Nurse Leaders Innovate to Create New Care Delivery Model

In 2020, The Covid 19 pandemic disrupted our normal organizational operations forcing us to create an innovative solution to mitigate patient volume surges and supplement the demand for personnel and monitoring equipment. Nursing leaders Melissa Cole, MSN, APRN, ANP-BC, CENP, Vice President, Danielle Sindelar, MSN, RN, CMSRN, Nurse Manager and Jodi Arth, RN, implemented and led an innovative solution to provide care to patients with Covid-19 to avoid hospitalization with the use of a remote patient monitoring (RPM) device that would continuously communicate patient symptoms to the care provider teams. In the UH Cleveland Medical Center Emergency Department, a clinical algorithm was used to assess patients for appropriateness of the remote patient monitoring device. Patients were either admitted into the hospital or sent home for monitoring with the RPM. The patient wore the RPM device, which transferred physiologic information through the patient’s smartphone to a central call center monitored by nurses. Patients are asked about symptoms daily by a chat bot that transmits answers to the patient file, allowing for a full assessment of disease progression. An algorithm used by the healthcare team provides a trigger to alert the provider if the patient’s symptoms are worsening and need for interventions, such as a virtual visit by a provider or recommendation to call 911.

From May 2020 - May 2021, there have been 2,087 patients enrolled and monitored with RPM, therefore avoiding hospital admission. The average length of monitoring is 1.567 days. The original pilot data demonstrated 17 out of 83 patients returned to the emergency department (an average of nine days after monitoring onset). Return visits were typically due to symptom progression, with approximately 50 percent of those returning requiring oxygen.

Further development of the program has already started with a comprehensive hospital at home program, which began in May 2021. The program has expanded to other diseases such as COPD, pneumonia, and cellulitis. Collaborations will continue to be formed to integrate additional medical technology and other special populations. More innovative features, such as artificial intelligence, can be combined to track the patient’s risk factors and behaviors to prevent further illness or progression of the illness.

Multiple patient benefits occur from RPM versus hospitalization, including decreased incidence of delirium, reduced risk of exposure to nosocomial infections, and increased satisfaction with remote monitoring. Patients also reported a sense of safety as they were already experiencing anxiety and uncertainty with Covid 19 symptoms and treatments. RPM permits real-time symptom assessment with nurse oversight delivered in the privacy of a patient’s home. Nurses use a treatment algorithm and the nursing process to coordinate the management of diseases. This ongoing monitoring allows for early identification of disease progression versus the episodic care commonly provided in the hospital setting. The typical burden of deciding to return to the Emergency Department for progressing symptoms is removed from the patient. Therefore, decreasing overutilization of hospital resources and providing the proper care at the right time. Patients and their family members are now integral partners in monitoring and managing their care in tandem with the healthcare team. This innovation also has the projected benefit of advancing the nursing profession, catapulting nurses in a remote practice setting, potentially filling gaps in access to healthcare and healthcare staffing shortages.

Commitment to serving the community is an organizational and nursing vision. This innovation meets the needs of the populations we serve and is leading a path for future care delivery. Evidence shows that hospital-delivered care puts patients at more risk for harm from errors. Given that Covid-19 patients were at more risk for social isolation while being hospitalized, this technology permitted the patient to quarantine in the privacy of their own home with family. In addition, our organization was challenged by limited personnel, bed space, PPE shortages and equipment, and RPM was able to alleviate some of this resource burden. Although Covid-19 accelerated RPM use, hospital congestion and Emergency Department boarding times have been a long-standing challenge affecting patient mortality rates. The continued use of RPM will potentially relieve these challenges.

Nurses were instrumental leaders in the operations of the Hospital Incident Command Centers during the pandemic. This responsibility required Nurse Leaders to collaborate with the community, repurpose physical hospital space, allocate limited personnel and equipment, and ideate non-traditional healthcare delivery. The work of interprofessional teams in our organization is exemplary and embedded in our culture. For example, nurse leaders collaborated with a group of physicians, nurses, pharmacists, communications and IT analysts, and representatives from healthcare technology. The clinical teams created a selection algorithm to identify patients at the highest risk for potential disease progression; they also developed treatment algorithms and education for patients and staff.

This innovation exemplifies nursing expertise in the design and implementation of technology to achieve high-quality care. RPM supports nurse autonomy in decision-making for patient treatment modalities and sets the stage for practice innovation. Nurses are constantly finding solutions and improvements to deliver quality patient care. The dedication and advocacy of nurses to explore and create programs throughout the pandemic allowed for a new delivery care model to emerge in our organization.

RPM has the potential to transform nursing practice by challenging regulatory requirements and removing barriers to care. More healthcare consumers are content with mobile health and receiving care over an electronic device. Nurses can deliver the right care at the right time by providing ongoing nursing expertise, in some cases on consumer demand. Any healthcare or other public setting where nurses are accessible can implement the RPMN innovation. Although the socioeconomic barriers may prevent some patients from receiving RPM, we can are looking to further partnerships to assist in removing those barriers.