
- Brief assessment and plan as part of a continuum of care, including laboratory and imaging studies ordered and consultants contacted.
WHAT ELSE IS IMPORTANT ABOUT THIS TOPIC?
As the use of telemedicine in healthcare expands, NYP has demonstrated a willingness to be at the forefront of innovation, and the ED has been an active partner in the enterprise-wide adoption of new technology. A critical element to successfully using telemedicine entails the provision of the same high level of care to a patient regardless of whether that patient receives an in-person treatment or a virtual telehealth service.6 Through our teleMSE program, our department can now staff one PA or NP in a remote setting to perform the MSE at two hospitals, allowing immediate initiation of patient care and workup.
The teleMSE program has let us duplicate the success of our in-person provider in triage model with improved staffing efficiency, and helps us ensure that we provide the same high level of care to a patient regardless of how they arrive at our ED. Implementation of the teleMSE program has had a positive effect on our overall ED door-to-diagnostic evaluation and the number of patients who leave without being seen (0.2% for adults between April and October 2018). We are evaluating how the teleMSE program has affected other ED quality measures such as total length of stay and time to admit decision.
Since April 2018, more than 17,000 teleMSEs have been completed for patients arriving to the ED by ambulance, with the PA or NP seeing about five patients per hour and a median time of 4 minutes from door to diagnostic evaluation by a qualified medical professional.
To ensure the quality of the teleMSEs, five charts per provider are reviewed each month. The process to review each chart includes making sure that the correct template is used, making sure that all elements of the MSE are followed, and applying a quality scale that measures appropriateness of the assessment and plan.
For institutions that do not have the volume to warrant a provider in triage model, using telemedicine to cover multiple EDs is a viable option. Availability of this option will increase as more institutions adopt telemedicine as part of their healthcare delivery in other areas, and the availability of the required tools and familiarity with their use increases. More than half of all US hospitals have a telemedicine program.7 With more than 7 million telemedicine patients in 2018, compared with 350,000 in 2013, in the near future, more patient interactions may occur by telemedicine than in person.8
Anecdotal reports suggest that PAs and NPs in our department have enjoyed being a part of this innovative program. Institutions seeking to reduce door-to-diagnostic evaluation time and the rates of patients who leave without being seen should consider the telemedicine equivalent to the traditional provider in triage model. According to the CDC, the national average time to be seen in an ED is 15 to 59 minutes.9 We look forward to future study of the effect of teleMSE both on these metrics and on the model's ability to affect other measures of ED efficiency. This teleMSE model may be particularly attractive to healthcare systems that can use one provider to perform door-to-diagnostic evaluations at multiple locations simultaneously, due to the efficiency of this approach in comparison to when the same work is done by an in-person provider.
WHAT ARE THE KEY POINTS FOR READERS?
- MSEs are a vital component of patient care
- A variation on the provider in triage model using telemedicine lets a provider be present in more than one location and may improve staffing efficiency
- MSEs performed via telehealth help reduce door-to-diagnostic evaluation times and rates of patients who leave without being seen
- A critical element to successfully using telemedicine entails the provision of the same high level of care to a patient, regardless of whether that patient receives an in-person treatment or a virtual telehealth service
- PAs can be deployed successfully using telemedicine to perform MSEs for patients arriving to the ED by ambulance.
1. Love RA, Murphy JA, Lietz TE, Jordan KS. The effectiveness of a provider in triage
in the emergency department: a quality improvement initiative to improve patient flow. Adv Emerg Nurs J
2. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Statistical brief 238: trends in hospital emergency department visits by age and payer, 2006-2015. www.hcup-us.ahrq.gov/reports/statbriefs/sb238-Emergency-Department-Age-Payer-2006-2015.pdf
. Accessed February 10, 2020.
3. Centers for Disease Control and Prevention. National Center for Health Statistics. Emergency department visits. www.cdc.gov/nchs/fastats/emergency-department.htm
. Accessed February 21, 2020.
4. Centers for Medicare and Medicaid Services. State operations manual. Appendix V—interpretive guidelines—responsibilities of Medicare participating hospitals in emergency cases. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_v_emerg.pdf
. Accessed February 10, 2020.
5. Holroyd BR, Bullard MJ, Latoszek K, et al. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med
6. Bond K, Ospina M, Blitz S, et al. Interventions to Reduce Overcrowding in Emergency Departments
. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2006.
7. American Hospital Association. Fact sheet: telehealth. www.aha.org/system/files/2019-02/fact-sheet-telehealth-2-4-19.pdf
. Accessed February 10, 2020.
9. Centers for Disease Control and Prevention. National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2016 emergency department summary tables. www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf
. Accessed February 10, 2020.