Virtual Healthcare at the Bedside: UAB’s Journey From Emergency Response to Everyday Innovation

The COVID-19 pandemic challenged everything we knew about healthcare. Our hospitals were overwhelmed with patients who had COVID. Everything from triage to treatment was affected. It did not matter if the hospital was rural, a community hospital, a level 1 trauma center, a tertiary facility or an academic medical institution. If there was an empty bed, it was needed. And, we had to find a way to care for all these patients no matter where they were located.

Why Virtual Healthcare Expanded During COVID

Although tele-ICUs and other virtual healthcare models have existed since the late 1990s, they emerged as beacons of light during the pandemic.

We changed our care models and introduced virtual care to overcome pandemic challenges. We encouraged people to schedule virtual healthcare visits using their phones or computers. We asked them to do this whenever possible instead of going to doctors' offices, clinics or emergency departments (EDs). We utilized mobile carts to bring physicians and advanced practice providers into community hospitals when they couldn't be present in person. We used tablets to connect patients to their families. We used remote monitoring tools to help guide patients in their care after their inpatient stays. By using technology, we found ways to deliver the care that was needed despite the unprecedented challenges we faced.

What were the results?

As the COVID waters began to recede, we were finally able to look at the impact of virtual healthcare in Alabama. We saw that in one rural community, a small hospital with a six-bed ICU became a lifeline for the nearby areas. It was the only hospital with critical care access for over 50 miles. With help from the UAB Tele-Critical Care Team, this rural community hospital kept higher-acuity patients, including those with COVID, at their hospital. This team reduced the strain on tertiary hospitals around the state and later led to the expansion of their ICU to eight beds.

Prior to the pandemic, The University of Alabama at Birmingham (UAB) developed several telehealth programs that quickly expanded during COVID. These include Tele-Nephrology, Tele-Neurology, Tele-Stroke, Tele-Critical Care, Tele-Psych and Tele-Trauma. They cover over 40 hospitals throughout Alabama. These specialty services are allowing patients to receive high-level specialty care in their home institutions and local communities.

During this time, UAB created the state's first tele-ICU. It is a 24/7 continuous monitoring program. Experienced critical care nurses from all ICU backgrounds support bedside teams virtually. They add virtual rounding, offload tasks, act as a second set of eyes, improve quality metrics and offer mentorship when needed.

With the support provided by physicians, nurses and other healthcare personnel, UAB later developed two additional virtual units, the UAB Virtual Nursing Unit and the UAB Virtual Sitter Unit. The UAB Virtual Nursing Unit brings the same support to the acute medical-surgical and intermediate care units as the tele-ICU. The UAB Virtual Sitter Unit adds additional monitoring and fall support to patients who are at risk for falls or need redirection.

Overcoming Resistance: Making Virtual Care Relevant to Clinical Staff

But just as we were starting to evaluate the successes of the virtual world, healthcare felt the pull to go back to the way things were prepandemic. Since we were no longer under the dark cloud of COVID, we started to question if we really needed "virtual" services anymore.

In healthcare, clinicians are often resistant to change. We like to live under the guise of "If it ain't broke, don't fix it." And, while virtual healthcare proved to be beneficial and successful during COVID, many clinicians felt as though it was pushed on them. It didn't feel like their choice, so many healthcare workers felt like they didn't want or need virtual care.

Demonstrated Benefits: Outcomes From Virtual Healthcare Implementation

When bedside nurses were asked about virtual care, there were times they would respond with "Well, I don't really use it" or "I don't see the benefit to me; maybe it would be more beneficial to someone else." UAB leaders started to realize there was a disconnect between what the data was showing us and what the frontline staff was feeling. A critical care nurse on one ICU may not be able to see the day-to-day improvement in patient outcomes. However, the data showed that in the course of four years on eight ICUs, the tele-ICU helped save 453 more lives than what was expected.

It was understandable how a medical-surgical nurse, who is pulled once every six months to a unit supported by virtual nursing, wouldn't know about the benefits. They wouldn't be aware that in two years on seven acute care units, the Virtual Nursing Unit completed over 9,000 admissions for our bedside teams, returning almost 4,000 hours to those nurses so they could focus on other tasks.

One of the biggest challenges was the reality that a nurse who may experience working with a virtual sitter only twice would look at it as a failed system if they had a fall during one of those instances. They wouldn't see that the fall rate per occurrence for a patient with a virtual sitter was less than 0.21%. The likelihood of being in a car accident on the way to work is 0.27%. A person is more likely to get in a car accident on their way to work than fall with a virtual sitter.

The data strongly shows that virtual healthcare should continue. However, it will not convince frontline workers if they do not feel its effects individually and often.

