ED Post-Discharge Digital Follow-Up: A Communication Comparison

Comparison of Communication Strategies in Post-discharge Digital Reassessment of Patients Attended In-person in the Emergency Department. Back to Digital Study.

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.

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.