EXECUTIVE SUMMARY
EDs that implemented teletriage approaches before the COVID-19 pandemic are ahead of the game just as the demand for virtual care has exploded. The approach has helped minimize in-person exposures and improved efficiency.
- Milwaukee-based Aurora Health Care integrated teletriage into the way it uses the provider-in-triage (PIT) model in 2016.
- The teletriage/PIT approach is associated with a 20% to 25% reduction in time-to-discharge for ED patients.
- Philadelphia-based Jefferson Health has used the PIT model and teletriage to significantly reduce the leave-without-being-seen rate in two EDs.
- Make it clear the role of the teletriage provider is to start any needed tests or medicines, not arrive at a diagnosis.
- With the advent of COVID-19, administrators moved the teleintake process out in front of the ED, helping minimize in-person contact for both screening and testing while also preserving PPE.
A virtual intake process has helped many providers handle the multiple priorities involved with caring for a surging number of patients with a highly infectious disease while keeping staff and other patients safe.
As the demand for virtual care has accelerated, teletriage has melded well with other telemedicine innovations that may permanently change many of the ways in which emergency care is delivered. Some early adopters explain what pushed them out of the gate early, how teletriage has helped them manage the challenges posed by COVID-19, and how they see the approach evolving.
Eliminate Downtime
Milwaukee-based Aurora Health Care turned to teletriage in 2016 when leaders there realized it could provide a big boost to efficiency in the way the health system leveraged the provider-in-triage (PIT) model in its multiple EDs.
Under the PIT approach, an advanced practice clinician (APC) is stationed at triage with a nurse. They start ordering labs and imaging for patients while those patients are waiting to see an emergency provider overseeing care. However, placing one APC at every site was not that efficient, according to Paul Coogan, MD, president of emergency services at Aurora.
By implementing teletriage, health leaders theorized one provider operating from a remote location could perform the PIT function for multiple EDs, thereby eliminating the need for onsite APCs and all the downtime. Although teletriage can be implemented in several ways, Aurora elected to work with the virtual platform developed by Brookfield, WI-based EmOpti.
After a patient checks in to the ED, he or she will be downloaded automatically into the teletriage system, explains Christopher Ellingsen, PA-C, the lead APC for Aurora’s teletriage team.
“When it is their turn to be triaged, they will come into a triage booth, the nurse will do their vitals and get their story, and the nurse will then enter that information into the electronic medical record [EMR] chart,” he says. “Then, the nurse will request a consult with [the teletriage provider] through the EmOpti software.”
(Editor’s Note: Read this March 2017 ED Management article for more background on the Aurora teletriage program.)
Keep It Short
Typically, the encounter with the teletriage provider will last for about 90 seconds. If any tests are ordered, those can start while the patient waits for the emergency provider. When the process works well, many tests are completed before the emergency provider arrives, according to Ellingsen.
Coogan notes the time-to-discharge for patients is 20% to 25% shorter when they have undergone a teletriage consult. “That only makes sense because half of their labs are done by the time the physician or APC in the ED sees the patient,” he offers.
Teletriage also is associated with a significant improvement in door-to-doc times. For instance, in the ED at Aurora Sinai Medical Center in Milwaukee, that time averaged an hour or longer before teletriage implementation. Now, that time is closer to 10 minutes because the patient encounters the remote teletriage provider on the front end of the ED visit.
Patients suffering from stroke, heart attack, or other conditions requiring immediate attention will bypass teletriage and go to the ED for immediate care. However, there are some low-acuity circumstances in which patients can be managed and discharged based solely on the encounter with the teletriage clinician. This is a scenario that has proven particularly useful in the context of the COVID-19 pandemic.
Generally, the tactic is used only for a few patients per day, but it does deliver benefits in terms of patient and clinician safety. “It decreases the amount of PPE that we need to use ... and it also decompresses the waiting room, allowing us to see the patients that need us most in the ED, those who are most acutely ill,” Ellingsen says.
Patients directly discharged from triage following their encounters with a remote clinician might be younger individuals with no comorbidities and stable vital signs. This group might include patients who have been exposed to someone with COVID-19 and need to be tested. “They are not hypoxic, they do not have tachycardia [rapid heartbeat], and they are not febrile,” Ellingsen notes. “Certainly, they are not our elderly patients, patients who require oxygen, or those with significant medical histories.”
Identify Champions
Remote teletriage providers tend not to write anything in the EMR other than orders because that hampers efficiency. “The patients understand their interaction with [the remote provider] is just a quick screening exam, and that they will eventually be seen by one of our onsite providers,” Coogan explains. “The physician assistant or nurse practitioner who is working ... can do 15 to 20 consults an hour, frequently covering five [ED] sites.”
For the most part, patients have been receptive to teletriage, and providers immediately saw value in the approach. “There is a lot of wasted time in medicine and in the ED,” Coogan notes. “Any time you can get things going on patients while they are waiting for their ultimate destination helps to improve the workflow.”
There were some initial concerns from nurses that teletriage might slow the process down. Coogan explains that while nurses may spend an extra 60 to 90 seconds in triage, there are 20 to 30 extra minutes saved in overall LOS downstream.