Making Virtual Care Relevant

The question became: How do we convince clinicians that virtual healthcare is relevant at the bedside? The answer was we can't; it could not be forced. The data already proved the high level of success with virtual healthcare. We needed to find a way for virtual healthcare to become a way of life organically. That's when we would know it was successful.

Virtual healthcare has been in a sort of limbo, but it is at a tipping point. We saw its value in our health system, but often those who were meant to use it, did not. So, we pivoted. We stepped back and asked, "How do we become relevant? How do we demonstrate value in a way that resonates with our frontline clinicians and gets them talking about this in a positive light so that others are wanting it? How do we create a shift in culture and practice in the hospital?"

Strategies for Integrating Virtual Healthcare Into Everyday Hospital Workflows

It began with listening. We wanted to know the pains and frustrations that were plaguing clinical and leadership teams. We found that staff needs did not require major life-changing actions; they were smaller tasks that often get overlooked or can become time-consuming. Tasks such as admissions and discharges, care plan initiations, interpreter services, charts, order and quality audits, etc., are all important aspects of care. But all of these tasks take a significant amount of the nurse's time away from the patient. We found that all of these tasks and more could be done virtually. By saying yes to taking on these smaller tasks, we opened the door for some larger requests as well.

Two of those requests resulted in implementing virtual care in two high-impact clinical areas:

• 1The inpatient dialysis unit took walk-in dialysis patients from the ED. Those patients were admitted as bedded outpatients, and the unit needed help discharging them. Nurses from neighboring units were being asked to stop what they were doing and come to the dialysis unit to handle the patient's discharge. To improve the process, the administration requested telehealth assistance. We delivered a virtual cart to the dialysis unit and in less than a year, virtual nurses completed the discharge teaching for over 130 patients. This solution kept neighboring unit nurses from floating to do the discharges and returned an additional 20-plus hours to the dialysis nurses to focus on patient care.

• 2In the ED, some patients were boarding longer than 24 hours. In these situations, float pool nurses were being pulled off the inpatient units to complete the admissions in the electronic medical record (EMR). To help, we delivered virtual carts to the ED so the virtual nurses could complete these admissions remotely. In the first month, the virtual nurses completed 349 admissions in the ED. In four months' time, they had completed over 1,800 virtual admissions. This process returned more than 750 hours to the ED, bedside nurses and float pool nurses. Float pool nurses were no longer needed in the ED, resulting in improved staffing on their units. Because admission tasks were already completed when the patient arrived on the unit from the ED, nurses throughout the hospital could focus on admission patient care instead of admission intake questions. "Effect of Virtual Nursing Implementation on Emergency Department Efficiency and Quality of Care" demonstrates how this process can reduce ED wait times and interruptions during the admission process and achieve more completed tasks on the admission forms.

The buzz was out! Virtual healthcare was beginning to grow. It started when the ED nurse called a transfer report to the inpatient unit, and the first question the inpatient nurse asked was, "Has Virtual seen them yet?" Then it grew into other units asking, "When can we get a cart for admissions and discharges?" Now, the bedside clinicians are coming to the Virtual Team with questions and requests. The narrative has changed from "I don't see the benefit to me; maybe it would be more beneficial to somebody else" to "I heard you were doing this for that unit; can you do this for me too?"

Is Virtual Healthcare a Pandemic Fad or Here to Stay?

Anytime nurses look toward the future, we are often filled with a mixture of emotions - excitement and anxiety, dread and anticipation. Looking at the future of virtual healthcare is no different. Whether it is due to the implementation of current virtual programs or the additions of artificial intelligence, there is much uncertainty in the growth of the virtual healthcare environment.

At UAB, we experienced this entire spectrum of emotions and the challenges that came with them. Going from the new kid on the block who was barely talked about to the name that is on everyone's lips didn't happen overnight. It was a journey - one that didn't truly take off until we learned to change the way we think. We had to realize virtual healthcare wasn't just about meeting patients where they are; it was also about meeting the clinicians where they are. Simply giving people the data on all the successes we have had wasn't enough. As leaders we had to show them how this change supported their needs and goals. So we did.

• We showed our nurses that they have access to support and specialty clinicians at the touch of a button, and virtual nurses are able to take some of the workload off their plates, giving them back time to focus on other tasks.
• We showed our physicians they no longer have to be on call 24/7/365. They can have supplemental coverage by virtual physicians on nights, weekends, holidays, etc., giving them a better work-life balance.
• And for our patients, we showed them they didn't have to travel to Birmingham, Alabama, to get specialty care. It is now just another part of the great care they are already receiving in their community hospitals.

We know that virtual healthcare is not a fad; it is here to stay. And at UAB, although virtual healthcare may not yet be a way of life, one thing we know for sure: Its future is very bright.

What are some ways virtual healthcare has benefited you?