QUALITY CARE is a key element for patient success as well as reimbursement and financial survival for today's health care system.1 Health systems are challenged to develop new models of care that ensure quality care for our patients in a cost-effective manner while addressing the quadruple aim. This article discusses a new and innovative model of care proposed to address these concerns now and in the future, utilizing virtual technology to deliver care.
Telehealth/Telemedicine programs were started as early as the 1870s, evolving from health information being transmitted over telegraph, to telephone, computerized decision support systems, to transmission of radiologic images, cardiac rhythms, and virtual physician visits.2–4 This has evolved into advanced technical equipment used in the current day electronic intensive care unit, virtual physician visits, and complex distant phone applications. Telehealth has become widespread, with more than 10% of intensive care unit beds monitored by intensive care unit telemedicine.5 The American Academy of Ambulatory Care Nursing published the first set of telenursing standards in 2001, with an update in 2011.6 The most prevalent models of telehealth/telenursing are based on a monitoring model or episodic visits. The Virtual Integrated Care (VIC) Team Model is unique in that the virtual nurse (VN) is a continuous member of the health care delivery team. The VN provides care through 6 core roles: patient education, staff mentoring/education, real-time quality/patient safety surveillance, physician rounding, admission activities, and discharge activities (see Table 1).
Table 1. -
|General patient education
|Staff education and mentoring
|Real-time quality dashboard
The VIC team consists of the typical care team (including registered nurses, licensed practical nurses, nursing assistants, physicians, and allied health team) and a VN. The professionals deliver care within a team model. The VN is an expert advanced care nurse who provides oversight of patient care for a specific group of patients via virtual presence. The patient load proposed for the VN is 20 patients. The VN provides direct patient care from a command center that is remotely located from the patient care unit. The VN is located off the unit, maintains access to the electronic record, and enters the room virtually through advanced technology. The VN interacts with the patient with a wall-mounted camera, ceiling speakers, large-screen video play, and smaller iPad-like call monitor and screen. Education materials, electronic records, videos, and radiographic images can all be brought into the system for the patient to visualize at her bedside.
The VN model enables reprioritization of the teams' workflow so that the most appropriate member of the team is completing the task, allowing each member to practice at the top of his or her scope, where the team members are fully utilized to provide efficient cost-effective care.7 The VN is an integral member of the team and helps provide a unique delivery method of patient care, a distinction worth noting upon comparison to other “telehealth” programs.
The purpose of this quality project was to examine the effect of the virtually integrated care team and 6 case uses on patient satisfaction, staff satisfaction, physician satisfaction, patient quality metrics, and financial metrics.
Two general medical-surgical units at different community hospitals in a large health system were utilized for the project. Site A was equipped with 20 patient rooms with virtual capabilities, which were contained on a 48-bed unit, with 24 hours per 7 days a week VN coverage. Site B was equipped with 24 patient rooms with virtual capabilities and encompassed the entire unit. Because of staffing shortages in a rural setting, VN coverage was provided 12 h/d Monday to Friday.
This project used baseline and postimplementation data, which were collected prior to implementation of the VIC team for 1 quarter at both site A (n = 415 admissions) and site B (n = 261 admissions). Data were also collected over the duration of a Health Resources & Services Administration grant (2½-year period), including site A (n = 2942) admissions and site B (n = 2199) admissions. Outcomes and data collection tools are identified in Table 2.
Table 2. -
Outcome Measures and Data Collection Tools
||Data Collection Tool
||HCAHPS Top Box Scores
||Performance Cultural Assessment
Teamwork: Missed Care subscale
||Physician Satisfaction Surveys
Physician Interviews and Communications
|Patient quality metrics
||Quality data gathered by the quality departments
Length of Stay
||Reports generated by finance department
||ED throughput times gathered through chart review
Discharge times gathered through chart review
Abbreviations: AHQR, Agency for Healthcare Research and Quality; ED, emergency department; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; NDNQI, National Database of Nursing Quality Indicators.
