December 2023 - TogetherTeam Program: Video-Based Telehealth in In-Person Nursing on Inpatient Floors

- Welcome everybody to our December, our last month of this calendar year, monthly meeting. We are very fortunate to have Karin Montgomery take time from her insanely busy schedule to present to us about the program that they've been using with nursing and telehealth there at Trinity Hospital in Ann Arbor. So Karin, I'm gonna let you have the floor if we usually do about 20+, 20 to 30 minutes and then we'll open up for questions. And so I'll let you give more information about yourself and about the program and we'll go from there.

- Okay, sounds good. So I actually have the opportunity to be part of this fresh and new idea. We heard from Oakland at Trinity that they were engaging in this process. And so very early on we were super excited and wanted to jump on board. I'm one of the nursing directors here and we have an incredibly supportive CNO who is very forward thinking. And of course as we'll get to a little further in this presentation, we know that we have some issues that we have to solve and continuing to do the same thing, hoping for a different outcome. It's by nature the definition of insanity. So we had to come up with some new plans with these staffing issues that we have. So we kind of watched, stood by the side and watched how Healthland rolled it out and then tried to take all of their learning and put it into our process and roll out something very, very similar to them. So we've worked very closely with them and now I know Trinity Corporate is actually sending this throughout multiple states and multiple hospitals. This is a one of our plans for staffing issues going into the future.

- Sorry Karin, it's Emily again. There's a little bit of feedback with your microphone. I don't know if maybe you can bring your microphone a little bit closer to you to maybe not get as much, not feedback but other like sort of echoes in the room.

- Let me see. Let me know if that's better. Yes?

- Yeah, I think that's a little better. Yeah.

