By Jeanie Davis
Two years ago, Dosher Memorial Hospital was losing one of its three hospitalists. This small-town hospital in Southport, NC, needed to fill the slot quickly, which had never been easy. Yet without that hospitalist, there would be no overnight coverage.
That is when the chief executive officer investigated telemedicine, and found the services to be a “much more economical way to go, more fiscally responsible to quickly fill the gap,” says JD Hammond, RN, clinical informatics nurse.
The 25-bed critical access hospital does not offer an intensive care unit, but the emergency department (ED) always is covered by a physician, he explains. Critically ill patients are stabilized and transferred (often via a 10-minute helicopter ride) to Wilmington, NC. This includes code stroke, code stenting, and code ventilator patients. Those who are not critically ill are admitted to the patient care unit under the supervision of the hospitalist or telehospitalist.
A team of 10 nocturnists — physicians caring for hospital patients from 7 p.m. to 7 a.m. — are available via telemedicine. They can access the electronic medical record and admit/assess patients with the assistance of an on-site staff nurse. A high-tech cart carries all components needed for the teleconsult, including a camera, TV monitor, sound bar, and a wired stethoscope.
During the teleconsult, the remote physician and patient can see and communicate with each other. The physician can ask questions, zoom in and zoom out, and pan the scene, using a high-definition camera. The physician also can read all bedside monitors, including ECG.
Staff nurses have received special training in interacting with a telenocturnist. For example, the nurse will palpate the patient, and the telenocturnist will use the wired stethoscope (held by the nurse) to hear lung sounds.
If a code blue occurs during the night, the telenocturnist is contacted immediately. It has only happened once in the past year, but the system went smoothly, says Hammond. The ED physician first responded to the room, then the respiratory therapist came in to intubate the patient. While that was happening, a staff member texted the telenocturnist that a code blue was occurring. At that point, the team ran the code blue according to the telenocturnist’s orders — pushing medications, monitoring compressions, just as if the physician was in the room. “It was like the physician was standing right there, with the nurses performing the interventions,” says Hammond.
Nurses receive training to operate the telemedicine cart, including troubleshooting connectivity issues. “The technology is pretty simple to operate,” he explains. “Training took less than an hour.”
“It really helps to develop a relationship between nursing and physicians,” Hammond adds. “The physician has to have confidence in nurses, and nurses must have confidence that the physician will be there when they reach out.”
Hammond has observed that staff nurses have gained more confidence in their everyday duties as well. They demonstrate more autonomy by not turning immediately to a doctor for things that already are within their nursing scope.
The financial savings — $200,000 — was evident in the first year due to the telemedicine program, he adds. Patient satisfaction scores also have improved.
“We found that patients were impressed their small community hospital had cutting-edge technology,” says Hammond. “The telenocturnists all have a bedside manner that builds rapport within the first few minutes. It feels just like the physician was right there, listening and focused only on the patient. No one interrupts a teleconference. Not one patient has voiced a negative experience with the telemedicine physician.”
Based on the success of the telenocturnist program, Dosher Memorial now has a contract for telecardiology services. Similarly, the cardiologist can hear a heart murmur or valve regurgitation via a cart stethoscope. “It’s very impressive,” Hammond says. Dosher Memorial also has expanded telephysician coverage to a nearby Dosher clinic, on an island off the North Carolina coast.
In every instance, telenocturnists have been “very quick to respond; typically within seconds we get a reply,” says Hammond. “We were pleasantly surprised.”