Baseline data were obtained from routinely administered surveys (see list of surveys in Table 2) and included the most recent results. Staff received orientation prior to implementation of the VIC team. Orientation included a description of virtual team concepts, team processes, expectations, roles/responsibilities of team members, and information about the following virtual equipment: monitors, electronic white boards, and communication equipment. Ongoing continuous rapid cycle change directed the activities, and as workflows changed and issues arose, evaluations were done to enable necessary modifications. A local operations committee was formed at both sites to provide leadership and a repository for valuable feedback and operational insight into the project. These teams had a shared governance model infrastructure and were integral in decision-making processes. Data analysis consisted of descriptive analysis. When appropriate, paired-samples t tests were conducted. Analyses of trends were conducted with Spearman rank-order correlation on quarterly estimates. SAS v 9.4 was used for statistical analysis; P value of less than .05 indicated statistical significance.
Patient satisfaction was measured using the Top Box score from quarterly Hospital Consumer Assessment of Healthcare Providers and Systems report cards. Hospital Consumer Assessment of Healthcare Providers and Systems relating to the roles of communication, education, and discharge education was examined. Site A saw a postimplementation average improvement (10 quarters) of 6.2% in Communication of possible side effect of new medicines, 8.26% in Understood responsibility of managing his/her own health, and 17.4% in Understood purpose of taking medications postdischarge. Site B saw an average postimplementation improvement of 8.5% in Nurses listening carefully to patients, 12.7% for Clear communication by nurses, and 17.4% Communication of possible side effect of new medicines. For further information, an annual survey was conducted by individuals not caring for the patients. Nursing students from a local university (who were not caring for the patients) conducted interviews. Of the patients surveyed (n = 130) about whether they would prefer a room with a VN, 58% would prefer to be in a room with a VN; 17% did not have a preference; and 25% would prefer not to be in a room with virtual capabilities. When the patients were asked what they found beneficial about the VNs, the following themes emerged: fast response, knowledgeable, informative, more thorough, always available, an additional nurse to check on the patient, and speedier discharge. Concerns included the following: can't help with physical cares, privacy, technical difficulties, and didn't understand their role well enough.
Outcomes related to the integration of virtual care included the institutions performance cultural assessment scores that improved an average of 5% on 2 repeated measures for site A, with no improvement noted at site B. Teamwork scores were variable, but when baseline was compared with the final score, site B did show an improvement in teamwork scores. The Agency for Healthcare Research and Quality survey results showed that percent positive scores improved from baseline each year at both sites. Site A improved an average of 5% and site B improved an average of 27% on both annual postimplementations surveys.
There were no statically significant changes in physician satisfaction from baseline through postimplementation at either site. Positive feedback received through e-mails, interviews, and personal conversations were received regarding rounding, rapid response team, and code situations. However, physician concerns included being “slowed down” on physician rounds and the fact that expert, respected nurses were removed from the floor to staff the virtual office.
Patient quality metrics
The National Database of Nursing Quality Indicators quality metrics were monitored throughout the project, meeting, or exceeding benchmarks most quarters. Through the grant period, site A incurred no central line–associated blood stream infections until the last quarter, with an overall incidence of 0.20; no catheter-associated urinary tract infections until last quarter, with an overall rate of 0.24; no hospital-acquired pressure injuries postimplementation; and 3 incidences of deep venous thrombosis. Site B reported 0 incidence of central line–associated blood stream infection; 1 catheter-associated urinary tract infection (overall rate: 0.47); 1 incidence of a hospital-acquired pressure injury in the first quarter of the grant, and 2 incidences of deep venous thrombosis.
For all quarters measured, site A showed a decrease in the time from final dismissal order to actual time of discharge. The average postimplementation was 14 minutes faster than baseline. Site B demonstrated a statistically significant (t8 = −4.21, P = .003) decrease in the time the final dismissal order was written to actual time of discharge, averaging a 20-minute decrease in the dismissal process.
Emergency department throughput
There were variable changes in times related emergency department ED throughput to the floor but no consistent changes over time.
