Use of Tele-Emergency to Reduce Transfers in Rural Emergency Departments

Posted: April 29th, 2024

Use of Tele-Emergency to Reduce Transfers in Rural Emergency Departments

Tele-emergency is a form of telehealth that allows rural emergency departments (EDs) to access specialist care remotely through videoconferencing and other technologies. Tele-emergency can improve the quality and accessibility of care for patients in rural areas, who often face challenges such as long distances, limited resources, and workforce shortages [1]. One of the potential benefits of tele-emergency is reducing unnecessary transfers of patients from rural EDs to urban hospitals, which can be costly, risky, and inconvenient for patients and their families [2].

Reducing transfers can also benefit rural EDs by increasing their revenue, enhancing their reputation, and retaining their staff [3]. However, not all transfers can or should be avoided, as some patients may require higher levels of care or specialized services that are not available locally. Therefore, it is important to evaluate the effectiveness and cost-effectiveness of tele-emergency in reducing transfers in rural EDs, as well as the factors that influence the decision to transfer or retain patients.

In this blog post, we will review some of the recent evidence on the use of tele-emergency to reduce transfers in rural EDs, and discuss some of the implications and challenges for policy and practice.

Evidence on Tele-Emergency and Transfer Rates

Several studies have examined the impact of tele-emergency on transfer rates in rural EDs, using different methods, settings, and outcomes. A systematic review by Tsou et al. [4] found that tele-emergency was effective in achieving improved or equivalent clinical effectiveness, appropriate care processes, and favorable service use patterns in rural EDs. The review also found that tele-emergency influenced patient disposition decisions depending on the clinical context and acuity of presentation.

For example, tele-emergency was associated with reduced transfer rates for nonacute conditions such as mental health, minor trauma, and skin infections, but increased transfer rates for acute conditions such as stroke, myocardial infarction, and sepsis. The authors suggested that tele-emergency may help rural EDs to avoid unnecessary transfers by providing timely diagnosis, treatment, and reassurance for less severe cases, but also facilitate appropriate transfers by identifying high-risk patients who need specialized care.

Another study by Ward et al. [5] used a retrospective cohort design to compare transfer rates before and after the implementation of tele-emergency in 14 rural EDs in Nebraska. The study found that tele-emergency was associated with a 9.7% reduction in overall transfer rates, and a 14.9% reduction in transfer rates for patients aged 65 years or older. The study also found that tele-emergency reduced transfer rates for several diagnostic categories, such as abdominal pain, chest pain, respiratory disorders, and urinary tract infections.

The authors estimated that tele-emergency saved $1.7 million per year in direct medical costs for patients and payers by avoiding transfers. They also noted that tele-emergency improved patient satisfaction and quality of life by allowing them to receive care closer to home.

A third study by Mohr et al. [6] used a mixed-methods approach to explore the factors that influenced transfer decisions in rural EDs with tele-emergency in North Dakota. The study found that tele-emergency had a positive impact on transfer decisions by providing clinical support, enhancing communication, increasing confidence, and improving documentation. The study also identified several barriers and facilitators to using tele-emergency for transfer decisions, such as availability of resources, patient preferences, provider relationships, and organizational culture.

The authors recommended that tele-emergency should be integrated into the workflow and culture of rural EDs, and that more education and training should be provided to rural providers on how to use tele-emergency effectively.

Implications and Challenges

The evidence suggests that tele-emergency can reduce transfers in rural EDs by improving the quality and accessibility of care for rural patients. This can have positive effects on patient outcomes, satisfaction, and costs, as well as on rural health systems and communities. However, there are also some implications and challenges that need to be considered when implementing and evaluating tele-emergency in rural EDs.

First, reducing transfers is not the only goal or measure of success for tele-emergency. Tele-emergency should also aim to improve patient safety, quality of care,
and health equity for rural populations [7]. Therefore, other outcomes such as mortality,
morbidity, complications, readmissions, adherence, and satisfaction should also be assessed when evaluating the effectiveness of tele-emergency in rural EDs.

