Back in early March, GWU Hospital did not have in-house COVID-19 testing for patients and, like many hospitals, was sending labs to the local health department. Instead of the discharging hospitalist following up by phone as usual, the hospital created a telehealth monitoring service for patients still waiting for test results after discharge.
“Many of the clinics, including our own in the area, shut down during the middle of the pandemic, so it was getting really challenging to find postdischarge follow-up for these individuals, even for people who were non-COVID,” said hospitalist Courtney Paul, MD, FACP. “It really ended up being a sort of virtual postdischarge clinic.”
Initially, inpatients who were tested for SARS-CoV-2 by the medicine and pulmonary teams, but who left before the results returned, received follow-up calls from the telemonitoring service. Then, as the pandemic escalated, the telemonitoring project served another purpose: allowing for early discharge in stable patients with COVID-19, Dr. Paul said.
“We were seeing these people who were testing positive, had some mild symptoms, but had no acute indication to be in an acute inpatient hospital,” he said. “So we were trying to create a process whereby we felt it was safe for the patients and the providers felt reassured that they could safely leave and continue to be monitored.”
How it works
By mid-March, roughly 75% of patients in the hospital had COVID-19, said Dr. Paul, an assistant professor of medicine and associate program director of the internal medicine residency at the GWU School of Medicine and Health Sciences. “We had converted one whole medical unit to a COVID unit and were caring for people who were on high-flow oxygen who would otherwise have been in the critical care unit here.”
As part of the project, the hospitalists' main responsibility was to add patients who had a positive or not-yet-returned test for SARS-CoV-2 and were being discharged to a shared list in a HIPAA-compliant database. “We would put the patient's information on the list, confirm some contact information for them, and that was really the end for us,” he said. “And I think that was the huge benefit from our perspective: We were able to focus on caring for patients in the hospital.”
Two hospitalists at GWU Hospital, Juan Reyes, MD, FACP, and ACP Member Kathryn Humes, MD, helped organize the project. For the follow-up component, two geriatrics fellows, ACP Members Louisa Whitesides, MD, and Dhiviya Tharmaratnam, MD, took on the responsibility of calling patients every day to assess symptoms, provide education, and report whether test results were back or not. “If the result was positive, then we would continue to call them for a few days after to ensure that they were improving . . . as well as identify any patients that were struggling. There were a few that ended up returning to the hospital, in part because of the call,” said Dr. Whitesides.
From March 13 to July 24, 232 patients with positive SARS-CoV-2 tests were discharged and followed, 39 at subacute rehabilitation centers or nursing homes and six on hospice. Of those who received the full telehealth service, 121 improved and 16 returned to a hospital. The outcomes of the remaining 50 were unknown because they were unable to be reached or they were followed by another organization, such as the local health department.
The results were a surprise because in the middle of the pandemic, local prediction models suggested that the hospital would potentially see three times its usual number of patients, noted Dr. Paul. “Fortunately, we never reached that threshold. I think this [project] was a component of that. . . . I'm surprised by the number of people who were able to be well enough and cared for at home by their families and maybe some home health services,” he said. “And I was surprised by the resilience of patients to be able to do that.”
In a follow-up survey that asked whether the project helped achieve the goals of early and safe discharge, all of the hospitalists who added patients to the list reported that they were satisfied with the service. “It's a smaller sample size—we're a smaller division—but they did feel that it was a useful process to help them in terms of earlier discharges, comfort with follow-up, comfort with outpatient monitoring,” said Dr. Paul.
Remembering to take the time to enter discharges into the list was a day-to-day challenge for the hospitalists, said Dr. Paul. “That's talking about in the middle of the pandemic, and people were very, very busy, wearing full protective equipment. It was an exhausting—mentally and physically—day,” he said.
Another challenge was the project's grassroots approach, with two geriatrics fellows calling hundreds of patients, said Dr. Whitesides, who wrapped up her fellowship at the end of June, became an attending in August, and is now an assistant professor of geriatrics and palliative care. Dr. Paul added that while the process could have been more systematic, “I actually ended up feeling like the two geriatrics fellows were the exact right people to make the callbacks because they were so skilled at ensuring patients could live in the community with the resources available.”
Having more of a template for the calls, which could allow nonclinicians to do the follow-up work with support, would be helpful, Dr. Paul said, “particularly if we have another wave of this pandemic and the numbers get high and we need the providers in the hospital.”
Words of wisdom
The success of the project speaks to the ability of clinicians to care for patients in their homes, “whether we realize it or not,” said Dr. Whitesides. Telehealth monitoring could be applied to other diagnoses as well, “helping care for patients where they want to be, which is ultimately their home,” Dr. Paul said.
The project is no longer in effect because the acute need resolved and because the geriatrics fellows who made the calls moved on to other opportunities, said Dr. Paul. “We moved the follow-up calls back on the providers now that we're seeing much lower numbers of COVID,” he said. However, he noted that this and potentially other telemonitoring services will be “necessary and critical” if the hospital sees a second wave.