Rural telemedicine, staffing model

Summaries from ACP Hospitalist Weekly.

Switch to advanced practice providers plus telemedicine for ED coverage yields benefits at some rural hospitals

Some critical access hospitals began covering their EDs with advanced practice providers plus telemedicine after CMS announced that this was permitted, and those hospitals reported lower costs and other benefits in a recent study.

Image by Getty Images
Image by Getty Images

The study, published in the December 2018 Health Affairs, looked at 19 rural hospitals in Iowa, Kansas, Minnesota, Nebraska, North Dakota, and South Dakota. All of the hospitals were already affiliated with Avera Health System, a provider of ED-based telemedicine, at the start of the study period (March 2013). In June 2013, CMS issued a memorandum stating that EDs at critical access hospitals could meet the regulatory requirements for physician availability by having advanced practice providers in an ED equipped with telemedicine, rather than having a physician available locally.

Before the CMS announcement, all of the hospitals had physicians either on site or locally available to back up advanced practice providers covering the ED. By March 2016, seven of the hospitals had begun to use advanced practice provider coverage with telemedicine at least some of the time. Two of the hospitals were using this as their coverage system all the time. The elimination of local physician backup was associated with decreased costs for clinician remuneration, the study found. The hospitals that switched to telemedicine had a decrease of $117,406 in such spending in 2014 to 2016, while those that didn't switch had an increase of $137,965 over the same period.

The study also included telephone interviews with hospital CEOs or administrators, directors of nursing, and ED managers. Those at hospitals that switched reported a number of benefits from ED telemedicine, “including assistance with patient transfers to referral hospitals, support for nursing staff in the documentation process, expert advice and guidance during procedures that were infrequently done in critical access hospitals, avoiding unnecessary delays in patient care, and additional support in cases of increased patient load or while dealing with complicated cases,” the study said. Implementing telemedicine coverage also decreased clinician burnout and aided in recruitment and retention of both physicians and advanced practice providers, according to the interviewees.

The interviewers also investigated why some hospitals didn't switch to advanced practice provider plus telemedicine coverage and found that some were not aware of the CMS policy clarification and others faced state-specific regulatory obstacles. “Given the initial evidence that using tele-ED physicians to back up advanced practice providers has a positive impact on cost savings and provider recruitment, rural hospitals should explore this option in their local context. CMS, as well as state hospital associations and others, may consider making further efforts to clarify and communicate the policy,” the authors said.

Model simulates effects of proposed changes to hospital staffing and wards

Simulation modeling allowed one hospital to predict the impact of changing the staffing and organization of its general inpatient medicine units, a recent study showed.

Researchers gathered administrative data about admissions and discharges, conducted a time-motion study, and applied expert opinion on workflow to create and validate a simulation of the hospitals' medicine units. They then simulated four potential changes: aligning medical teams with nursing units by localizing housestaff and patients; adding a 26-bed nursing unit; adding a hospitalist team; and adding both a nursing unit and a hospitalist team with four additional admissions per day. Results were published by the Journal of Hospital Medicine on Nov. 28, 2018, and appeared in the January 2019 issue.

The simulation showed that the first change (geographic localization) would decrease rounding time and patient dispersion for the teams but increase length of stay and ED boarding times. The second change (adding a nursing unit) did the opposite. Adding an additional hospitalist team did not have a significant effect on patients' average time in the system or the number of patients waiting for a bed but did decrease average team census, team utilization, and patient dispersion. The final change (adding a unit and a hospitalist team) increased admission volume while maintaining utilization and time in the hospital and ED but increased rounding time and patient dispersion.

“The outcomes for these what-if scenarios provided some important insights about the secondary effect of system changes and the need for multiple, simultaneous interventions,” the study authors said. “Leaders who want to increase capacity may need to consider both adding a hospitalist team and a nursing unit, and model the impact of each choice as described with a simulation.” They cautioned that such modeling is not simple and that all simulations are limited by the assumptions underlying their models. Other data and variables could be added to the model and affect the results, they said.

“This study is a breakthrough in the scientific rigor of hospital operations,” said an accompanying editorial. However, the editorialists noted a number of other factors they thought could be helpful to include in the modeling, such as the effects of multidisciplinary workflow and transfers; impacts of changes on burnout, patient satisfaction, and other wards' function; and calculation of costs.

Review evaluates hospitals' efforts to combat spread of carbapenem-resistant organisms

Quasi-experimental studies have found that multimodal interventions can prevent and control transmission of carbapenem-resistant organisms, but the quality of these studies is low, according to a recent analysis.

To inform World Health Organization guidelines, researchers conducted a systematic review and reanalysis of studies that assessed the impact of practices and procedures to prevent and control transmission of carbapenem-resistant organisms (Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa) in inpatient health care facilities. The 17 included studies, which were compatible with effective practice and organization of care quality criteria, assessed interventions in interrupted time series analyses and ranged in duration from 15.6 months to 7.0 years. Results were published online on Nov. 23, 2018, by Clinical Infectious Diseases and appeared in the March 2019 issue.

Most infection prevention and control measures were implemented using a multimodal approach (i.e., three or more components implemented in an integrated way). Among all studies of carbapenem-resistant organisms, the most common intervention components were contact precautions (90%), active surveillance cultures (80%), monitoring, audit, and feedback of measures (80%), patient isolation or cohorting (70%), hand hygiene (50%), and environmental cleaning (40%). Nearly all studies of these interventions found a significant reduction in trend over time and/or immediate change. However, the quality of studies was very low to low, and all studies were classified as having a high risk of bias.

The review authors noted limitations, such as potential publication bias within the included studies and the difficulty of ascertaining the effectiveness of single interventions contained in multimodal infection control and prevention strategies. The results should be interpreted in the context of local epidemiological setting, resource implications, acceptability, values, and preferences, they added.

While it would be helpful to know which element or elements of a bundle perform the bulk of the work, a future meta-analysis of studies with more similar characteristics might not be necessary, even if it provides more evidence-based guidance, according to an accompanying editorial. “Instead of reanalyzing prior work and interventions, perhaps we just need to get better at these basic [infection prevention and control] elements and focus research efforts and investments on developing the next novel intervention to prevent [health care-acquired infections],” the editorialist wrote.