- Okay. All right. So I will go ahead and move through these. So the real question was why are we changing? And as I already started to say, you know, we went through COVID as you all experienced as well in the emergency area, and we went through a great resignation. So we had a lot of people that started debating quality of life over quantity of work and what did they wanna do? And also those that were getting closer to retirement decided just to retire, which left us in this deficit with staffing. We also created new roles. We had clinical care models, you know, the wage benefit inflation that has just hit all of us and I know you've all experienced that. And then we utilized a large amount of contract labor throughout COVID because staff were deciding they didn't wanna work at the bedside and put themselves in harm's way. So we utilized contract labor because we had to fill up those gaps and continue to take care of patients. During that same time, all of the services that we were, you know, offering, there was a huge shift in patient populations as you guys well know, and a growth in urgent care, virtual and home visits. All of that came into being. And then reimbursements as you've all experienced as well. And also patients and members, I repeatedly hear, you know, we're paying more than we would for a hotel. So no tells this isn't a hotel because we're paying more than we would for that. So the expectations on staff and the care they deliver has gone up immensely. That combined with a lot of other factors just led us to know that we're in an unsustainable situation and we have to do something differently. The highest utilizers of healthcare now are 65 plus. As you all know, I'm not telling you anything you don't know saying. We live and breathe by all of these numbers, but 56 million or more will be 81 million by 2040. So this is not gonna get better in the foreseeable future. And with almost a 50% increase in patients, we do not have that same issue with our staffing. We actually have it going the other direction. So three and a half working adults for every senior person today. And by that it will be down by 2030. We'll be down to 2.9. 3 million nurses today are needed and we're gonna need 3.3 million by 2030. So definitely not solving our problem. And nursing schools are having to turn applicants away because all of the instructors have also hit that 65 plus. So we had a 50% retirement rate in the nursing instructors, which led to a huge deficit and inability to put students through the school. So where we used to have, you know, multiples lining up to go, now we have not as many in line to go to nursing school and we have huge wait lists. Two and three years long or more waiting to get in. So it has become incredibly competitive and it has become a really tough situation for all our students. So, what is TogetherTeam altogether, and this goes back into the shortage and why they came into it, but with that 1.1 million deficit of RNs by the end of 2022, it's gonna take more than 10 years for us to even get close three pointing. If we can't even do that. So it's a three-person care team. We have multiple areas that have used PCTs or PCAs as part of their, which is a patient care tech, so an unlicensed third person and then others that utilize LPNs or licensed practical nurses for that third person care team. We here at Ann Arbor are currently utilizing LPNs, but as we move this forward, we are talking about certain areas that we may use PCTs just because of the needs of the unit. So medication heavy units for our medicine units, we can need the LPNs just to help pass medications. But for some of our surgical units we may do better with the PCTs because of the mobility and other things that they can help participate with and fill out that third percent care team. The other two members of that team are a registered nurse at the bedside and then a registered nurse that's called a virtual registered nurse that actually sits behind the computer and connects through the TV and the patient room. What we have experienced with that, this is gonna help build a pipeline of caregivers. So those LPNs and those PCTs, it helps drive them to go back to school so that they're no longer the one taking the orders. They're actually the RN that's able to help. Hoping that we can wet their appetite to further their education. It also with the vRNs, they're all experienced licensed nurses. So they have, we take a minimum of eight years of experience before they're able to be a vRN. So often these are the older nurses that no longer wanna be at the bedside because it's too taxing for them physically. But it provides mentorship for those newer nurses. And as you all know and probably have experienced, we have a huge number of branded grants at the bedside, which also increases the risk to the patient care. It increases the difficulty in taking care of patients. A lot of questions, not sure what to do. They're reading those orders and having, you know, going back and forth. And especially as physicians, you get those phone calls and you're wishing they had someone that could guide them and these RNs can actually check right into the room while the new grad is at the bedside. If they're doing a new procedure or a new process or holding order, they don't understand and they can guide them through. So it's experienced nurses that know how to read those orders can check them and do check those orders and read through and say, hey, you might wanna get ahold of the doc for this because this doesn't look quite right or this is how you go through this process. This is what you need to do. This is helps ultimately decrease turnover, decreases labor plus, requires 20% fewer our ends. So one of the questions we have gotten frequently is, are you trying to get rid of the registered nurses? And the answer is absolutely not. If we did not need to do this, if we could utilize technology but not have to decrease RNs, we would do it hundred percent. Our problem is they just aren't there to be utilized. So you know, needing to move on and find a way to get through with less nurses, but still giving the same quality of care and still giving the same safe care, making sure that those patients are in good hands. And then the byproduct of this of course is it does really reduce labor costs. Approximately average 80% per day. So the bedside, what do all these people do? The bedside RN actually provides the direct patient care. They gain experience through the vRN mentorship. They have more time to spend with their patients because the vRNs are taking some of those tasky things off their plate as well as anything that can be done that doesn't require hands on. So they can check into the chart, they can go over orders, they can review tests that are coming up. They can answer questions from the patient's families. They can be a go-between at times with the physician, if the physician just has a quick update that they wanna give and then the vRN can let the bedside nurse know if it's not something that requires immediate action. They also can help in the event of an emergency and mobilize some of the, for instance for us, they call the stat team, get the stat team up, their rapid response, that type of thing. And the bedside nurse also has that on guidance. So when they're in that room they can push that vRN button just as quickly as the patient if they need an extra set of eyes on something. The RN Partner and that can be a nursing assistant, a CNA or an LPN. They partner with the bedside RN and they work together as a team. Now this I will tell you has been as we've gone live, it has been our challenge. The vRN has come in since seamlessly has not been an issue at all. But the partner because they have not been used to working in a team approach. And I date myself when I say this because when I started nursing we were in a team so I had no problem selling this. But then teaching them how to split up the assignments and be able to have those conversations, it takes skill and it takes time to develop that. So, that is what we are working on currently. But the plan is with that as well to continue to mentor and to push to encourage them to go back to school and get their registered nursing license. The Virtual RN, they do so many things in the background, so they're going through the chart, they do rounding on the patients, so they check in every hour just to see how the patient's doing. There have been things found, for instance, one virtual nurse knocked to go into the room and the patient did not respond and the vRN said could hear something over the line that wasn't right. So without waiting for permission just went ahead and turn the camera on and the patient was seizing. So they were able to call the rapid response and get someone in there right away. And the patient's nurse had been in there just five minutes before, so would not have been coming back for a while and they were able to urgently respond to that patient. So definitely additional support. They can do the admissions, they can do the discharges, they are doing standardized education with the patients. So any new meds that the patients get while they're there, they can go over those in detail. And then, you know, I say three partners in this care model, but the fourth is definitely the patient and family member. And they by far have been the ones that have been the most positive about this entire experience. They feel so much more cared for in this process. And they said, you know, we worry about the nurses on the floor because they seem so busy, we see them running up and down the hall and we don't wanna bother them but they don't have any hesitation in pushing that we're in button and asking questions, which is exactly what we want. We don't want family members and patients in the room with questions or feeling maybe that there's questions. You know, the doc comes in and talks to them, the nurse comes in and talks. They don't necessarily say the same things so they need clarification. This way they can get that clarification because the vRN can read the physician notes and see exactly where the physician was going with things and then straighten it out. So we have seen a ton of help with that just in the short time that we have been up and working. Safety is another thing that is huge. They're able to monitor the patients, make sure that things are