The Virtual Hospitalist: A Single-Site Implementation Bringing Hospitalist Coverage to Critical Access Hospitals
BACKGROUND: On-site hospitalist care can improve patient care, but it is economically infeasible for small critical access hospitals (CAHs). A telemedicine “virtual hospitalist” may expand CAH capabilities at a fractional cost of an on-site provider.
OBJECTIVE: To evaluate the impact of a virtual hospitalist on transfers from a CAH to outside hospitals.
DESIGN, SETTING, AND PARTICIPANTS: A 6-month pilot program providing “virtual hospitalist” coverage to patients at a CAH in rural Iowa.
MEASUREMENTS: The primary outcome was the rate of outside transfers from the CAH Emergency Department (ED). The secondary outcomes included transfer from either the ED or the inpatient wards, daily census, length of stay, transfers after admission, virtual hospitalist time commitment, and patient and staff satisfaction. The preceding 24-week baseline was compared with 24 weeks after implementation, excluding a 2-week transition period.
RESULTS: At baseline, there were 947 ED visits and 176 combined inpatient and observation encounters, compared to 930 and 176 after implementation, respectively. Outside transfers from the ED decreased from 16.6% to 10.5% (157/947 to 98/930, P < .001), and transfers at any time decreased from 17.3% to 11.9% (164/947 to 111/930, P < .001). Daily census, length of stay, and transfers after admission were unchanged. Time commitment for a virtual hospitalist was 35 minutes per patient per day. The intervention was well received by the CAH staff and patients.
CONCLUSIONS: The virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally. A single virtual hospitalist may be able to cover multiple CAHs simultaneously.
© 2018 Society of Hospital Medicine
DISCUSSION
The virtual hospitalist service allowed a higher percentage of acute inpatients to receive care in their local hospital and was positively perceived by providers and patients. The per-patient time commitment by virtual hospitalists was similar to traditional hospitalist coverage14 and could scale to multiple simultaneous institutions.
Despite the increase in the proportion of patients admitted locally, neither the mean inpatient census nor the complexity of patients (as measured by CMI) increased. The increase in patients admitted locally was offset by a parallel increase in the number of ED patients discharged home. Although virtual hospitalists were available to consult on ED patients, this consultation was not mandatory unless the CAH provider felt that admission was indicated. It remains unclear whether the changes in ED disposition were due to direct intervention by virtual hospitalists, increasing local expertise with inpatient medicine, or unrelated local factors.
Although outside transfers directly from the ED dropped, there was a potential increase in acute inpatients transferred after admission that failed to reach statistical significance. We anticipated increased transfers after admission as a potential consequence of accepting more complex patients for CAH admission. Reasons for transfer included emergent transfers for medically unstable patients and scheduled transfer for subspecialist evaluation or testing. Despite the possible increase in delayed transfers, there was no significant change in CAH inpatient mortality, and the total fraction of combined ED and inpatients transferred decreased after the intervention.
Despite the benefits of keeping patients within their communities, 20%-60% of rural patients bypass their local facilities when seeking emergent care.15 Despite publicity on local media,16 we did not observe an increase in daily ED visits after implementation. Although some investigators have found that increasing the services offered decreases in rural bypass,17 others have found no or mixed effects.18,19 Further investigations into the local factors contributing to rural bypass may yield important insights, and future implementations should not rely on rapid increases in patient volume to establish economic viability.
Although telemedicine has been applied to a variety of previous settings, to our knowledge, this marks the first collaboration between an academic medical center and a CAH to provide continuous hospitalist coverage. A previous model for pediatric inpatients showed a similar decrease in patients transferred to tertiary centers.20 Virtual hospitalists differ from other adult telemedicine projects, which focused on subspecialty care or overnight coverage.21 The advantages of our model include the ability to proactively address deficits, even when local providers are unaware of changes to the standards of care. We believe that mandatory scheduled interactions decreased the barriers to communication and increased provider reassurance in telemedicine management of their patients. The scheduled interactions also provided additional training and development for CAH personnel, were well received by local staff, and may contribute to local provider job satisfaction, retention, and recruitment.
Past efforts to integrate academic hospitalists into CAHs improved quality metrics and provider satisfaction but were economically infeasible due to low patient volumes.22 In contrast, virtual providers can distribute their efforts across multiple areas, including covering additional CAHs, providing local patient care at their home facility, or completing academic projects. By combining two or more CAHs into a single provider, sufficient patient volume can be generated to dedicated personnel.
There were several limitations to this initial investigation:
