Leverage Telemedicine to Speed Care for Lower-Acuity Patients
By Dorothy Brooks
A common issue for many EDs is patients with lower-acuity concerns often experience excessive lengths of stay (LOS) while higher-acuity patients receive care first. Not only can this result in a less-than-satisfying experience for patients, but it can lead to crowding and staff frustration.
While many high-volume EDs have effectively addressed this problem by triaging their lower-acuity patients to a dedicated fast track, this only works well when there are enough lower-acuity patients to support the staffing needed to operate a fast track. This was an issue that confronted the ED at Stanford Hospital in Palo Alto, CA, in the months before COVID-19 arrived. By leveraging telemedicine technology, the ED established a Virtual Visit Track (VVT), a solution that accelerated care for lower-acuity patients and helped ED staff effectively manage at least some of its pandemic-related challenges. Furthermore, it’s an approach that might even be more applicable for health systems that operate multiple EDs.
Ryan Ribeira, MD, MPH, assistant medical director of the Stanford ED, notes there were few low-acuity patients visiting the adult ED, pediatric ED, and the walk-in clinic. “We were trying to figure out a workflow that would allow us to have one clinician who would be able to see [patients] at all three sites [virtually] because we couldn’t really justify having three physicians — one at each individual site,” Ribeira explains.
What the developers of the VVT approach did not anticipate was that a pandemic would necessarily alter their original concept. However, the fact that all the groundwork for the VVT was in place turned out to be fortuitous. “[The VVT] turned out to be phenomenally useful, in particular because of the large number of patients who presented to the ED because they wanted to get a COVID test,” Ribeira shares.
Using the VVT, patients seeking a COVID test could be moved in and out of the ED quickly. However, Ribeira notes the walk-in clinic was shut down in the early days of the pandemic, nixing that part of the original plan, at least temporarily. Ribeira says he hopes to reopen the walk-in clinic within the next few months and to add the telemedicine capability there as planned.
Meanwhile, appropriate patients continue to be seen in the VVT. Data show their care is accelerating. Investigators comparing patients seen through the VVT with a matched cohort of patients seen in the traditional manner found VVT patients spent less than half as much time in the ED as patients cared for in the traditional manner.
Specifically, the average LOS for VVT patients was 1.9 hours vs. 4.2 hours for the matched cohort. Further, investigators reported the return visit rate for VVT patients was slightly lower than it was for patients in the matched cohort, both at 72 hours and at seven days after the original encounter. However, the differences observed were not statistically significant.
The researchers noted this finding suggests the care delivered through the VVT is not inferior to the care provided in a traditional manner.1
Ribeira says most patients classified during triage as Emergency Severity Index (ESI) 4 and 5, the lowest severity, meet the criteria, as well as many ESI 3 patients. “Actually, 40% of the patients we see through the program are ESI 3 patients,” he observes, noting any ESI 3 patient who the telemedicine physician believes is an appropriate candidate can be seen via the VVT.
For example, Ribeira says that a young patient with chest pain could be seen through the VVT. “The patients are located physically in the ED, so they can still get lab tests, they can get chest X-rays, and they can get ECGs,” Ribeira says. “[The VVT] is relatively capable in terms of the breadth of patients that we can see.”
If a patient is triaged to the VVT, but then the telemedicine physician determines the patient should undergo an in-person evaluation, that switch can be made easily. “This [capability] has allowed us to pull patients relatively aggressively into the [VVT] program,” Ribeira reports. “If it turns out that we need to advance a patient into the main ED, that is not really a problem.”
When the VVT program was rolled out, it was offered as an option to patients who met the criteria to be evaluated virtually. However, Ribeira notes VVT is now more of a routine part of ED operations, although patients still can decline the VVT in favor of in-person exam. Nonetheless, most patients readily agree to be seen virtually because it puts them in front of a physician faster.
Nicholas Ashenburg, MD, an emergency physician at Stanford Health, says the remote physician assigned to care for VVT patients is located in an office at a Stanford location in Menlo Park. “We are in communication with our nurses and techs in the ED,” he says, referring to how the process works when he is serving as a VVT physician. “They let me know when [a VVT patient] in is in a room, and then I will log in and see the patient.”
For example, Ashenburg says a typical patient cared for via the VVT might be a young woman with right ankle pain. Ashenburg will ask the patient about her chief complaint and review symptoms. For the physical exam, Ashenburg will instruct the tech or nurse who is with the patient in the ED where to focus the camera. He may ask the clinician to push down in certain areas near the injury. Next, Ashenburg might order an X-ray. The patient would return to the lobby until images return.
Once the X-ray results have been completed, Ashenburg will communicate with the nurses and techs who are staffing the VVT, and the patient will be brought back to the dedicated VVT room to reconnect.
“Sometimes, I ask the tech or the nurse to pull up the X-ray so the patient can see,” Ashenburg says. “Then, we make a plan.”
For instance, if it is a sprain, the patient will be provided with crutches and an air cap for the ankle. There will be a discussion about taking pain relievers and using ice and elevation. Then, the patient will be discharged. “The patient is generally pleased; that has been my experience for most,” Ashenburg says. “Recently, we have had a lobby full of patients who were ESI 3 or higher, and we were able to get a lot of patients in and out that would otherwise be waiting for five or six hours to be seen.”
Ashenburg adds the VVT also has been used effectively for some scheduled follow-up visits for patients who have been seen in the ED but may not be able to see their primary care physicians timely.
“Anecdotally ... it has been very positive for the patients,” Ashenburg says. “It saves these people another trip to the hospital, but still makes sure they are getting better.”
Ribeira notes it took considerable planning to roll out the VVT program. For example, he and colleagues prepared training videos for physicians on how to be an effective telemedicine clinician. Similarly, nurses and techs viewed training videos instructing them how to properly use the equipment to examine patients and communicate effectively with the offsite physician. In addition, there were in-person training sessions.
To mitigate any potential challenges in the early stages of the program, Ribeira limited the number of clinicians staffing the VVT to a core group of trained physicians, nurses, and techs. Slowly, the program expanded to include additional staff.
While some physicians like the program better than others, Ribeira is surprised at how well received the program has been.
“I thought that [working the VVT] was going to be a very hated shift in our department just because it is so different from normal emergency medicine,” he says. “I was worried that many people would feel that this was not what they signed up for, but actually that hasn’t turned out to be the case.”
In fact, several physicians ask for as many VVT shifts as they can because they really like the experience. Further, as part of their research on the VVT model, physicians were asked to rate their ability to deliver care that is comparable to an in-person encounter. Seventeen out of 50 VVT physicians said their ability to provide comparable care through the virtual approach was excellent. The remaining 33 physicians reported their ability to provide care in this manner was very good.
Another step that was critical to the success of the VVT was making sure the offsite physician can see patients from multiple sites all through the same workflow.
“That was something that we worked very closely with our [EHR] team to build, and it took a long time,” Ribeira says. “A lot of the value from this model comes from the fact that you can manage multiple sites at once, and you can really only do that effectively if your work streams are combined.”
The VVT approach carries appeal beyond Stanford. Since publishing data about their experience, Ribeira, Ashenburg, and colleagues have received calls from several health systems to discuss the model.
“Some of the health systems have four, five, or six hospitals, in which case a program like this would be very beneficial,” Ribeira says.
Ribeira notes he and colleagues have explored potentially enabling physicians to see patients virtually from their homes rather than the offsite office in Menlo Park. Thus far, the technical issues involved have been more than the ED is ready to tackle.
While the approach has worked well for Stanford Medicine, Ribeira cautions it is not necessarily a good fit for everyone.
“One of the features of our ED that made this valuable is the fact that we do not have an overwhelming number of lower-acuity patients. We usually have a lot of higher-acuity patients. For us, a traditional fast track does not make sense,” he says. “If you have enough lower-acuity patients in your high-volume ED, then the model might not make sense if you can manage this lower-acuity volume through a dedicated fast track.”
However, for those EDs that could benefit from implementing a VVT, it is quite manageable. “It was a fair amount of work for the training [aspect], but it wasn’t an impossible amount of work,” Ribeira says. “We were able to take people who were otherwise trained only in traditional adult emergency medicine and make them pretty effective telemedicine physicians.”
1. Ashenburg N, Ribeira R, Lindquist B, et al. Converting an ED fast track to an ED virtual visit track. NEJM Catalyst Innovations in Care Delivery. Oct. 19, 2022.
By leveraging telemedicine technology, the ED at Stanford Hospital established a Virtual Visit Track, a solution that accelerated care for lower-acuity patients and helped staff effectively manage at least some of its pandemic-related challenges. Furthermore, it is an approach that might even be more applicable for health systems that operate multiple EDs.
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