going well. Our first question was, will these work with our demented patients or our patients with altered mentation? And they do. Because they can round on them, they can see if things aren't going well and often when they call the unit and say hey, you need to get into room 805 right now because we've got a problem. So these types of things are working. Being a faith-based organization, we are working the care test processes in that is applying both to the team members, the patients and the families. We have gotten a ton of feedback that they feel cared for. They feel like people are taking an interest in them, people have more time. It's just inherent, just like they tell you, if you sit down with a patient, they perceive that you've spend their money, then it's more than you have. So it is what the vRN when they check in. They perceive that they talk to them much longer than they do. So often the rooms are two to four minutes by no longer than that and unless they're doing an admission or a discharge, but to the patient they perceive that as a 5 to 10 minute interaction if not longer. So they definitely feel like they're getting much more individualized care and attention through this process. And I think we kind of hit on this. I'm not gonna spend too, too much time. Just from the going upstream with that, what the nursing leaders and of course the leaders of the hospital see increased staff engagement, increased retention, being able to bring those care task solutions to the team, less time on staffing. Once the model is stable, what you notice is that teams hire in and when they become accustomed to this process, they don't wanna leave. And interestingly enough, we have used some contract labor to initially house in and run our vRN hub. And of those that we started with, eight of them have already become full-time employees of the hospital. They just don't wanna leave. They love the process, they love what they're doing, they feel like they're nursing again in a way that is sustainable for them. So this is a definitely a very high staff engagement factor. And then with, you know, from the leadership side of things, long-term outcomes, less money and better metrics in the long term because anytime you have an experienced nurse, you're gonna have better outcomes. And that's, you know, the more education, the more experience. We kinda went through this, but just to break it down a little bit. The Virtual Nurse Roles. They can do dual sign off, they can do chart audits, discharge planning, discharge education, mentoring. If they need to add consults, they can do those. I know within our first week of going live, someone from nutrition reached out to me and said, "Did something change because we have never had this many consults since we can remember." I said, "Yes, they're actually filling out the questions correctly now and you're hearing about our patients that are at risk." So all of the right things being done and they can also keep an eye on those LPNs and mentor those as well. And then the bedside of course, anything hands on they do. And the nurses and the options then share some of those things. The rounding, the patient education, all of those types of things can be shared between those RNs. This is what the call light looks like. Now it has that vRN button, that blue button. We encourage the physicians here at the hospital as well. If they go in and they need something that does not require the bedside nurse or if it's just something in the middle, if they need a second set of eyes, if they have to do a procedure that requires someone to witness, they can push that button. vRN is instantly in the room and able to help. So they have stated it's been super helpful. I know there was some questions initially, is this gonna cause a communication where we have to tell three different people three different things because you know, it increases the workload and they just have not seen that be the case. The communication is working out. And then this is just some of the things from our go by. This is a virtual nurse actually sitting in the hub. She has the headset on. Those on noise canceling headphones because they're all in a hub together. But the patient and it does dampen. It's very directional mic. So they're not hearing the people in the background talk and the virtual nurse is not hearing their colleagues talking, you know, throughout the room. And we do have kind of, we put out some binders on those sides so that they kind of feel like they're in a little and yet they can lean around it and ask for help if they need to. There's another one that's speaking and you can see we blurted out for privacy purposes but they pull the chart right up while they're in there with the patient. They're going through those orders, they're going through the medications so that when they have those interactions they're meaningful, making sure that they're checking everything as they go about their day. And that was just our fun pictures as we were starting there. These, I can't talk about enough I will say. And that is bringing in the bedside staff. So technology is wonderful but it's only as good as the people using it. And it's only sold if we sell the people at the bedside. And I think this has been, you know, this is not the first thing that I've had to help rule out throughout the hospital. In every case when we've rolled out a new process like this, you cannot essentially enough the bedside staff and selling it there because if you don't get their involvement, you might as well write it off. They have to understand it, they have to be willing to embrace it and they have to know how it's gonna impact them. So bringing them all together and we do have daily huddles and meet with them talking about what's going well, what's not going well, what can we do better and how can we make it better for them so that we have buy-in there. And then this is a large overview, it's another layout from another facility, but very similar to what we have. In all cases, they have the three screens so that they can pull out the patient in the overhead large screen. And then the screen's down below, they can see all of the patients and what's going on with them. And then on the left hand side they can pull up the chart so that they're looking through what is needed for the patient. Now the other piece of that, it is bidirectional. So they can actually do a screenshot if they're working through education. So if they have something specific, for example our enhanced recovery patients, there's very specific instructions that they have to go through with the patient. They can take a screenshot of that education piece, turn it around and put it up on the screen for the patient and walk through step by step with them what it is that they need to know before they're discharged or what it is that they need to know while they're in the hospital. So it really helps manage all of those expectations. And we see often that patient satisfaction is built completely around expectations and whether we meet those or not and meeting those expectations is so, so important. You can see in the corner of the room on that one where it says what our patients see. If you look, you can see right below the clock, there is a camera and then that large piece down below is actually the audio piece of that. So, that is the speaker and that is what's working the camera is the small one. They can zoom in from the far corner of the room and tell you what screwdriver you need for a screw. That's on the far side of the room. So you can zoom in, it stays very clear. They can assess IVs, they can assess skin, they can assess whether an IV is infiltrated. They can check drip rates on the pumps to be a second source. They can check ice or fuel reaction they need to if they have a light source. So there is so much that can be done through that camera and it truly is amazing the things that they can do and very little they can't do unless it requires hands on. So some of our quick wins, we have seen an increase in discharges. So what we notice is the physician is going through and they get those discharges put in in the morning and then nursing gets to them when they can. And what we're doing is having the virtual nurses do those discharges. So when they see a discharge pop in, they go into the room, they have the nurse at the bedside. Deliver the ABS and then they literally walk right through it from top to bottom. Talk about medications. They educate the family, they educate the patient, they can see what processes they've had done and they make sure that they get what they need. We didn't have a Comfort Care patient. This was one of our wins on the very first day. A Comfort Care patient that was going on was a language barrier. The family was super worried about taking him home. Very well loved man and they wanted to give him his best care as he would expect, but did not know what to do because they did not speak English and they were able to find their language. The vRN was able to look it up online and get everything translated for them and they were able to optimize that post discharge experience. The family couldn't say enough because when they left they knew exactly what was expected and they knew they were gonna be able to do what they needed to do. Measurement felt success. What we all need because you can try anything but we need to know that it's gonna work. So our lagging indicators, colleague engagement, turnover rate, we are gonna track all of that. Leading indicators, the nursing time and the flow sheet. We have already seen this go down. And then the virtual nurse connections. So interestingly I just ran the numbers this morning on our virtual nurse connections and they're averaging 2 to 300 connections a day per virtual nurse. So you take that many connections off of the plate of a bedside nurse and they have that time to do other things. Other things impacts the patient patient satisfaction falls with injury and because they're rounding and they're able to check on them, we're seeing those go down. And then for leading indicators, the discharge order, time to discharge. And then of course the impact to the organization, the financial metrics and too soon to tell on that for us. But I know they have seen this in that . So I have talked enough. I'm sure you guys have questions. I'm more than happy to answer any that I can.

