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Reengineering the Discharge Transition Process of COVID-19 Patients Using Telemedicine, Remote Patient Monitoring, and Around-the-Clock Remote Patient Monitoring from the Emergency Department and Inpatient Units

Editor


Objective

To describe the evolution of processes that enabled early safe Emergency Department and hospital discharges and follow-up of low- and moderate-risk COVID-19 patients, using limited clinical staff, to expand hospital capacity to accommodate the massive influx of high-risk and critically ill patients.

Background

As of July 21, 2020, over 14.7 million COVID-19 cases worldwide were confirmed with over 3.8 million of them in the United States.1 The first case of community spread of the COVID-19 was identified in New York City on March 1, 2020. New York City became the epicenter within the United States with 221,703 confirmed cases and 23,411 deaths.2 This stretched the bed capacity of all New York City Hospitals to the limit in a very short time. Innovative contingency plans such as deploying the USNS Comfort to New York Harbor, and turning the Jacob K. Javitz Convention Center into a field hospital were employed to meet the demand.

Brooklyn is the most-populous borough in New York City with an estimated 2,648,403 residents in 2020. It was particularly overwhelmed with 61,488 confirmed cases and 7,206 deaths.2 NewYork-Presbyterian Brooklyn Methodist Hospital (NYPBMH) is a large, 651-bed, major teaching hospital affiliated with the Weill Cornell Medical College, and is a member of the NewYork-Presbyterian Healthcare System. At NYPBMH, we were equally inundated with the surge. Our intensive care unit, which is usually 40 beds, expanded to 200 beds having to convert areas such as ambulatory surgery, pediatric ward, endoscopy suite, and psychiatry unit to accommodate the surge. There have been ∼1,850 COVID-19 admissions with the average daily census between April 1 and May 10, 2020; out of 200–385 COVID-19-positive inpatients, 80–108 patients required mechanical ventilation.

Respiratory complications and rapid deterioration of COVID-19 patients were common, devastating, and unpredictable. There were no reliable indicators to foresee who would progress into the cytokine storm phase. This uncertainty created angst and worry among caregivers. Reports of death after discharge home became more frequent, which created a significant problem: how does the hospital deal with a massive influx of patients with no clear discharge criteria? How can we safely and timely discharge patients to meet the increasing demand for sick COVID-19 patients requiring admission?

The solution required a reengineering of the discharge process with quick implementation (over a period of 1 month) for stable patients identified for discharge. Patients were given pulse oximeters with follow-up telehealth visits done by faculty at NYPBMH from Medicine, Critical Care, and Emergency Medicine with a template and designed algorithms for escalation based on vital sign triggers. Virtual encounters limit exposure to other patients and staff members, which could further increase the number of COVID-19 cases due to contact, droplet, and fomite transmission.3,4 This model, however, was not sustainable as it was extremely time-consuming and required a lot of staffing. Physicians had to call the patient to get the readings rather than a system where the vitals were automatically uploaded to a server. Inundation of patient care with limited manpower and resources forced us to align with a third-party vendor, around-the-clock (ATC) alert, to make remote patient monitoring (RPM) possible (Fig. 1).

Fig. 1.

Fig. 1. Summary of the program’s methodology.

RPM, a biometric monitoring with nursing intervention and escalation based on physician-determined protocol and algorithm, is an extension of the physician’s office, giving providers the ability to manage more patients safely at home than by physician. RPM is continuously monitored by a professional and therefore follows a patient between telehealth visits. Deterioration of vital signs would result in immediate action.

A pulse oximeter, which records their oxygen saturation and heart rate, was delivered to the patient identified for discharge before the discharge process. Case managers facilitated the setup between the vendor and the patient. The vendor would contact the patient while still in the hospital to explain the technical aspects and to help download the smart phone application. A follow-up call between 6 and 8 h after the patient physically left the hospital would test the equipment and acclimatize the patient to the program. A nurse was assigned to monitor each patient with a ratio of 1 nurse to 50 patients. NYPBMH worked with the vendor to modify the software to monitor vital signs twice a day, both at rest and then 20 s after 60 s of exercise. Triggers for escalation were based on the results of the biometrics and a delta between the resting and postexercise readings. Each patient received two phone calls a day (about 10 AM and 7 PM) by the ATC nurse who could review the data via a dashboard. Based on the data, the nurse may choose to monitor the patient with more frequent vitals, transfer the call to a physician, or refer them directly to the nearest ED. These decisions were based on a protocol developed by pulmonary and critical care experts.

The inclusion criteria included adult patients older than the age of 18, oxygen saturation of <92% during the hospital stay, discharged home, and patient reliability such that the patient or a family member would be able to use a pulse oximeter. Patients who were discharged to a skilled nursing facility and those who refused were excluded.

Based on the vitals obtained by the pulse oximeter, there were escalation criteria (Table 1). Every escalation resulted in the nurse contacting the patient. The options for escalation were to repeat the biometrics after a short period, speak directly to a physician, or go back to the hospital. The criteria were decided by our team of physicians doing telehealth visits as there were no prior guidelines established for COVID-19.

Table 1. Escalation Trigger Criteria
Pulse oximeter SaO2 < 90%, or
decrease of >5% exertion +20-s rest
HR HR >115 at rest, or
HR >125 exertion +20-s rest, or
increase of HR >10 between rest and exertion +20-s rest
RR RR >22, or
RR >30 exertion +20 s, or
increase in RR >8 between rest and exertion +20-s rest

The patients would graduate from the program at the end of 14 days. Patients getting readmitted and discharged were assessed on a case-by-case basis for re-enrollment in the program. Successful graduation was defined as oxygen saturation above 96% for three consecutive days. If this were not the case, the patient would remain in the program. At the end of the 14 days, each patient received a satisfaction survey by the NewYork-Presbyterian Digital Health team.