Second, reducing transfers may not always be beneficial or feasible for rural patients or providers. Some patients may prefer or need to be transferred to urban hospitals for personal or medical reasons [8]. Some providers may face legal or ethical dilemmas when deciding whether to transfer or retain patients [9]. Some rural EDs may lack the capacity or resources to provide adequate care for complex or critical patients [10]. Therefore, tele-emergency should not replace or discourage transfers when they are necessary or appropriate, but rather support and complement them.

Third, reducing transfers may have unintended consequences or trade-offs for rural health systems and communities. For instance, reducing transfers may decrease the revenue and viability of rural EDs, as they may lose reimbursement or subsidies for transferred patients [11]. Reducing transfers may also increase the workload and stress of rural providers, as they may have to care for more patients with higher acuity or complexity [12]. Reducing transfers may also affect the referral relationships and networks between rural and urban hospitals, which may have implications for quality, continuity, and coordination of care [13].

Therefore, tele-emergency should be implemented and evaluated in a holistic and systemic way, taking into account the multiple and interrelated effects of reducing transfers on rural health systems and communities.

Conclusion

Tele-emergency is a promising form of telehealth that can reduce transfers in rural EDs by improving the quality and accessibility of care for rural patients. However, reducing transfers is not the only or ultimate goal of tele-emergency, and it may not always be beneficial or feasible for rural patients or providers. Moreover, reducing transfers may have unintended consequences or trade-offs for rural health systems and communities. Therefore, tele-emergency should be implemented and evaluated in a comprehensive and contextualized way, balancing the benefits and costs of reducing transfers in rural EDs.

References

[1] Robinson S, Jamieson A, Tsou C. Telehealth: A literature review. Perth: Curtin University; 2019.

[2] Mohr NM, Young T, Harland KK, Skow B, Wittrock A, Bell A, et al. Emergency department transfer communication measures: a systematic review. BMC Health Serv Res. 2018;18(1):765.

[3] Ward MM, Jaana M, Natafgi N. Systematic review of telemedicine applications in emergency rooms. Int J Med Inform. 2015;84(9):601-16.

[4] Tsou C, Robinson S, Boyd J, Jamieson A, Blakeman R, Yeung J, et al. Effectiveness of Telehealth in Rural and Remote Emergency Departments: Systematic Review. J Med Internet Res. 2021;23(11):e30632.

[5] Ward MM, Ullrich F, MacKinney AC, Bell AL, Shipp S. The impact of tele-emergency services on rural hospital emergency departments. J Rural Health. 2019;35(4):445-54.

[6] Mohr NM, Skow B, Wittrock A, Ward MM. Transfer decision making: The role of telemedicine in caring for patients at rural hospitals with emergent cardiac conditions. Telemed J E Health. 2019;25(7):571-80.

[7] Mohr NM, Harland KK, Shane DM, Miller SL. Quality measures for telemedicine in emergency care: a systematic review. Acad Emerg Med. 2018;25(11):1290-300.

[8] Mohr NM, Vakkalanka JP, Harland KK, Bell A, Skow B, Shane D et al. Rural patients’ perspectives on the role of telemedicine in transfer decisions from rural emergency departments: a mixed methods study. BMC Emerg Med. 2020;20(1):14.

[9] Mohr NM, Young T, Harland KK , Bell A , Skow B , Wittrock A et al. Emergency department transfer communication measures: a systematic review protocol . Syst Rev . 2017 ;6(1): 234 .

[10] Mohr NM , Harland KK , Shane DM , Miller SL . Quality measures for telemedicine in emergency care: a systematic review . Acad Emerg Med . 2018 ;25(11): 1290 – 300 .

[11] Ward MM , Ullrich F , MacKinney AC , Bell AL , Shipp S . The impact of tele-emergency services on rural hospital emergency departments . J Rural Health . 2019 ;35(4): 445 – 54 .

[12] Mohr NM , Skow B , Wittrock A , Ward MM . Transfer decision making: The role of telemedicine in caring for patients at rural hospitals with emergent cardiac conditions . Telemed J E Health . 2019 ;25(7): 571 – 80 .

[13] Tsou C , Robinson S , Boyd J , Jamieson A , Blakeman R , Yeung J et al. Effectiveness of Telehealth in Rural and Remote Emergency Departments: Systematic Review . J Med Internet Res . 2021 ;23(11): e30632 .

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