- Karin, thank you. This is amazing to be seeing this. You're speaking to a crowd of people that have already drank the Kool-Aid about the benefits of Telehealth and I think many of us are trying to figure out how this will be working with our nursing colleagues too. And so really appreciate this. There's a question that came up in the chat from Judd Hollander. Those cameras and those microphone speakers, are those wifi, are they hardwired into the wall? Did you have to like retrofit everything with hardwired equipment?

- Oh they are hardwired, yes. And we did have to do that. Now a lot of hospitals have that already there. I'll be honest, as you know, the newer hospitals especially have already run that. And much of what we have runs off that fiber cable anyway, we had to upgrade on those two specific units because of the systems we were using were older. But I know our Oakland friends did not have to rewire. And I know our Livingston Hospital that's being built with that army run.

- Thank you. Mike Baker, Dr. Baker.

- Yeah. So thank you again so much for coming in and talking with us about what it is that you're doing with the nursing side 'cause I know that a lot of us are focused on the doctor side of Telehealth, but there's a huge, I think option for the nursing side as well for us to be knowledgeable about, know about as they start bringing some of these things into our hospitals and emergency departments. Obviously this is a group of emergency physicians. I know that most of the work that's being done right now is on the floors, but there is a plan at some point to bring this and extend this into the emergency room as well. One thing specifically that you mentioned that you are already doing on the floor at least it looked like you mentioned it, was that you're helping with codes. So could you explain how the virtual nurse might be helping with that scenario? Especially coming from a person who in the past has been a medical director at a very small site where we didn't always have enough nurses to help us with code sometimes and we were getting the security guy to come and help and stuff. So, tell us about that a little bit.