Results

Fifty patients were enrolled in the program (Table 2). A total of 13 patients were escalated 29 times (Fig. 2). Of the escalations, only 3 patients (10.3% of escalations; 6% of enrolled patients) got referred to the ED, of which only 1 (3.4% of escalations; 2% of enrolled patients) resulted in readmission. The patient who was readmitted was found to have an acute pulmonary embolism.

Fig. 2.

Fig. 2. Representation of the escalations based on abnormal vitals.

Table 2. Summary of Escalations, Emergency Department Referrals, and Readmissions
CAMPUS PROGRAM START DATE PATIENTS ENROLLED ESCALATIONS ED REFERRALS READMISSIONS
NYPBMH May 1, 2020 50 29 3 (10.3%) 1

There was a high compliance with numerous daily vital submissions. Most of the escalations were from 9 PM to 4 AM. There were 60 h of direct phone conversations between the patients and ATC nurses.

At the end of the 14 days, there was a patient satisfaction survey sent to each person. Of 23 patient satisfaction surveys, 74% strongly agreed with the RPM with ATC nursing (Fig. 3). In addition, 91% of the surveys were likely (score of 8 or more out of 10) to recommend the program to a friend or colleague (Fig. 4).

Fig. 3.

Fig. 3. Patient satisfaction survey results.

Fig. 4.

Fig. 4. On a scale of 0–10, patients were asked to report how likely they were to recommend the program to a friend or colleague.

Discussion

The COVID-19 pandemic has been one of the most significant medical challenges of modern medicine. To accommodate for social distancing to prevent spread of disease, the use of remote monitoring and telehealth became more prominent. RPM has created a way to discharge patients safely with high satisfaction and confidence, as was demonstrated by the outcomes of our study. By incorporating RPM, there is potential to decrease the length of stay while providing patients and their families with a seamless transition home while maintaining connectivity to ensure safety. Our results indicate that having secure access with regular monitoring results in high patient satisfaction and confidence. In addition, this program can limit unnecessary visits to the emergency department and reduces the risk of exposure for others involved in patient care (e.g., nurses, nurse technicians, janitorial services, and physical therapists).

Our reengineering process was not without hurdles. First, it took several iterations before finalizing the program, and the initial rollout was not until May. The design and implementation took only 1 month, which was remarkable during the height of the pandemic. Next, there were no previous experiences to decide on escalation criteria. The criteria were chosen via consensus from our group of critical care, emergency medicine, and general internal medicine physicians. Another significant hurdle was in clarifying and coordinating the fine details of roles and responsibilities within the process. For example, where would the pulse oximeters be stored as they were not usual hospital stock? How would they be tracked and delivered to the patient? Finally, there were technical difficulties with creating the pulse oximeter orders within our electronic medical record system.

The use of RPM and telehealth is not new. It has proven to work in other conditions, such as monitoring oxygen saturation in chronic obstructive pulmonary disease and glucose monitoring in diabetes. It has also been used in patients with congestive heart failure.5–8 There is no doubt that COVID-19 has changed the landscape of medicine. As more COVID-19 spikes happen throughout the country and with the threat of the second wave, we will be more capable of handling this overwhelm with safety and cost-effectiveness.

There have been other programs incorporating RPM for patients with COVID-19. One program at the University of Minnesota was also able to demonstrate the cost-effectiveness of an RPM program for screening purposes.9 They also used referral incorporated into the EMR for enrollment into the program. Our program used registered nurses (RNs) and later expanded to the use of nurse practitioner (NP) students with a supervising NP. Through ATC, there was always 24/7 availability of an RN through a hotline. Their program added oxygen saturation monitoring with pulse oximeters toward the end of their application. They also used patient surveys using a Likert scale showing similar results.

Northwestern Medicine, an integrated academic health system with 10 hospitals and over 200 sites throughout Chicagoland developed a robust and comprehensive outpatient telehealth monitoring program manned by 193 nurses, 70 advanced practice professionals, 152 medical students, and 115 attending physicians. They did not, however, use RPM.10 One of the major differentiators between their program and ours was that we had limited nonclinical resources such as research nurses or outpatient care coordinators to deploy to the program.

Our program used telemedicine for regular patient follow-up, along with RPM as a safety net allowing for peace of mind for patients and their providers. A physician regularly evaluated the patients. They were also contacted by an RN as often as daily, and the patients had access to a 24/7 hotline for any emergencies. On top of the scheduled encounters, any irregularities seen on the data presented on the RPM dashboard prompted action, which allowed for early interventions for patients who may have been clinically deteriorating.

Conclusion

Our experience shows that in a short period, telehealth and RPM’s concurrent use with a third-party vendor could be successfully utilized for safe discharges with high satisfaction. Our reengineering innovation was to integrate with a third party as an extension of our offices by using their staff to do the monitoring of the provided RPM devices and to provide interventions as needed. We understand that a limitation is the sample size; however, it provides evidence for further implementation. With the exponential rise of cases in the United States and outside of New York City, hospitals experiencing similar types of crises when faced with a limitation of internal staff should consider this model.

Acknowledgments

Special thanks to the NYP Innovation team for their approval, and the NYP Digital Health team for survey administration.

Authors’ Contribution

All authors took part in the planning, writing, and finalizing the article for submission.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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