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Introduction: Telehealth has been used nominally for trauma, neurological, and cardiovascular incidents in prehospital emergency medical services (EMS). Yet, much less is known about the use of telehealth for low-acuity primary care. We examine the development of one telehealth program and its impact on unnecessary ambulance transports. Objective: The objective of this study is to describe the development and impact of a large-scale telehealth program on ambulance transports. Methods: We describe the patient characteristics and results from a cohort of patients in Houston, Texas who received a prehospital telehealth consultation from an emergency medicine physician. Inclusion criteria were adults and pediatric patients with complaints considered to be non-urgent, primary care related. Data were analyzed for 36 months, from January 2015 through December 2017. Our primary dependent variable was the percentage of patients transported by ambulance. We used descriptive statistics to describe patient demographics, chi-square to examine differences between groups, and logistic regression to explore the effects with multivariate controls including age, gender, race, and chief complaint. Results: A total of 15,067 patients were enrolled (53% female; average age 44 years ± 19 years) over the three-year period. The 3 primary chief complaints were based on abdominal pains (13% of cases), nausea/vomiting/diarrhea (NVD) (9.4%), and back pain (9.3%). Ambulance transports represented 11.2% of all transports in the program, while alternative taxi transportation was used in 75.6%, and the remainder were self- or no-transports. Taxi transportation to an alternate, affiliated clinic (versus ED) was utilized in 5% of incidents. After multivariate controls, older age patients presenting with low-risk, non-acute chest pain, shortness of breath, and dizziness were much more likely to use ambulance transport. Race and gender were not significant predictors of ambulance transport. Conclusions: We found telehealth offers a technology strategy to address potentially unnecessary ambulance transports. Based on prior cost-effectiveness analyses, the reduction of unnecessary ambulance transports translates to an overall reduction in EMS agency costs. Telehealth programs offer a viable solution to support alternate destination and alternate transport programs.

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BACKGROUND: Emergency physicians make treatment decisions in patients who present to the emergency department (ED) with acute venous thromboembolism (VTE). They also encounter patients on target-specific oral anticoagulants (TSOACs) who require urgent intervention. New approvals and increasing prescriptions for TSOACs (e.g., apixaban, dabigatran, edoxaban, and rivaroxaban) for the management of several thromboembolic disorders warrant an evaluation of the impact of these agents in the ED setting. OBJECTIVE OF THE REVIEW: This review discusses the use of TSOACs in the ED for the treatment of acute VTE, and highlights strategies for the management of patients on TSOACs who present to the ED with other complications, such as bleeding complications or requiring emergency surgery. DISCUSSION: Apixaban, dabigatran, edoxaban, and rivaroxaban have been approved for the treatment of acute VTE. We discuss the impact of this on ED management of TSOAC-naïve patients and highlight results with TSOACs in high-risk subgroups including the elderly and those with prior VTE or active cancer. This review also discusses management strategies for patients on TSOACs. For emergency physicians, strategies for the management of bleeding, approaches to patient care when emergency surgery is needed, laboratory assays for measuring plasma concentrations of TSOACs, and drug-drug interactions are of special importance. CONCLUSIONS: Familiarity with TSOACs will better position emergency physicians to provide state-of-the art care to their patients with VTE and help them manage potentially complicated circumstances related to the chronic use of these drugs.

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OBJECTIVES: High-fidelity medical simulation (HFMS) is increasingly utilized in resident education and evaluation. No criterion standard of assessing performance currently exists. This study compared the intermethod reliability of real-time versus videotaped evaluation of HFMS participant performance. METHODS: Twenty-five emergency medicine residents and one transitional resident participated in a septic shock HFMS scenario. Four evaluators assessed the performance of participants on technical (26-item yes/no completion) and nontechnical (seven item, five-point Likert scale assessment) scorecards. Two evaluators provided assessment in real time, and two provided delayed videotape review. After 13 scenarios, evaluators crossed over and completed the scenarios in the opposite method. Real-time evaluations were completed immediately at the end of the simulation; videotape reviewers were allowed to review the scenarios with no time limit. Agreement between raters was tested using the intraclass correlation coefficient (ICC), with Cronbach's alpha used to measure consistency among items on the scores on the checklists. RESULTS: Bland-Altman plot analysis of both conditions revealed substantial agreement between the real-time and videotaped review scores by reviewers. The mean difference between the reviewers was 0.0 (95% confidence interval [CI] = -3.7 to 3.6) on the technical evaluation and -1.6 (95% CI = -11.4 to 8.2) on the nontechnical scorecard assessment. Comparison of evaluations for the videotape technical scorecard demonstrated a Cronbach's alpha of 0.914, with an ICC of 0.842 (95% CI = 0.679 to 0.926), and the real-time technical scorecard demonstrated a Cronbach's alpha of 0.899, with an ICC of 0.817 (95% CI = 0.633 to 0.914), demonstrating excellent intermethod reliability. Comparison of evaluations for the videotape nontechnical scorecard demonstrated a Cronbach's alpha of 0.888, with an ICC of 0.798 (95% CI = 0.600 to 0.904), and the real-time nontechnical scorecard demonstrated a Cronbach's alpha of 0.833, with an ICC of 0.714 (95% CI = 0.457 to 0.861), demonstrating substantial interrater reliability. The raters were consistent in agreement on performance within each level of training, as the analysis of variance demonstrated no significant differences between the technical scorecard (p = 0.176) and nontechnical scorecard (p = 0.367). CONCLUSIONS: Real-time and videotaped-based evaluations of resident performance of both technical and nontechnical skills during an HFMS septic shock scenario provided equally reliable methods of assessment.

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