Length of stay/readmission
Length of stay decreased but this was not statistically significant. Readmission rates varied but there was no statistical difference noted from baseline.
Site A and site B both demonstrated statistically significant decrease in labor cost per unit of service. Site A decreased cost from $493 to $348 (mean postimplementation), t9 = −3.35, P = .008, and site B decreased cost from $531 to $363 (mean postimplementation), t8 = −3.410, P = .009.
Other noted outcomes
The VN served as a staff mentor and as education support for “on-the-job” training. The VNs provided an iPad through which direct care nurses contacted the VN for a virtual one-on-one consultation. The VN met with the direct care nurse in a nonthreatening environment to see whether help was needed in prioritizing, reviewed the patient's plan of care with direct care nurses, and served as an expert when reviewing patient needs. Virtual nurses coached staff as needed and provided real-time education with the nurse in the patient room by assisting with a procedure or talking through an assessment with a nurse. The following are examples of mentoring and staff education:
- Staff nurse had not put a nasogastric tube in for a while and was uneasy about the procedure. The VN came on the monitor and explained the procedure and told the patient that she would describe what the nurse would be doing every step of the way. This was to assist the nurse who did not feel confident in the skill, but content was presented as education for the patient.
- New graduate nurse had a question concerning the patients' wound and the VN was able to zoom in via virtual technology and evaluate the wound alongside the new nurse. Together, they discussed the wound and the VN was able to educate the new graduate nurse.
- A new licensed practical nurses had a patient with new stroke symptoms and knew that there were actions that should be taken. She called VN for assistance because she had never called an rapid response team or stroke alert. The VN came on the monitor, was able to call the stroke alert, and guided the direct care nurse through the process.
- Float staff nurse was unfamiliar with a chest tube and how to reconnect to suction due to an increasing pneumothorax. The VN noted her hesitancy, educated her, and walked her through the process via virtual technology.
The VN also tracked “Good Catches” to watch for trends in care. When the VN would find a good catch, (near miss, potential error, care plan deficiency, etc), she or he mentored and educated the staff and followed up as needed. Good Catches impacted cost, process changes, and quality. Table 3 illustrates examples of good catches discovered by the VN. The VNs garnered about 1400 good catches, including both sites, per quarter.
Table 3. -
Examples of Good Catches
|Patient was admitted from emergency department, and VN noticed that Hgb was 7.2 with no further laboratory tests ordered. Notified the physician and every 8 hours Hgb ordered and blood transfused.
|The VN noted that a respiratory viral panel was written in the progress note but no actual order written. The VN contacted the physician and received order and placed the patient in droplet precautions.
|The VN noted a trend of several ED patients who had come in with microscopic UAs ordered in ED. No culture was ordered at that time. The VNs discovered that cultures were being missed and discussed this with the CNS from ED. Together, they identified that the missed labs were due to a physician who ordered the microscopic UA but no culture. The inpatient doctor did not always follow up. This was discussed with the ED physician and hospitalist and the process was changed.
|Mg level was 1.2. Virtual nurse called bedside nurse to make sure that this was communicated to the physician. The staff nurse was a float nurse and unsure of “normal” values for Mg and did not realize the urgency of getting replacement Mg boluses. Staff was educated, and the physician was called.
Abbreviations: CNS, clinical nurse specialist; ED, emergency department; Hgb, hemoglobin; Mg, magnesium; UAs, urine analysis.