- Yeah, so what we're finding, again, they can't do anything with the hands-on piece of it, but anything that can be done visually. So, they can record, they could be part of that second set of hands watching. Because often we know, especially with newer nurses, the first thing they forget is hands on, right? So the patient goes unresponsive and everybody forgets CPR and it's just inherent in the process. They get so worried about getting the crash card and getting everything else that the main thing that patient needs in the first two seconds is the thing that gets overlooked. So they literally can guide until someone with more knowledge or someone with experience can get there. They can guide those newer nurses through that process. And that's what we're noticing. They're in there quicker. And actually this is a very proactive approach because they watch the trends. So what they're seeing is in the chart, they'll notice that the patient's been tacky all day. The heart rates been in the eighties, nineties, now we've got a trend. They're in the 130s, they're in the 140s, they're checking the census, they're checking for all these other things. And proactively they're telling them, hey, get some help now before it becomes a code because you're headed to a bad place. The blood pressure is dropping, the heart rate's going up. You've got all of these things that are going backwards and you're new enough, you're still checking the box. They have a pulse and they have a pulse X and you think you're good and you're not. So, that's the things that they're able to help with proactively and step in and mentor those nurses is really watching those trends, watching those things. And I can see in the ER where it would be super helpful with some of these patients that come in. We know we have a ton of behavioral health patients now. That can be incredibly challenging. They would be able to help with them and they also can help with those patients that are, you know, with our crowding and with our other situations where we just don't have the staff to stretch. They can check on them more frequently and watch those trends and call things out that might get missed now.

- Thanks, Karin. There's another question about back to hardware questions. Do you have mobile carts? I can see that you know the patient that goes down to CT scanner and you may not be able to have one of the physical RNs go down with them. Are you using for that or for hallway patients? So are you using mobile carts and if so compared to the number of rooms, like how many rooms do you have actually fixed and how many mobile carts do you have?

- That is a great question and it's where we have talked about. We actually started out with 66 hardware rooms is what we've started with. But with the conversation for the ED and what our future is gonna look like, yes we would've mobile cards, it's very possible. And our wifi here, they have upgraded it so it would support this process. So we do have these hardware, we do have a wireless option in answer to the former question as well. And they can put them on mobile carts, they work just as well. And where I see that being super helpful is when our EV is overcrowded as it often is, having them for those hallway patients that we just don't have the eyes on and being able to run on them and consistently take care of them. They are talking about that it would increase your capacity so those hallway patients are cared for in a better way and then they would be hardwired in the room. So the rooms would be hardwired, the hallways would be carts.

- So, to follow up on that question, maybe you can address this. You know and most of the people on this call know I run the telemedicine program not just in the ED, but enterprise wide and we are entering the virtual nursing, virtual safety observer tele-space reasonably aggressively, but it's reasonably costly and I'll share numbers that are not proprietary. For us to drop wires in the room and replace a TV for a two-way camera is, you know, $3,000 to $4,000 per room in our relatively old hospitals which can support wifi on mobile but couldn't support wifi on 30 rooms on the same ward. So we're trying to figure out the balance in that. When we've done and we've had from the C-suite, intense pressure to, you can spend the money but tell me what you're cutting, like don't tell me it's nursing turnover or patient's gonna go home an hour sooner 'cause we're doing 12,000 things to reduce length of stay and you can't tell me the toy you're mounting on the wall is gonna be the thing that does that. So our ROI is built around the easiest thing to build ROI around, which is a reduction in one-on-one sitters for non-suicide patients and converting them to tele-sitters. And the magic number for people on this call is removing four one-on-one sitters and replacing them with one safety observer remotely basically pays for the cost of your devices and the wire install. But it's easier for us to do the safety monitoring with mobile devices because it's really hard to make sure that everybody who needs a sitter ends up in a room with a fixed device. How are you dealing with that and how did you convince or whoever convinced your institution to allow you to begin this without like, there's obvious benefits, everybody could see that, but it's not quite as obvious what the impact on virtual nursing without sitting is on finances. So how did you walk that line and how did you make that work?

- That's a great question. So the answer is, we had a sister hospital that went first and paved the way is the true answer for that. And when they started, you're right. Initially, if you pick one section, it is not cost effective. So if you have two units, it's not cost effective, but what you find is the further you spread it, the more cost effective it becomes. And so that hospital started out with two units, they now have just brought the entire hospital, they're in the process of. So the entire hospital is going to be that way. And as you do that, you're able to spread the staff over further patients because initially with two units you have a virtual nurse on each unit, but as you stretch that out, it becomes more and more spread and the cost goes down because they each one take 20 to 25 patients. So you know, if you have seven units, you're not gonna need as many as you do for two. So it just piece for itself as you stretch it. And then the true story is then you have to look at everything else that's going with it. So they told the story for us and then we didn't have such a big sell to get there, but they have been able to show us through patient satisfaction, staff engagement and the fact that on the units that have vRNs, they literally have decreased their turnover from 30% down to 12. So when you see that kind of long-term decrease it does. Right now it's 60. I think they said 65,000 was our average to train a new RN. So if you go from a 30 to 35% turnover down to 12%. It doesn't take too long to pay for the cables.