“It can be perceived initially as a challenge to nurse autonomy, but once they see the process going, nurses have realized that it is actually championing their autonomy,” Ellingsen says. “Our nursing staff ... are really in control of this process, and I think they are the most important players.”
Aurora uses teletriage at five EDs between 10 a.m. and 8 p.m., the busiest period. In addition, the system uses the platform with the 15% to 20% of patients who arrive by ambulance. Each ED uses “free-roaming ED,” or “Fred,” which is essentially the teletriage platform in portable form. This tool can be transported easily, allowing patients to interact with a remote provider even while patients are traveling from an ambulance gurney to a regular bed.
Aurora leaders are thinking about how they can leverage teletriage in even more ways. One idea is to use it for discharging patients at short-staffed sites. For example, there may be only one physician physically present — and he or she is busy sewing a complex laceration on one patient while many others are waiting for final instructions before going home. Coogan suggests these waiting patients could interact with a remote clinician through a mobile teletriage tool, receive their needed information, and leave without waiting so long.
Coogan says EDs struggling with boarding, patient flow, long waits, or patient satisfaction might want to consider teletriage. The platform could work well for sites thinking about adding staff but are unsure if there is enough volume to pay for extra personnel.
“It is not a cure-all for all of your problems, but it is a way to address the front end of the process of patient arrival and getting things started,” he says.
Begin with PIT
Philadelphia-based Jefferson Health’s journey toward teletriage began as part of an effort to reduce the leave-without-being-seen (LWBS) rate in one of its EDs. First, the health system implemented the PIT model, which made a sizable difference. The LWBS rate declined from about 5% to less than 1%. Door-to-provider times shortened from an hour or more to between nine and 14 minutes, explains Judd Hollander, MD, senior vice president for healthcare delivery innovation and the vice chair for finance and healthcare enterprises in the department of emergency medicine at Thomas Jefferson University.
Then, in a different ED, Jefferson started experimenting with teletriage between 11 a.m. and 6 p.m. “We picked those seven hours for practical reasons because we had a provider who could double-dip, doing two duties at the same time,” Hollander explains. The approach proved successful, reducing the LWBS rate from about 3% to 1% in that ED.
At this point, it occurred to Jefferson leaders that one remote clinician could be handling the PIT role for the EDs at both hospitals: Thomas Jefferson University Hospital and Methodist Hospital. Administrators expanded teletriage hours to cover most of the day. The approach has delivered significant dividends in terms of efficiency.
“We see as many as 235 people through a single provider during the 16 to 18 hours we are covering [with teletriage], depending on the day of the week,” Hollander reports. Overall, teletriage kept the LWBS rate in the 1% or less range at both EDs.
Clarify the Role
Be clear about what the role of the remote teletriage provider is. “I don’t need to know what is wrong with the patient in teletriage. It may be pneumonia, bronchitis, or asthma. Once I decide the patient needs an X-ray, I am done,” Hollander says. “The patient can then go to X-ray or I can give him a nebulizer, but I don’t need to do a complete history and a complete exam.”
Hollander adds teletriage providers do not really need any high-tech instruments to fulfill their role. In fact, when teletriage was implemented, he notes there was a remote stethoscope available to the remote clinicians, but providers barely touched it. “We used it eight times in the first 10,000 patients,” Hollander says.
In the few cases for which more information might be helpful to the remote clinician, the in-person nurse or the tech who is with the patient during the teletriage encounter is on hand to listen to the lungs or perform any other assessments.
The teletriage process has helped frontline providers manage the demands of the COVID-19 pandemic, but they did make some adjustments. “We were able to take the teleintake process and put it out in front of the ED,” Hollander explains. That helps minimize in-person contact for both screening and testing while also preserving PPE supplies.
The teletriage function also has fit in well with some other telemedicine initiatives Jefferson has deployed. For instance, ED staff have placed tablets in patient rooms to facilitate communications while minimizing clinician exposure. “We have decreased the amount of in-room visits to our COVID-19-positive patients and our patients under investigation. We have [also] leveraged those tablets to do face-to-face consults with other services as well,” Hollander says. “We have a very low infection rate [among staff], and I think part of that is related to these [techniques].”
Another innovation is “JeffConnect,” an on-demand app that enables anyone in the Jefferson region to visit with an emergency provider at any time of the day or night. Hollander notes the health system has leveraged clinicians who are quarantining but are well enough to take calls through this service.
To launch an effective teletriage process, EDs need a secure platform, reasonably clear video, software that can queue patients, and an ability to integrate the process into the EMR. Hollander acknowledges these features can be costly.
“I think [you need] to figure out what the institution’s needs are, and balance them with the fact that healthcare is having a lot of financial issues right now,” he says. “The trick is going to be [determining] how we can provide better virtual technology in a way that is money-saving for everybody.”
As the demand for virtual care has accelerated, teletriage has melded well with other telemedicine innovations that may permanently change many of the ways in which emergency care is delivered. Some early adopters explain what pushed them out of the gate early, how teletriage has helped them manage the challenges posed by COVID-19, and how they see the approach evolving.
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