Barriers to Virtual Nursing Innovation
Barriers to this project included resistance to change, new role ambiguity, organizational change, technical difficulties, and a shortage of health care workers. Resistance to change, especially the rapid change occurring in health care, is common and can leave individuals fatigued. During this project, there were many organizational changes and changes in leadership, equipment, roles, and infrastructure. Developing the new role of the VN was threatening to some staff who were concerned about their positions changing or that other nurses were watching them. The literature addresses this phenomenon and reports that when a new telehealth role is created, a sense of protectiveness and efforts to maintain boundaries around the professional's previous roles develops between the telehealth and primary care professionals.8 When new roles are implemented, it is important to consider and deal with the interactions and tensions concerning boundaries between telehealth nurses and other health care team members. Bedside nurses' acceptance of new telehealth nurses is a documented barrier and includes perceptions of intrusiveness and invasion of privacy.9 A key strategy to success is addressing the knowledge gap between nursing knowledge and telehealth.10 For this project, new staff, as well as current staff, were reassured, reeducated, and supported through the change. Information was provided frequently to educate staff on changes and new processes. Role modification and teamwork were a focus. A full day teamwork conference was offered 2 of the 3 years of the study.
To address technical difficulties, designated staff members from the technology solution were on call to address any issues with the equipment. Both site A and site B experienced the nursing shortage, and recruitment and retention strategies were employed as well as modification of site B's VN scheduling. Because of the nursing shortage, there were times when the VN was pulled from the command center to relieve direct care nurses.
The VIC team added value to the patients' care in a cost-effective manner. Many lessons were learned from this project. Quality measures were key, and the development of a real-time quality metric monitoring tool was essential to the VNs' workflow. The VNs not only monitored the outcomes measured for the project but also followed and participated in care bundles such as congestive heart failure, pneumonia, and stroke bundles of care. They provided value to the care team with their expertise and mentoring. Although nursing is one of the largest expenditures of our health care system, we have yet to define the importance of nursing's contribution and value-add to the patient's care.11 Virtual nursing as a component of the care team needs to continue on the trajectory of defining its role and contribution, both financially and in quality improvement.
Introducing new roles and responsibilities to workflow can be challenging and resistance did occur. Reeducating staff, instituting daily huddles on each shift to provide a key environment for communication and discussion, and working with identified teams provided a means to meet that resistance and educate staff. Procedures, policies, and a handbook on implementation of a virtual program were developed.
Patients' lack of knowledge related to virtual nursing was also identified as an issue. Information from surveys prompted the project team to develop more information (brochures, informational cards, and signage) to better inform the patient. This finding was supported by current literature. Significant gaps related to communication have been reported and identified that demonstrate a need for patients and their families to be more informed on telenursing concepts.12 Technology integrated with health care is ever changing and we must consider our patients' educational needs as technology advances.
Physicians voiced concerns regarding the staffing pattern and moving experienced expert nurses to the command center versus leaving them on the unit to provide direct care. Physicians were reeducated on how to call the VN when in the patients' room, how to utilize the nurse on rounds, and other services. The VNs discussed with the physicians their ability to provide expert care to a larger base of patients as well as other nurses. Some physicians and licensed practitioners embraced the process while others were more hesitant.
As noted, there are numerous examples of incidences in which the VN was able to assist staff, mentor, and educate. When an error was found, the VN could use it as a teaching moment in real time. The ability to contact a VN from the patients' room for mentoring became a recruitment tool. New graduate nurses and licensed practical nurses verbalized that this was helpful and was one reason they joined the unit. The health system applied for and received US Patent # 10,019,553 B2, issued July 10, 2018. This is a utility patent for systems and methods for virtually integrated care delivery.
The VIC model can be an effective model to deliver high-quality care in a fiscally responsible manner. New and innovative care delivery models must be explored and evaluated. Determining the optimal model to leverage the best experience for the patient, staff, and physician while assuring the highest quality of care is essential. This model of the future must deliver extraordinary care in a financially responsible manner. By leveraging the technology we have available, nursing can improve workflows, walk paths, and interruptions. Electronic health record provide nurses with the information to remotely provide care. Audio and video advances make it possible for nurses to assess, communicate, and care for patients, making the VN a valuable asset to the health care team. Implementation of a new model of care requires excitement, engagement, creativity, and perseverance. Nursing is up to this challenge. Further study and exploration of this role are needed in preacute, acute, and postacute sites as well as for primary, secondary, and tertiary health promotion. The only true limits to the applications of virtual nursing are the limits of our ideas.
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