- And so who are your virtual RNs? Are they, you know, old ready to retire people, young people? Do they only do virtual nursing or are they people who rotate out for a break? How have you found it best to, you know, select the virtual RNs?

- So the answer to that in most cases is yes to your question. It's a little bit of all of the above. So we do have some that were ready to retire and have decided to stay on for additional years because they're still valued at what they are doing. The vast majority of those I would say are the new though. Those 30 to 40 years olds who were getting to the point where they were either gonna go back to school because they didn't wanna be at the bedside any longer or they were gonna pursue something else. And a lot of them are the ones that have latched on and said, you know what, I love this. I'm able to mentor the new ones and these are literally that I'm quoting that I've heard over the last few weeks. I love being able to help the newer nurses. I feel like what I do is worthwhile. I feel like the patients are happy we're here. I feel like I'm making a difference and I'm seeing what I'm doing in real time. So as I'm helping the patients, I'm having good interactions with family members where at the bedside sometimes you get the bad end of that. They're seeing the good end because they're incredibly thankful for any help they get them and they're more careful with their interactions, which is a little curious to me over the TV than they are in person. So they're less apt to say and do things that they might do when you're at the bedside. Maybe it's that comfort level, I don't know. But they're much more appreciative of the care that the RNs provide and they often talk about their vRN. Sally is gonna be checking in just a minute. I have to go because they know what the schedule is and there's a trust that's built throughout that. So I was up in the vRN hub the other day and I heard one talking and literally the patient was sharing stuff and the vRN was knowing them, how proud they were of them because they were doing the things they needed to do after surgery to recover and had such a great interaction. So I'm seeing a little bit of all of that and then we have, you know, we don't take anyone with less than eight years of experience, so we do not have any grants doing this. They are meant to be truly the clinical experts that are providing this care. But even for the ones that have only been on a nursing school for eight or nine years, they're finding incredible value in it. So I just see where this is going to help us. I do think it's going to be a situation where we have people competing to get there because they love that. That work so much.

- Thank you.

- And Karin, one other piece I think of the question he had too was are any of the ones that are the RNs, is there either a requirement? Sounds like not a requirement for them to also do like one in-person shift a month. Or do some of them do some in-person or is it really, once they do this they don't go back and they're always virtual or it's up to them?

- It's up to them, but we have chosen right now not to have them go back and forth. A big share of work is organization and the flow for your day looks very different as a vRN than it does as a outside nurse. And what we don't want is that role confusion where someone tries to do both sides of that because that causes chaos with the patient care. You truly do have to keep everyone in their lane, communicating well but doing what they're supposed to do to make this work. Otherwise the team falls apart. And as long as they have those clinical skills, they're gonna be fine. They're not doing the hands-on things but you don't lose the knowledge that you've learned and they're able to talk people through it. So and we talk to our sister hospitals, they have chosen to do the same thing so they do not go back and forth.

- There's another question sort of in the same vein with what would the ideal, this question in the chat. Ideal virtual nurse to bedside nurse ratio. And I'm curious too, adding onto that, is this in any critical care units or is this only on the floors? So, and if that would change obviously the stashing ratio.

- So another really great question. We have talked about that. Our hope is eventually was we do the critical care units. We're not there now, but our hope is to do that when we go house wide. And I mean the rationale is the same in all honesty and if not more needed there because of all of those high-risk drugs, everything else that's going on, everything is just more in a critical care department and much as it's in the ED, right? So you want that extra set of eyes. You want that mentorship. You want because we have new grads everywhere and they need the support, they need the help to make sure that we're giving safe and good care for our patients. So I can see we're it will benefit in every area of the hospital. Currently our ratio ratio, I should not use ratios, our workload, they don't like ratios. So our workloads, so our one virtual nurse to 20 to 25 patients. So it's all in patients speak rather than nurse speak. And then the bedside nurses. So we do have a different workload for PCU versus GMB. Our GMBs, it's one to seven and that would be a nurse, an LPN and at the bedside and then vRN, they have 20 to 25. So they would have, if you're looking at nurse-to-nurse workload, it would be one to three if it's not exact on that patient because the patient assignments don't always line up exactly. We try to do them as closely as weekend so that there's not a ton of overlap where they're getting pulled multiple directions. And then on the progressive care side, it's one to six and one to five. So on days one to five, one to six and then again, the vRNs are the same number, so 1 to 25-ish.

