COVID-19 Proactive Disease Management Using COVID Virtual Hospital in a Rural Community

Abstract

Purpose: A community teaching hospital serving a rural population established an intensive "hospital at home" program for patients with COVID-19 utilizing disease risk stratification and pulse oximeter readings to dictate nurse and clinician contact. Herein, we report patient outcomes and provider experiences resulting from this "virtual" approach to triaging pandemic care.

Methods: COVID-19-positive patients appropriate for outpatient management were enrolled in our COVID Virtual Hospital (CVH). Patients received pulse oximeters and instructions for home monitoring of vital signs. CVH nurses contacted the patient within 12-48 hours. The primary care provider was alerted of the patient's diagnosis and held a virtual visit with patient within 2-3 days. Nurses completed a triage form during each patient call; the resulting risk score determined timing of subsequent calls. CVH-relevant patient outcomes included emergency department (ED) visits, mortality, and disease-related hospitalization. Additionally, a survey of providers was conducted to assess CVH experience.

Results: From April 22, 2020, to December 21, 2020, 1916 patients were enrolled in the CVH, of which 195 (10.2%) had subsequent visits to the ED. Among those 195 ED visits, 102 (52.3%) were nurse-directed while 93 (47.7%) were patient self-directed; 88 (86.3%) nurse-directed ED visits were subsequently admitted to inpatient care and 14 were discharged home. Of the 93 self-directed ED visits, 3 (3.2%) were admitted. A total of 91 CVH patients (4.7%) were ultimately admitted to inpatient care. Seven deaths occurred among CVH patients, 5 of whom had been admitted for inpatient care. Among 71 providers (23%) who responded to the survey, 94% and 93% agreed that the CVH was beneficial to providers and patients, respectively.

Conclusions: Proactive in-home triage of patients with COVID-19 utilizing a virtual hospital model minimized unnecessary presentations to ED and likely prevented our rural hospital from becoming overwhelmed during year one of the pandemic.

Keywords: COVID Nursing Questionnaire; COVID-19; primary care; pulse oximeter; virtual hospital; virtual visits.

Figure 1

Schematic of the COVID Virtual Hospital (CVH) and patient flow. Patients with a positive COVID-19 test and DS CRB-65 score of <3 can be enrolled in the CVH. DS CRB-65 is a scoring tool for assessing severity of pneumonia and determining whether the patient requires inpatient or outpatient treatment. Once enrolled, patients receive a pulse oximeter, have a virtual visit with their primary care provider (PCP), and have regular phone calls from nurses who assess COVID-19 Nursing Questionnaire (CNQ) score. Based on the CNQ score and clinical judgment, nurses may order mobile health visit or direct the patient to visit the emergency department (ED). Extensive messaging and documentation through the electronic medical record (EMR) keep the patients’ health care providers informed.

Figure 2

COVID Virtual Hospital nurse call frequency based on COVID Nursing Questionnaire (CNQ) score (top row).