As the COVID-19 pandemic threatens to overwhelm the U.S. health care system, New York State is especially vulnerable as the new epicenter, with over 80,000 documented cases as of early April. Northwell Health, with one of the largest cohorts of confirmed cases in New York State, is at the forefront of one of greatest challenges to health care delivery in recent times. An unprecedented surge in volume of hospitalizations, with the majority of patients being managed on the medical floors, has stretched health care delivery teams thin. Like other health systems, we're looking at innovative strategies to provide the highest quality care while keeping the health care team safe and healthy.
Telemedicine is one such key strategy that offers the potential to not only screen and manage patients at home and thus reduce unnecessary visits to the ED, but also expand access to clinicians and reduce their risk of exposure. In this article, we share strategies for implementing and utilizing a telehospitalist program to support the bedside team in increasing their bandwidth, efficiency, and safety.
Telehospitalist program at Northwell Health
Northwell Health, with 23 hospitals, is the largest health system in the state of New York. It has a robust telehealth program in both inpatient and outpatient settings. The telehealth center is staffed by a cross-disciplinary team of critical care physicians, hospitalists, psychiatrists, nurses, and advanced care practitioners.
The telehospitalist program was implemented to streamline patient flow and improve patient satisfaction in EDs. Requests for telehospitalist evaluation come from bedside hospitalists whenever there is a delay in evaluating patients in the ED. A phone discussion occurs between the ED attending and the telehospitalist, who then evaluates the patient remotely via a cart, reviewing the patient's laboratory and radiology results, documenting findings, and providing an assessment and care plan in a consultation note. The telehospitalist also places admission orders while the patient is still in the ED and hands the patient off to the bedside hospitalist via a phone call.
Since its implementation in 2017, our telehospitalist program has completed over 2,300 ED evaluations, with consistently high patient satisfaction scores. (Patients are texted four questions after each visit.) Based on this success, the scope of the program has been broadened to providing cross-coverage in stepdown units, ED holding areas, and skilled nursing facilities.
Telehospitalists and COVID-19
During the COVID-19 epidemic, the aims for the telehospitalist program are to increase access to hospitalist services, maximize the efficiency and bandwidth of the bedside team, and reduce their need to don and doff PPE, thus conserving much-needed resources. Some of the ways these goals can be achieved are highlighted as follows.
Admitting patients in the ED. The ED poses the highest risk of COVID-19 exposure for clinicians, as they are often dealing with incomplete patient data. Allowing telehospitalists to evaluate patients in the ED not only provides an additional layer of triage before patients are transferred to the floor but also allows the bedside team to focus on the patients they already have, thus increasing their efficiency during a time of increased workload and minimizing their risk of exposure.
Covering COVID-19 patients on floors and ICUs. When patients are being transferred out of the ICU, telehospitalists can discuss their ICU course with the intensivist and virtually examine them. Telehospitalists can review laboratory and radiological data in the electronic health record, enter the acceptance note, order follow-up labs, review medications, and provide signout to the bedside hospitalist. Telehospitalists can also round with bedside teams on specially designated floors using mobile carts. In addition, cross-coverage calls can be handled by telehospitalists without interrupting the workflow of the on-site hospitalists.
Providing oversight to rapid response teams. Telehospitalists can respond to requests from bedside nurses or advanced care practitioners for urgent evaluation and management of a sudden decline in patient condition.
Facilitating virtual family visits. To limit exposure and spread, many hospitals have imposed restrictions on visits by family members, causing a sense of isolation. Telehospitalists could hold a three-way conference with the patient and family in a HIPPA-secure manner, providing reassurance and comfort.
Standardizing care and compliance with best practices. Health care systems can use telehospitalist platforms to decrease variation in care across different sites and promote compliance with best practices (e.g., the latest recommendations for COVID-19 treatment), thereby improving the efficiency and quality of care.
Planning for discharge. Many post-acute care facilities have placed strict acceptance policies on COVID-19 patients. Telehospitalists can screen patients to determine if they are appropriate for transfer, perform medication reconciliation, provide discharge instructions, and complete the handoff to the post-acute care team, ensuring continuity of care.
Facilitating transfers from EDs to other hospitals during surges. Within the same geographical location, some hospitals may be overwhelmed with patients while others will have available beds. Telehospitalists can be used to optimize bed utilization by evaluating and admitting patients for direct transfer to the medical floor of another hospital.
Rounding from home by quarantined hospitalists. Equipping hospitalists who are quarantined at home with the ability to provide remote consultations decreases the impact of quarantine on the hospitalist workforce.
Fast-tracking a telehospitalist program
Setting up a telehospitalist program is a complex endeavor requiring collaboration from many hospital teams, ranging from information technology to legal services. However, the current crisis has led to a significant reduction in regulatory barriers by various national agencies. Hospitalist programs could take this opportunity to implement telehospitalist programs that will help them meet the unprecedented challenges presented by COVID-19.
Important considerations to setting up a fast-track program include the following.
- 1. Define a clear objective. Perform a gap analysis to clearly define the objectives for the telehospitalist program and determine what institutional need or needs it will fulfill.
- 2. Define measurable performance metrics to show the program's value and develop tools to collect and analyze data from the outset.
- 3. Collaborate with cross-disciplinary clinical leadership early in program development.
- 4. Design workflows that integrate easily with the on-site team's workflow.
- 5. Conduct mock scenarios to uncover practical barriers that may have been overlooked in planning and provide all users with camera etiquette training prior to implementation.
- 6. Involve legal staff, medical staff services, and revenue cycle teams to take advantage of relaxation in regulatory requirements for telehospitalist licensing, privileging, and reimbursement.
- 7. Survey patient satisfaction (e.g., by texting patients after a televisit) to demonstrate program value and assist in continuous process improvement.
COVID-19 presents an unprecedented challenge for health care. Telemedicine has long been touted as the “next big thing” in health care delivery. Today, a well-developed telehospitalist program could go a long way in fulfilling that promise.