- What do you think, given your experience with this so far, what do you think might be some of the challenges? I dunno if I wanna say challenges or the actual opportunities in the emergency department with using this. Things that we would probably be surprised by. With all the experience you have of what you'd think would be a problem there.

- I think in all honesty, the technology has not been a difficulty at all. I'll tell you that the technology we work with, you know, these generations have worked with technology all their lives for the most part now. So, that is not an issue. And I think the thing we were most surprised by were the ages of patients that were so engaged with the technology. So on both of these units, our average age of patient is 60 plus and they have been fully embracing this process. They love it. Because most of them during COVID, their doctors did home visits over FaceTime. And so this is not new to them and they love it. And they feel more cared for, they feel safe. I think the thing that will be the biggest challenge and it has been everywhere we've gone live, we did pick the brains of the team that came to help us go live and said, has this been the case everywhere? Their answer at unequivocally was yes, and that is the team. So team work and I think in the ED, they're used to working as teams so they probably don't struggle as much as some of the forced to, in all honesty because they depend on each other to get through the tough times and everybody dives in because every patient is everyone's patient when they're not doing well. So I think in the ED that it probably would be a much easier sell in all honesty, where the challenges on the floor, we have struggled with that teamwork because the nurse has been used to owning those patients and it's my patient instead of our patient. And so we have had to really climb quite the hill to get them to release some of that and know that it's still safe and it's still okay.

- Then it looks like another question here in the chat. I think you might have answered this too. The nurses, the vRNs do the sort of when a patient comes up the floor, the initial intake and or like the social determinants of health questions and safety and so those are things that they do on the floors, the virtual side?

- Yeah, they go through. So anything that is a questionnaire that is currently answered, they can work through for and some of it's for the physicians as well, but they can do it and it doesn't take time away from the bedside where everybody's already feeling strapped for time. So it has really been a huge help. I know the first week that we went live, one of the teams had 15 discharges in the matter of like five hours. And then they turned around of course, as we all know, had 15 admits in the matter of about four hours, which hit so hard. But it was so much help for them that was the biggest win that we had because they said, wow, we normally would've felt like that was a day that wasn't doable and we were able to get through it and together it made us so much easier because they're able to take so many of the tasks off the plate of the people at the bedside.

- Other questions. Judd, I'm trying to see because I know you're trying to get this all set up throughout that enterprise there. I'm trying to anticipate your next question, but I can't right now.

- No, I mean we've done a unit with about or two units with about 35 patients with virtual nursing and we have more than a hundred remote tele-sitting devices deployed. We're now actually thinking of like, actually honestly the nurses are more enthralled with the mobile devices and I'm more excited about fixed devices. So we're going forward with really a compromise where we're putting, you know, I think it's 88 fixed devices in and we're upgrading our mobile devices, which is a little more than a hundred and we're gonna see what works best. So internally, you know, we'll do this, but you know, it's fascinating to see the little hiccups that arise and I think you know, everybody said it best. The technology's not the issue. I mean honestly you could set this up with a million different pieces of technology. The ability to zoom in and see the IVs and read what's on the pumps is, you know, really nice for the nurses. But what's really just important is how you sell this, because I think there are a million good things about this, but we have such a capitally constrained environment right now that getting money to do anything is hard. and you know, I may have said this story to this group, but I went to present the whole nursing program with our CNIO to our operations council and C-suite to get money. And one of the ways we save money is PPE, right? You don't need to go in the room, you don't need PPE. And we did a calculation of exactly the number of people on isolation, how many of them would qualify, how many masks, how many gloves we'd save a day, assuming just 10 contacts with each of them a day were transmitted from in-person to virtual. and in the rooms we were gonna put it in, it was $1.05 million. And I'm like, paid for the whole program just on PPE alone, forget all the other things. and the answer from our health system president was, "No, we don't." I said, "It's math, it's simple math." He said, "I trust your math. What I don't trust is our supply chain. We'll order less PPE. And the difference is rather than being used on your wards, it'll be sitting on a pallet in a warehouse. So I'm not really gonna save a penny." So we've gotten really pushed and you know, I've learned a kind of a bit more staunch financial way of thinking about it that you can't spend X unless you're gonna cut Y. And that's the way we're looking at it. And there are a lot of great things, but I'm not allowed to use nursing turnover until I prove I can use nursing turnover. So Yale has a brilliant way of doing it. They're gonna be rolling out the program, they're gonna start, they're gonna spend money. They ask for it in one tranche, may I'll call it a ward, but it may be larger than a hospital unit. And then they're gonna show the ROI there and say, take the money. They save there to do it in a second and a third and a fourth, which is, you know, a really nice approach as well. But it's the technology. There's great technology out there, the use cases are brilliant. The patient satisfaction, you know, out at Trinity and other places that are doing it, as you heard, patients love it. It's all a question of dollars.

