Virtual Urgent Care Quality and Safety in the Time of Coronavirus

Abstract

Background: Telemedicine use rapidly increased during the COVID-19 pandemic. This study assessed quality aspects of rapid expansion of a virtual urgent care (VUC) telehealth system and the effects of a secondary telephonic screening initiative during the pandemic.

Methods: A retrospective cohort analysis was performed in a single health care network of VUC patients from March 1, 2020, through April 20, 2020. Researchers abstracted demographic data, comorbidities, VUC return visits, emergency department (ED) referrals and ED visits, dispositions, intubations, and deaths. The team also reviewed incomplete visits. For comparison, the study evaluated outcomes of non-admission dispositions from the ED: return visits with and without admission and deaths. We separately analyzed the effects of enhanced callback system targeting higher-risk patients with COVID-like illness during the last two weeks of the study period.

Results: A total of 18,278 unique adult patients completed 22,413 VUC visits. Separately, 718 patient-scheduled visits were incomplete; the majority were no-shows. The study found that 50.9% of all patients and 74.1% of patients aged 60 years or older had comorbidities. Of VUC visits, 6.8% had a subsequent VUC encounter within 72 hours; 1.8% had a subsequent ED visit. Of patients with enhanced follow-up, 4.3% were referred for ED evaluation. Mortality was 0.20% overall; 0.21% initially and 0.16% with enhanced follow-up (p = 0.59). Males and black patients were significantly overrepresented in decedents.

Conclusion: Appropriately deployed VUC services can provide a pragmatic strategy to care for large numbers of patients. Ongoing surveillance of operational, technical, and clinical factors is critical for patient quality and safety with this modality.

Figure 1

(a) Completed VUC visit volumes (blue), ED referrals for each day (yellow), and 72-hour VUC re-presentations (green) and ED presentations after a VUC visit with (red) and without admission (light blue) that were attributable to the index VUC visit date are presented. (b) VUC incomplete visits (“terminations”) are shown stratified by whether or not the patient checked in; “no-shows” (green), patient criteria unqualified (blue), technology/connection issue (red). VUC, virtual urgent care; ED, emergency department.

Figure 2

Cumulative revisits to virtual urgent care are shown on a per-visit basis.

Figure 3

(a) Cumulative visits to the emergency department following a virtual urgent care (VUC) visit are shown on a per-visit basis. (b) Emergency department visits following a VUC visit that required admission are shown on a per-visit basis.

Figure 4

Return visits to the emergency department (total and visits with admission) following an initial ED visit are shown on a per-visit basis.

Figure 5

Shown here are (a) the time from index virtual urgent care (VUC) visit to emergency department presentation in decedents and (b) the time from index VUC visit to death in decedents. Both are stratified by referral patterns.

Figure 6

The outcomes captured during period 2, in which telephonic follow-up occurred in the virtual urgent care workflow for selected patient visits, are shown. ED, emergency department.