Avera Health, based in Sioux Falls, South Dakota, has been at the forefront of virtual care since the mid-1990s. But with the arrival of COVID-19, the organization was challenged with revisiting its telehealth strategy to reduce virus spread while still providing essential care services to its rural communities.

Avera undertook a multifaceted approach to safer coronavirus diagnosis and treatment through telehealth, including a COVID-19 hotline, virtual visits and a hospital-at-home program. Its internationally recognized eCARE model helped to protect clinicians and staff in the emergency department, even when they were performing high-risk procedures.

Prompt diagnosis and treatment

There are a few keys to Avera's approach to promptly diagnosing and treating patients during a pandemic, said Dr. Andrew W. Burchett, chief medical information officer at Avera Health.

"During the COVID-19 pandemic, Avera, like many healthcare organizations, was challenged with maintaining a high level of care for its community, while reducing the risk of disease spread among patients and hospital staff," he said.

"It did this by undertaking a multifaceted approach to diagnosis and treatment, using technology to serve its community's needs while minimizing unnecessary in-person interactions."

This strategy included four main elements.

"First, the COVID Clinic, a process for coronavirus screening," Burchett said. "Patients seeking testing call a hotline nurse – who then triages patients based on symptoms, exposure history and medical problems, and directs qualifying patients to a drive-up COVID testing center. Patients are swabbed in their vehicles by an employee in appropriate PPE."

Second is hospital-at-home – remote monitoring for mild-illness COVID-19 patients who are recovering at home.

"Patients are given a thermometer and pulse oximeter and report data from these devices to the hospital-at-home program run by Avera physicians and nurses," he explained. 

"Select patients deemed higher risk are given an HRS remote patient monitoring device and home oxygen if needed. The HRS platform provides more comprehensive data, including oxygen saturation, weight, blood pressure and temperature. It also presents patients daily questions regarding their symptoms.

"If patients begin to decompensate, physicians are immediately able to triage them for direct admission to the hospital, allowing them to bypass the emergency department and minimize exposure to other patients and staff," he added.

Virtual care for non-COVID-19 patients

Third is virtual visits for non-COVID-19 patients to continue receiving routine care at home.

"Telemedicine for routine patients has become the new standard in primary care and subspecialty clinics at Avera," Burchett explained. "Endocrinology, psychiatry, dermatology and cardiology are a few specialties where virtual care has been critical."

And fourth is Avera eCARE, which allows care for severe COVID-19 patients in the emergency room while minimizing risk to hospital staff.

"Avera has embraced this approach in subspecialties clinics, as well, protecting physicians who may be one of only a few doctors providing care in their field throughout the region," he noted. 

"Endocrinology, psychiatry, dermatology and cardiology are a few specialties where virtual care has been critical. It is clear from Avera's model that telemedicine can and should be embraced in all areas of medicine, not just primary care, in order to prevent the spread of the virus, cancellation of appointments, and delays in care for patients."

Other services, like chaplaincy, social work, case management and music therapy, have been able to use virtual platforms to continue interacting with patients.

Protecting patients and caregivers

"By embracing multiple forms of technology and having a commitment to adaptability, Avera has been able to provide compassionate care to these most vulnerable patients and protect them and their caregivers from exposure and disease," he said.

When a patient presents to the emergency department at Avera, they are first triaged by a staff member at the front door to determine if their visit is coronavirus-related or if the patient is experiencing symptoms of coronavirus.

"Patients triaged as potentially suffering from COVID-19 are put in designated rooms in the emergency department – specifically, rooms in a single hallway to prevent non-COVID patients from as much exposure as possible," Burchett said.

"From there, the patient waits until a nurse enters the room wearing goggles or a face shield, an N95 mask covered by a surgical mask, a surgical gown, and double gloves.

"This nurse uses the Avera eCARE system to call a physician outside the room, who can then speak with the patient and do a full history," he continued. "This physician can either be on site using an iPad, or one of the physicians off site at the Avera eCARE telemedicine hub. The nurse can provide initial vital signs, as well as obtain the COVID-19 swab."

Step-by-step for physicians

Once the history and swab are obtained, the physician on site typically dons the same PPE to do a physical exam or perform any necessary procedures.

"If a patient is very low risk and has only mild symptoms, the physician may not need to enter the room at all," he said. "This initial triage system allows for the minimum exposure possible for both the physician and that physician's non-COVID emergent patients. It also saves PPE by allowing for minimal visits into the patient's room, as the gown and gloves must be doffed before exiting.

"The physician can still regularly check in with the patient, answering their questions and providing instructions as needed via the video system," he added.

Burchett will offer more detail during his HIMSS21 session, "Virtual Care in the Age of COVID-19 and Beyond." It's scheduled for August 11, from 2:30-3:30 p.m. in Venetian Marco Polo 701.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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