ED uses telemedicine to ease crowding, wait times

Patients, providers give remote visits high marks

Telemedicine has been used to connect patients in rural areas with providers, and to obtain quick access to a neurologist when patients present with symptoms of stroke. However, a group of emergency providers at the University of California San Diego Health System (UCSD) are testing whether telemedicine may also provide a cost-effective solution to crowding in the ED.

"What we realized is that in the current environment, we are seeing a trend of increased visits to the ED. This is not just true in academic medical centers. Community hospitals all across the country are operating at capacity, and dealing with overcrowding" explains Vaishal Tolia, MD, MPH, FACEP, an emergency medicine physician at UCSD, and a co-investigator on the project.

With more demand than capacity, hospitals have come up with a number of different strategies to alleviate long wait times, but Tolia observes that many of these are far from ideal. "One solution is just putting a physician in triage so if someone comes in, they get seen by a physician quickly," he says. "This helps to reduce the number of patients who leave without being seen [LWBS], but the problem with just having a fixed time for the physician to be there to deal with a potential surge is that emergency medicine is very unpredictable. You never know when you are going to have that surge, so it is a potentially costly resource."

By applying telemedicine to the problem, Tolia and colleagues theorize that EDs can easily activate an on-call physician precisely when they need the extra help, and they can just as quickly deactivate the physician when he or she is no longer needed. There are technical and administrative hurdles, but armed with a $50,000 University of California Health Quality Improvement grant, the UCSD team is in the process of implementing the approach, and investigators say that early results are promising.

Patients feel more involved

As part of the study, dubbed Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency (EDTITRATE), telemedicine is first being deployed at UCSD's Hillcrest Medical Center, a level I trauma facility that sees about 60,000 patients a year in the ED. "The logistics of it right now are that we have one full telemedicine module in a patient care room…and we have a cadre of physicians within our group that have gone through the training, and have agreed to participate in this study," explains Tolia. "Since this is still a pilot project, we are making the telemedicine available Monday through Friday, from about noon until 8pm."

The on-site telemedicine module is equipped with a video screen, a camera that can be controlled by the remote physician, and tools that enable the physician to evaluate a patient much as he or she would during an in-person encounter. A dedicated, on-site nurse handles the peripherals and facilitates the telemedicine encounter. "The nurse's hands are what we are using remotely to assist us in examining patients," says Tolia. "We ask them to press in different parts of the abdomen, and we have shown them where to put the stethoscope so we can listen to heart and lung sounds."

The remote physician requires a laptop or desktop computer that is equipped with a camera as well as the software that enables a secure connection with the telemedicine module. Most physicians already have the basic hardware required to manage a telemedicine encounter, says Tolia. Further, while the equipment has not been used in this manner before, it has been used in other medical settings, he says.

The technology has not presented any problems, says Tolia. To the contrary, patients who have been treated via the telemedicine unit thus far have provided positive feedback on the approach. "They really feel more involved in the care process themselves because when we are evaluating them and looking at their throat because they have pharyngitis or strep throat, for example, they can actually see what we are looking at," explains Tolia. "That is usually not the case in a typical provider-patient encounter, whether it is in a clinic or the ED."

At the conclusion of each telemedicine encounter, an on-site physician will reassess the patient to confirm the findings of the remote provider.

Managing workflow is challenging

While there have been no issues with the technology, there have been administrative hurdles to work through. For instance, as the telemedicine unit requires a dedicated nurse and physician, the UCSD team has had to figure out how to manage these requirements with existing staff. Currently, the ED has assigned the nurse charged with making follow-up phone calls to patients to also manage the telemedicine visits, and the physician on-call is handling the remote encounters, explains Benjamin Guss, RN, the nurse champion on the telemedicine project.

Since the telemedicine unit is only set up in one room, another challenge is trying to keep up with the need to constantly clean the room for the next telemedicine patient. "This takes up a lot of the nurse's time, and you end up not seeing as many patients," says Guss. "One [potential solution] is to use a room that is big enough to accommodate four patients, so the module can be moved from patient to patient."

In that case, there would be curtains between each patient to provide some privacy. "That is something we might do in the future," says Guss. "Right now, since this is a research project, we have to consent each patient, so that takes us extra time as well."

Managing the workflow is still a struggle, acknowledges Guss, but he observes that the team is working out the kinks. "We are improving the process each and every time we do a telemedicine encounter," he says.

Approach offers intriguing advantages

Since the ED first began the telemedicine visits in November of 2012, most of the patients examined in this manner have been on the lower acuity side. "We are not remotely evaluating the most critically ill patients," says Tolia. "That is not the purpose of this. The purpose is to initiate care on patients who would otherwise be sitting in the waiting room."

However, Tolia notes that some patients evaluated via the remote visits have required hospital admission. "There is no particular criteria for telemedicine other than that the person would otherwise be deemed safe after being triaged to be waiting in the waiting room when the ED was full," he says. "Then that person, in general, would qualify for a telemedicine consultation."

For this early phase of the study, investigators are primarily gathering data and analyzing parameters regarding safety, outcomes, and satisfaction. Early trends are positive, according to Tolia. "We survey each patient, nurse, on-site physician, and remote physician for each of our cases just to judge how they felt the encounter was," he says. "Patients have rated us extremely high, close to 5 [the highest possible ranking] almost unanimously. And we have had almost no pushback from the physicians."

Tolia acknowledges that there has been some constructive criticism, but he says both the nurses on site and the remote physicians have all provided ratings that are well above 4.5. "In terms of provider and patient satisfaction, we are very pleased," he says.

Later this year, investigators plan to move to the next phase of the study, where they will hone in on whether using this approach makes a difference in alleviating crowding when the ED is busy. If the telemedicine visits work as intended in a cost-effective way, they could then be implemented at another UCSD ED in La Jolla, CA as well as other hospitals in the UC system.

"One way this could be deployed is that a single physician could potentially remotely see patients at different sites simultaneously," offers Tolia. "It is not something we have tried yet, but it is definitely something that is done in non-emergency applications of telemedicine."

SOURCES

• Benjamin Guss, RN, Nurse Champion, Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency, University of California San Diego Health System, San Diego, CA. E-mail: bguss@ucsd.edu.

• Vaishal Tolia, MD, MPH, FACEP, Co-investigator, Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency, University of California San Diego Health System, San Diego, CA. E-mail: vtolia@ucsd.edu.