Emergency physicians are accustomed to making decisions on whether patients should be admitted or discharged. However, it is not uncommon to encounter patients who are borderline, particularly in the age of COVID-19. Is there another option?

The University of Miami (FL) Health System has devised a third potential pathway. Certain COVID-19 patients who meet appropriate criteria can be discharged home with a device that facilitates remote monitoring by a care team operating out of the health system’s division of internal medicine.

The UHealth Televigilance program has helped the health system manage capacity during a period of high demand for inpatient beds. Patients and providers have taken a liking to the new option, and program developers are already thinking of additional ways to deploy the technology.

Candidates for the Televigilance program tend to be those who are on the fence between going home or moving to a hospital bed, explains Richard Zaidner, MD, associate director of emergency medicine at UHealth Tower, the hospital arm of the University of Miami Health System.

“These are patients who we don’t think are quite sick enough to stay in the hospital, but they are also not well enough to go home on their own without any close follow-up,” he explains.

There are specific criteria emergency providers consider when deciding whether the program is a good option, although nothing is set in stone. For instance, a key indicator is an oxygen level around 94%.

“A normal person has an oxygen level that is around 98%, 99%, or 100%. We see COVID patients who may go down to 96%, but they are not really symptomatic or they don’t really have significant shortness of breath. Those patients don’t really qualify,” Zaidner observes. “But someone who is at 94% — that is on the border ... where you are teetering on some significant hypoxia.”

Providers also look at whether patients have comorbidities that might put them at higher risk. For example, patients with diabetes, high blood pressure, or pulmonary disease might benefit from closer monitoring. The caveat is the patient must not be so sick that he or she requires hospital admission. “The goal is not admitting a patient who would do well at home with just closer monitoring,” Zaidner adds.

If patients appear to meet the criteria for the Televigilance program, they still must be able and willing. This includes determining if they are equipped with the right videoconferencing technology at home and can use it.

Stress Education

When an emergency physician decides a patient is appropriate for the Televigilance program, he or she will place an order in the EMR, notifying the nursing team. A nurse will retrieve a monitoring device and give it to the patient before discharge.

“A staff member will then walk the patient through how to use the device, make sure the blood pressure cuff fits, and answer any questions about the device before the patient goes home,” Zaidner shares.

Once home, these patients receive a call from a patient educator, who will ensure the patient understands how to use the device.

“The device monitors temperature, blood pressure, heart rate, and oxygen saturation, and sends these data to the patient’s electronic medical record,” explains Sabrina Taldone, MD, MBA, medical director of the Televigilance program. “The [internal medicine] physician reviews these data, and if there are concerning vital signs, the provider follows up with a telemedicine visit.”

Even with all these precautions, fear remains, which may manifest as a false emergency. One COVID-19 patient with pneumonia went home with the device, and then submitted vital signs showing tachycardia. “In the follow-up telemedicine visit, I identified that she was having anxiety attacks associated with palpitations,” Taldone explains.

Through education, the patient learned how to control her anxiety, which resolved the tachycardia and prevented the need for a return trip to the ED. “Both she and her daughter felt empowered and relieved to learn how objective measures like oxygen saturation and other vital signs, along with self-awareness of her symptoms, could be used to inform whether or not [the patient] would be safe at home or need to go back to the hospital,” Taldone says.

At press time, only about 50 patients had been involved with the Televigilance program, and there are no outcomes data yet. However, Taldone says program developers will be analyzing ED visits, readmissions, and other outcomes associated with device usage. Further, she notes the Televigilance program may expand to include other patient populations, including cancer and postoperative patients.

Consider Challenges

Anecdotally, emergency patients seem pleased with the remote monitoring option. “There have been patients who love it. Often times, they feel a bit nervous about going home with their symptoms, knowing that COVID has been causing so much damage to some patient populations,” Zaidner observes. This has been particularly the case among patients with comorbidities who realize they are at higher risk of suffering from virus complications.

Zaidner says some internal medicine provider monitors have reported on patients who have handled the system well. Other patients have been asked to return for further in-person evaluation. In either case, the monitoring has enabled clinicians to keep close tabs on patients who are in the program so that any change in status is picked up quickly.

Overall, emergency physicians seem pleased to have this option available to them. “We all want to send patients home who we don’t think require admission 100%,” Zaidner admits. “The patients love it, so it has also increased patient satisfaction.”

Still, there have been some challenges. For example, certain patients do not meet the technical requirements to participate, or they simply are not tech savvy enough to use the device. Zaidner says a patient went home with the device, expecting family members to help navigate the technology. But once they learned the patient was infected, they were nervous about risking exposure.

“The patient has to be somewhat tech savvy, although it is really not that complicated,” Zaidner says. “If you can use a smartphone, you are able to do it. But if you don’t have a smartphone, that makes it difficult.”

Prepare for Surges

The theoretical goal of the Televigilance program was to create capacity at a time of high demand, but there has not yet been a huge impact in that regard. Nevertheless, that does not mean it has not been meaningful. Even select inpatients are receiving the device, enabling them to be discharged earlier, too.

“We are using this on the order of one to two times per day, but it all counts. COVID patients, once they are hospitalized, they tend to stay for a long period of time. There is an accrual effect,” Zaidner observes.

The Televigilance program has been in operation only a few weeks; thus, administrators may not have been able to recommend it for as many COVID-19 patients if the program was available earlier in the year.

“If there is another peak [in volume] during flu season or later on in the year, we will be more ready for it,” Zaidner says. “There is nothing worse than being over capacity for a hospital. That is when patients do poorly. That is when, unfortunately, sick people die. I really think surge capacity, and having this as a kind of buffer, is great. It just adds extra capacity for beds.”