Abstract
Many health systems employ nurse telephone advice services to facilitate remote triage of patients to appropriate level of care. However, the effectiveness of these programs to reduce ED and subsequent health care utilization remains to be demonstrated. We describe a novel virtual urgent care program implemented within a Veterans Affairs (VA) health care system that interfaces with a nurse telephone advice line and leverages telemedicine tools to rapidly address and resolve nonemergent conditions. During a 4-month pilot period, 104 unique patients received care through the program, and over 85% of patients achieved timely resolution for their urgent complaints on first contact with the health care system. Demonstrating feasibility for such a program has potential implications for the optimization of remote triage and urgent care services to improve health care utilization and outcomes.
1. Introduction
Over the last two decades, emergency departments (EDs) have experienced a dramatic increase in visits for nonemergent conditions [1, 2]. This has led to higher patient costs, increased wait times, and potential delays in care. Nurse telephone advice services have been implemented by many health systems to reduce the burden on EDs but typically rely on computerized triage algorithms that are overly cautious, resulting in referral of patients to the ED for conditions that could be managed in less resource-intensive settings. We describe a novel virtual urgent care program interfacing with a nurse telephone advice line implemented at a Veterans Affairs (VA) health system in Northern California.
2. Materials and Methods
2.1. Program Description
We describe the results of a quality improvement project involving a convenience sample of Veterans who telephoned a nurse advice line during business hours (Monday to Friday, 8 am to 4 pm) between June 1, 2019, and September 30, 2019, at San Francisco VA Health Care System. For instances where the computerized triage algorithm recommended in-person evaluation within 24 hours, telephone triage nurses would contact an urgent care provider (physician or nurse practitioner) to discuss whether the case could be addressed via an on-demand video or telephone visit. For appropriate nonemergency cases, the triage nurse offered the patient the opportunity to be evaluated immediately through a video or phone visit with an urgent care provider.
2.2. Measures and Analyses
We used electronic health records to obtain patient demographic information, patient care assessment needs (CAN) comorbidity score [3], chief complaint, telemedicine modality utilized, and original triage recommendation for time frame and location of care. The primary outcome of interest was the proportion of cases that achieved first contact resolution (FCR) [4] which we defined as appropriate diagnosis or treatment within 24 hours or redirection to a less urgent follow-up appointment outside of the 24-hour window. A secondary outcome of interest was the proportion of cases seen in a VA or community ED within 72 hours following initial triage.
Basic patient demographic and clinical characteristics were compared between cases that achieved FCR with those that did not. Student’s t-test was applied for continuous variables and the Fisher exact test for categorical variables. We constructed multivariable logistic regression to determine the association of video-based telemedicine visits on FCR and subsequent ED visit. Statistical significance was set at a two-sided α = 0.05, and analyses were performed using STATA (version 16.0, StataCorp, College Station, TX).
3. Results
During the 4-month period, urgent care clinicians were available on 50 unique weekdays. On those days, an average of 36 ± 8 patient calls per day were triaged by the computerized algorithm to the same day (within 24 hours) in-person evaluation. A total of 104 unique patients were offered and agreed to a virtual urgent care visit: 78 visits were conducted by video and 26 were conducted by telephone. All visits were conducted immediately after the nurse advice call. Ninety-two (88.5%) cases achieved FCR. Patient demographic and clinical characteristics were largely similar between those who achieved FCR and those who did not (Table 1). Visits conducted over video had a 7.6 (95% CI: 1.2–47.3, ) odds of FCR and 0.04 (95% CI: 0.003–0.5) odds of subsequent ED presentation than those conducted over telephone when adjusted for demographic and clinical characteristics. Though a large proportion of cases were initially recommended for the same day care at an outpatient clinic, 20% (21/104) of cases were successfully diverted away from the ED, and only 7.7% (8/104) of cases resulted in a subsequent ED visit. Common reasons for failure to achieve FCR were related to technical difficulties connecting with patient via video, insufficient assessment by telephone alone, and patient preference for in-person care (Table 2).
4. Discussion
Adoption of virtual urgent care has risen dramatically over the last decade, but few such programs have been linked with a nurse telephone advice line. Our pilot program demonstrated the feasibility of a seamless transfer of patients from an existing nurse-led telephone triage line to an immediate virtual evaluation by an urgent care provider. In over 85% of cases, the first contact resolution was achieved immediately. Patients in our study were on average older, more rural, and more likely to be male than those in previous studies of direct-to-consumer telemedicine platforms [5, 6], suggesting a relatively high acceptability of video visits in a population previously thought to be limited by the digital divide.
Our study was limited by a modest sample size given the availability of urgent care providers on select days during the pilot period as well as generalizability of the VA population and integrated health system to the private sector. However, the success of such a program to resolve patient concerns immediately via telemedicine has implications for change across various health care systems. In addition to saving time, travel, money, and ED clinic resources, virtual urgent care offers the opportunity to care for potentially contagious patients in isolation and to protect patients with noninfectious conditions from exposure to virulent infections.
Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.
Conflicts of Interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgments
Dr. Lu was supported by the VA Quality Scholars Program funded through the VA Office of Academic Affiliations (grant no. AF-3Q-09-2019-C).