"Tele-observation": Evaluation of a Virtual Provider Program in an Emergency Department Observation Unit

ABSTRACT

Objectives: The critical shortage of health care providers has been accelerated by the COVID-19 pandemic into a staffing crisis. In this setting, it became infeasible for our large tertiary academic hospital to consistently staff our emergency department observation unit with on-site providers. Telemedicine has been utilized and studied as a solution to this shortage in part because it enhances access to a larger staffing pool and allows for increased flexibility without geographic constraints. While telemedicine is well vetted across the continuum of health care, there is a paucity of data regarding the use of telemedicine in the observation medicine setting. This study aimed to primarily evaluate the safety and quality of care and secondarily the satisfaction of staff and patients when using a virtual provider in an emergency department observation unit. Design/Methods: This prospective observational quality improvement study occurred over a three month period where a virtual provider was piloted in an emergency department observation unit on dedicated night shifts at a tertiary care, academic hospital. Utilizing structured survey instruments and post shift interviews, nursing and provider perceptions of care were assessed across multiple domains of both health care quality, safety, and workflow efficiency. Secondary objectives evaluated include patient and staff satisfaction, overall observation unit census and number of patients upgraded to a higher level of care. Patient satisfaction was assessed through surveys with questions based on Emergency Department Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS) questionnaires. These were compared to the unit's ED- CAHPS results in the three month time frame prior to the pilot. Results/Findings: 89% of nurses rated the virtual provider as equal, or better than an in-person provider when addressing clinical concerns. 96% of nurses similarly reported that the virtual provider was more or equally accessible. Moreover, 89% highlighted that the telemedicine workflow resulted in minimal or no increase to their work burden. Of the 16 virtual providers, 14 reported that they were "extremely" or "very" able to deliver appropriate care and engage with patients;the other 2 providers reported they were "somewhat able." 97% of patients reported satisfaction regarding their telemedicine experience. 3% of patients reported a neutral experience and none endorsed being dissatisfied. For ED-CAHP scores in the following categories "treated with courtesy and respect," "listened carefully," "explained in a way you understand," virtual providers scored "always," the highest mark possible, greater than 93% of the time. Comparatively, in-person providers scored, "always", 63-73% of the time in the above categories during the three month period prior to this pilot. There was only one patient upgraded to a higher level of care, which compared favorably to baseline. Conclusion(s) After implementation of a virtual provider in an emergency department observation unit, clinical staff and patients perceived virtual care to be either similar or improved as compared to an in-person provider. A virtual provider may be an efficient and safe staffing solution in an emergency department observation unit. This may be particularly relevant in the context of an ongoing nationwide staffing crisis. No, authors do not have interests to disclose Copyright © 2022