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ObjectivesTo identify risk factors for inpatient mortality after patients’ emergency admission and to create a novel model predicting inpatient mortality risk.DesignThis was a retrospective observational study using data extracted from electronic health records (EHRs). The data were randomly split into a derivation set and a validation set. The stepwise model selection was employed. We compared our model with one of the current clinical scores, Cardiac Arrest Risk Triage (CART) score.SettingA single tertiary hospital in Singapore.ParticipantsAll adult hospitalised patients, admitted via emergency department (ED) from 1 January 2008 to 31 October 2017 (n=433 187 by admission episodes).Main outcome measureThe primary outcome of interest was inpatient mortality following this admission episode. The area under the curve (AUC) of the receiver operating characteristic curve of the predictive model with sensitivity and specificity for optimised cut-offs.Results15 758 (3.64%) of the episodes were observed inpatient mortality. 19 variables were observed as significant predictors and were included in our final regression model. Our predictive model outperformed the CART score in terms of predictive power. The AUC of CART score and our final model was 0.705 (95% CI 0.697 to 0.714) and 0.817 (95% CI 0.810 to 0.824), respectively.ConclusionWe developed and validated a model for inpatient mortality using EHR data collected in the ED. The performance of our model was more accurate than the CART score. Implementation of our model in the hospital can potentially predict imminent adverse events and institute appropriate clinical management.

Study Objective: Hospital systems and insurance companies often utilize an Ask-My-Nurse (AMN) phone line to address patients' health concerns and direct them to appropriate care sites in an effort to avoid costly emergency department (ED) care. Nurses follow strict and conservative protocols, potentially sending more patients to the ED unnecessarily. The study objective is to examine the impact of using an emergency physician (EP) telemedicine visit to assist the AMN line for patients who would otherwise be referred to the ED. To our knowledge no study has evaluated this concept. We believe implementing this workflow will reduce the number of patients being unnecessarily sent to the ED. The primary outcomes measure is reduction in patients referred to the ED. Patient satisfaction is a secondary outcome.Methods: This was a 4-month pilot study that includes patients who called a large county hospital system with two acute care hospitals' AMN line Monday thru Friday 8AM-5PM between November 16, 2020 and March 19, 2021. Patients deemed to have an immediate life-threatening emergency, <28 days old, and pregnant patients >32 weeks pregnant were excluded. All other patients who otherwise would be sent to the ED by nursing protocols were then routed to an EP on-call for telemedicine. The EP would evaluate the patient either by telephone or video interface. A nurse was available to assist with executing orders for outpatient labs, imaging, or primary care doctor referral. Patients deemed to require an ED visit by the EP would then be referred with an electronic referral note. Trained interpreters were available to assist the EP. Notably, the EP's were drawn from two different physician groups that staff each of the health system's two hospitals. Demographic information and disposition information were recorded for each patient. Statistics were analyzed using Excel (Microsoft, Redmond WA).Results: Within the study period, EP's staffed 707 hours of telemedicine. 1351 patients who called AMN met criteria by nursing protocol for ED evaluation. 102 patients declined to be seen virtually by the EP or were unable to connect due to technical difficulties. 1249 patients had a telehealth visit with an EP; 74% were video visits. 894 patients (72%) successfully had their health issue addressed by the EP and avoided an ED visit. Overall satisfaction was 77.9%.Conclusion: This study examines a novel role of EPs in telemedicine, where EPs augment an ask-my-nurse line to avoid ED visits. In the trial period, a significant majority of patients (72%) successfully avoided the ED and were treated definitively or referred to other less intensive sites of care such as primary care clinic. EP's are ideally suited to treat urgent complaints via telemedicine and recognize emergent conditions that require in-person evaluation.Importantly, health systems that wish to reduce ED visits should consider investment in tele-triage systems staffed by EPs.