Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study - 19/12/22
, Uche Okoro, MBBS, DrPH a, Karisa K. Harland, PhD, MPH a, Brian M. Fuller, MD, MSCI d, e, Kalyn Campbell, MD a, f, Morgan B. Swanson, BS a, Cole Wymore, BS a, Brett Faine, PharmD, MS a, g, Anne Zepeski, PharmD a, Edith A. Parker, DrPH, MPH h, Luke Mack, MA i, j, Amanda Bell, MHA i, Katie DeJong, DO i, Keith Mueller, PhD k, Elizabeth Chrischilles, PhD c, Christopher R. Carpenter, MD, MSc e, Kelli Wallace, MS a, Michael P. Jones, PhD l, Marcia M. Ward, PhD kAbstract |
Study objective |
To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs).
Methods |
Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence.
Results |
A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI −0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori–defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86).
Conclusion |
Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.
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| Please see page 2 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Donald M. Yealy, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: NMM and MMW conceived the study, secured research funding, conducted the study, and drafted the manuscript. UO, KKH, and MBS analyzed and interpreted the data and critically revised the manuscript for important intellectual content. BMF, AAP, KM, EC, and CRC contributed to the study design, interpreted the results, and critically revised the manuscript for important intellectual content. KC, CW, KW, BF, and AZ developed data collection tools, participated in data collection and validation, interpreted the results, and critically revised the manuscript for important intellectual content. LM, AB, and KD provided data access, and content expertise interpreted the results and critically revised the manuscript for important intellectual content. MPJ provided statistical consultation for the data analysis, interpreted the results, and critically revised the manuscript for important intellectual content. NMM takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This study was funded by the Agency for Healthcare Research and Quality (K08HS025753) and the Institute for Clinical and Translational Science at the University of Iowa through a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health (UL1TR002537). NMM is additionally supported by funding from the Rural Telehealth Research Center with funding from the Health Resources and Services Administration (U3GRH40003). LM, AB, and KD are employed by an organization that provides commercial telemedicine services. These contents are solely the responsibility of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality and the official views of the NIH. |
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| Trial registration number: NCT04441944 |
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| Presented the results in this manuscript at the Society of Critical Care Medicine Annual Congress, April 18 to 21, 2022 (held virtually). |
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