Wake Forest Baptist Health

Chi-Cheng Huang

The COVID 19 virus has been a disruptive innovator in the healthcare industry over the last two years. Cliché as it may, disruption often stimulates growth and doing things differently and possibly better. This 0.1 micron virus led to an mRNA vaccine being developed in less than 1 year along with the development of medications such as remdesivr, baricitinib, nirmatrelvir and ritonavir.  Unfortunately the COVID 19 virus also caused 6.2 million death and approximately 2.9 trillion dollars in economic losses worldwide.  Although the concept of telehealth has been discussed for decades, insurance reimbursement, risk taking, and concerns about safety led to inaction at worst and cautious optimism at best.  The delta and omicron surges created the needed stress test on health system around the world and the United States.  Specifically at Atrium Wake, we have created and implemented Hospital at Home, Inpatient Teleconsults and Virtual Hospital over the last two years.

In the winter of 2020 with the support of senior leadership at Atrium Wake Forest Baptist  and the Atrium Wake University Group Practice along with the collaboration of Atrium Charlotte, Dr. Padageshwar Sunkara, Dr. Raj Nagaraj, and John Blalock launched the Hospital at Home Program in Winston Salem, North Carolina and its surrounding areas. We collectively identified patients that could be safely discharged from the inpatient service.  These patients often required additional treatment such as continued monitoring for COVID 19 requiring multiple liters of oxygen supplementation or intravenous diuretics for acute on chronic congestive heart failure. With the agreement of the patient, the clinician discharged the patient from the hospital with specific instruction for Hospital at Home (H@H) follow up team.  A few days after discharge from the hospital, the paramedic in the ambulance arrived at the patient’s home at the designated time and conducted a synchronous visit with the inpatient physician or advanced practitioner. Depending on the clinical scenario, the visit consisted of reviewing of discharge medications, checking the vitals, conducting a physical exam, performing lab draws, providing intravenous medication and discussing clinical direction.  Our initial evaluation over the last two years have preliminary yielded lower 30 day readmission rates and sustained patient satisfaction scores.

“Although COVID 19 ignited the spark, it paved the path that our healthcare industry needed to spur innovation in telehealth”

As the COVID 19 hospitalization continue to surge in 2020 and 2021, inpatients at the network hospitals and rural hospitals had challenges transferring patients to the tertiary academic center that required subspecialty consultations. Under the leadership of Dr. Shayn Martin, Dr. Brian Heistand, and John Blalock, the inpatient teleconsults were started at Atrium Wake.  This innovation allowed for subspecialists to see patients in a synchronous manner of inpatients at the outlying hospitals.  Typically in the morning, the onsite clinician requested the consults through the electronic health record (HER). Afterwards, the administrative staff helped the clinical team arrange the synchronous virtual consult with patients in the afternoons.   A free standing smart tablet on wheels allowed the virtual consultant to discuss with the patient and the nurse the clinical case at the bedside. Afterwards, the consultative recommendation was either discussed or placed in the medical chart for the primary attending of note. The process not only permitted timely consultation but improved triaging capabilities of patients that either only need the consult versus required to be transferred to the tertiary hospital for such interventions such as carotid endarterectomy, coronary artery bypass grafting or thrombectomy. 

In winter of 2021 as a snowstorm and other competing factors hit western North Carolina, we started the virtual hospital program at Wilkes Medical Center which is designated to be in a critical access site by CMS. Upon its inception on Christmas Eve 2021, patients of lower acuity were designated as possible virtual hospital patients with their permission.  Under the leadership of Dr. Harsh Barot, our virtual healthcare providers synchronously had rounds with our nurses at the bedside.  The virtual cart was able to conduct a physical exam with our tele-stethoscope in which the clinician could auscultate the heart for murmurs, the lungs for rales, and abdomen for bowel sounds.  Moreover, the camera pivoted 180 degrees and we were able to have discussion with the patient and families in a multidisciplinary fashion. Our on-site clinicians facilitate any opportunities that may arise such as a rapid response or bedside procedures.

COVID 19 has been the disruptive innovator that our healthcare industry needed to spur innovation in the telehealth. Hospital at Home, Inpatient Teleconsults, and Virtual Hospital provides care in a more efficient manner while not compromising quality or safety. The true beneficiaries are often our patients, their families, rural hospitals, and traditionally marginalized populations who may not always benefit from tertiary care access.