- I'm looking through the chat for a couple of other questions 'cause I know looking at the time we are coming to a close. One was the question, and I think that this is true, that the virtual nurses documentation, so the history and admission or any of their progress notes go directly in and hopefully they sign it right away or share it right away so they're able to. So the bedside nurses can see the information right away. Is that true?

- Yes, that is absolutely accurate. And honestly, we were worried. I'll be honest, as the one trying to get this off the ground, I was incredibly worried about the communication piece because communication is key and I could see how this could create a lot of issues. And when we first rolled it out, we were talking about it and I was meeting with our IHA physicians, our in-house physicians. And their big concern was we don't wanna have to continually repeat ourselves, right? We don't want somebody to call us. And then the bedside nurse calls us, the vRN calls us, the LPN calls us and we're constantly answering pages all day long because they're not communicating. So our ask and our mandate when we started with the vRNs is everyone charts in real time so there is no rounding and then charting three hours later. When you're in the room and you're rounding, you're charting right then. What you're finding, how it's going, what you talked about, what went on as you've had those communications, if they speak to a physician, the expectation is they either communicate via directly to the bedside nurse or they make a note in the chart or goes through secure chat so that everyone sees it together so that those communications are occurring and we don't have, you know, three-way communication that's just creating chaos in the background or someone does something and then someone else goes back in and does it again. It took a few days to get that down, I'm not gonna lie, it was not perfect to start with, but the feedback from the patients was, I already was on by the vRN as the bedside nurse came in. So they started looking to see if the rounding was done. If the rounding was done, they would go to vaccination and that is how they really saw the improvement in their time management. And that also is how the physicians found an improvement in orders and beds, everything else that occurs because those text messages, those went down and they're not getting paged as often because things are being communicated better.

- Great and then we're gonna take this as the last question that's in the chat, so we do. We're coming up to the hour. Patients that are, are there a list of characteristics or patients that are not appropriate for this? That you say that this patient cannot have a virtual nurse or any other sort of limitations that way?

- So I'll tell you when we were getting ready to start this, that was the main question that we got from almost everyone other than workload was how is this gonna help us? Because you know, half of our patients, I have altered mental status or half of our patients are too old or half of our patients are whatever. I don't know that we have had a single patient that has refused in all honesty. We are presenting it. They're part of the care team. Would you ever say that a nurse can't take care of a patient? If this is your nurse, this is how you're getting your meds for the day, right? And so that's how it's presented. This nurse is your nurse for the day, not in the room but on the TV. And this is just part of the care team. Much like the physician, you would not say, I don't want a doctor in my room today because you are here for a reason. The physician has to be there, so does the nurse and they're giving care. And so that's how we presented it. It's in all of the paperwork that we give them from the very minute they enter the unit. So it's just an expectation. And then we have cautioned everyone. If someone adamantly refuses, then you know, we'll give them some time, do some more explanation about what it is and try again. But we honestly haven't had to do that. We tried to plan for it and we just haven't seen it come to fruition. Everyone has embraced it. And I think the one patient that was, as I say that we had one patient that was a bit of a challenge. It was day one when we went live and they hadn't gone through and told all the patients what we were doing and the patient heard someone talking and didn't know where the voice was coming from and got and was afraid. So once they explained to them what was going on, they were okay. And then we had one demented patient that thought God was talking to them so they had to talk to them. But it worked out good because it calmed them down for some reason and they were happy. So we were fine, but there is really no patient that it's not appropriate. It may change their workflow. So if they may do different things with different patients based on mentation, development stage, whatever the case may be. But there are things they can do with all patients and there's workloads that they can take off of the hands of others.

- Great. Thank you so much Karin. I think that this is something that what you're doing is amazing and I think it's really put a lot of good thinking for the people on the call and those who are gonna be watching this video later on of how these tools of Telehealth, how they're being integrated into care models to, for this one, help out with the shortage that you had and to be able to leverage people's scope of practice and experience differently than we had before. Now that we have the technology. But it's just great to see. So thank you for sharing. Thank you for doing what you're doing and sharing your experience and I hope that if there's other people that have questions, if you don't mind, we might share your email. Is that okay? We can share it with people if they have questions, we can do that. And I wish you luck as you guys keep expanding.

- Thank you so much. Thank you for this opportunity and thank you for supporting this process.

- Yeah. All right everybody, thank you. Have a great rest of the holiday season here and we'll see everybody in 2024. Thanks everybody. Take care.