Emergency Department Overcrowding
Conditions
Keywords
Communication Strategies, Post-Discharge Digital Reassessment, Emergency Care Unit, Telemedicine, Patient Follow-Up
Brief summary
Emergency department overcrowding is a universal phenomenon associated with worse patient outcomes and a negative impact on healthcare teams. Telemedicine has been routinely implemented as a strategy to mitigate the harmful effects of overcrowding, particularly in pre-hospital assessments and triage processes. Since April 2024, the Emergency Care Units of Hospital Israelita Albert Einstein (HIAE) have offered low-risk patients-after nursing triage and in-person medical evaluation-the option of administrative discharge followed by digital reassessment via telemedicine. Currently, the initial communication strategy consists of an audio telephone call conducted by the telemedicine nursing team. In this study, we aim to test the hypothesis that the addition of alternative communication strategies may be associated with improved outcomes. This prospective, single-center, randomized, open-label pilot study will be conducted at a telemedicine center that serves five Emergency Care Units of HIAE. The study population will include patients aged 18 years or older who spontaneously seek care at an Emergency Care Unit, are classified as ESI 3, 4, or 5 during nursing triage, undergo in-person medical evaluation confirming low-risk status, and have complementary laboratory tests requested. Patients will be excluded if imaging exams are requested, if laboratory tests are expected to have a turnaround time exceeding 24 hours, or if they do not have access to a smartphone with WhatsApp and email for communication. After administrative discharge from the Emergency Department, patients will be randomized to one of two communication strategies: standard care, consisting of telephone contact by the telemedicine nursing team, or an incremental strategy, which includes instructions to check laboratory results via an application, reminder messages prompting patient-initiated contact through WhatsApp and email, and a telephone call in cases where no spontaneous contact occurs. The primary endpoint will be the time elapsed between medical discharge from the Emergency Care Unit and patient contact with HIAE.
Interventions
BEHAVIORALStandard Telephone Follow-Up
1. The telemedicine nursing team registers the patient in the telemedicine system and periodically checks the results of the requested laboratory tests. 2. A telephone call is made immediately after laboratory results become available. 3. If the initial call is unsuccessful, a second attempt is made after 2 hours.
BEHAVIORALEnhanced Digital Communication Strategy
1. Prior to discharge, patients are instructed to check their test results independently (via the "Meu Einstein" app) and to contact HIAE within a maximum of one hour after laboratory results become available. 2. Immediately after laboratory results become available, a WhatsApp message and an email are sent to the patient with instructions to contact HIAE. 3. An audio phone call is performed according to the standard protocol if no patient response occurs within 1 hour after results become available and the message has been sent. 4. If the call is unsuccessful, a second attempt is made after 2 hours.
Sponsors
Hospital Israelita Albert Einstein
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age ≥ 18 years; * Initial in-person evaluation at the Emergency Care Unit of Hospital Israelita Albert Einstein; * Emergency Severity Index (ESI) classification of 3, 4, or 5 during nursing triage; * In-person medical evaluation confirming low-risk classification; * Request for complementary laboratory tests; * Acceptance of digital reassessment after discharge; * Provision of written informed consent.
Exclusion criteria
* Request for blood culture testing; * Request for imaging studies (except chest X-ray evaluated in the Emergency Care Unit prior to discharge); * Laboratory tests with an expected turnaround time greater than 24 hours; * Change in clinical complexity level after medical evaluation; * Failure to transfer the discharged patient's identification to the Telemedicine Center; * Activation of a scheduled contingency plan at external units preventing timely patient registration in the telemedicine system as required by the program; * Lack of access to a smartphone with WhatsApp and email for communication.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Time to Telemedicine Contact After Emergency Department Discharge | Within 24 hours after laboratory result availability. | Time elapsed (in minutes) between documentation of medical discharge in the electronic health record of the Emergency Care Unit and the moment of patient contact with the telemedicine team, while in possession of laboratory test results. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Patient Satisfaction with Digital Reassessment Process (QAS-Tele Questionnaire) | Within 48 hours after telemedicine reassessment. | Patient-reported satisfaction measured using the validated QAS-Tele questionnaire (adapted version including nursing participation in items 7, 10, 11, and 12). The survey link will be sent via WhatsApp and/or email. The questionnaire consists of items rated on a Likert scale ranging from 1 (lowest satisfaction) to 5 (highest satisfaction). Total scores are calculated by summing item responses, with higher scores indicating greater patient satisfaction (better outcome). |
Contacts
CONTACTTarso Accorsi, MD, PhD
Outcome results
None listed