Virtual Daily Rounding for COVID-19 Facility Outbreaks: A Standardized Telehealth-Centered Approach May Reduce Hospital Transfers and Mortality

Introduction

The vulnerability of postacute and long-term care (PA/LTC) facility residents to COVID-19 has manifested across the world with increasing numbers of PA/LTC outbreaks associated with high hospitalization and mortality rates. ¹ As of February 2021, in the commonwealth of Virginia, although PA/LTC facility residents account for 4% of total COVID-19 cases, they represent a group that carries the disproportionate burden of 41% of all deaths and 94% of outbreak-associated deaths. ² This disproportionate number of outbreak-associated deaths among PA/LTC facility residents underscores the medical vulnerability of this population. PA/LTC facilities must implement Centers for Disease Control and Prevention guidelines to support PA/LTC facility preparation to prevent the spread of COVID-19. ^3,4 However, systematic protocols to guide specific health decisions to respond to COVID-19 outbreaks have yet to be delineated.

Methods

As described in detail in previous publication, ^5,6 virtual daily rounds is a component of our interprofessional COVID-19 Outbreak Response, after rapid response kit delivery and training, infection control consultation, and resource integration for facility needs, such as personal protective equipment (PPE) or staffing. We describe the implementation of virtual daily rounds as a tool for increasing hospital and facility collaboration at a rural facility with large COVID-19 outbreak.

This facility had no known COVID-19 positive residents until two staff members tested positive, followed by five symptomatic residents for a 3-day period. Our team was contacted for assistance with clinical support in this facility. Owing to staffing limitations, we initiated virtual daily rounding 8 days later. Telemedicine pulmonary consultation has been shown to be effective in increasing treat-in-place and improving care co-ordination between the facility and the hospital.

Virtual daily rounds were initiated to create a systematic approach in care of these patients. The goals of virtual daily rounds include (1) facilitating HIPAA-compliant communication between nursing and all providers efficiently, (2) rapid identification of patients with clinical decline, (3) facilitation of care escalation, (4) care co-ordination to facilitate bidirectional transfers between the facility and the hospital, and (5) rapid and efficient identification of patients appropriate for telemedicine pulmonary consultation. Virtual daily rounds were held each morning, allowing for the nursing staff to record vital signs on all COVID-19 positive or suspected residents. Facility nursing would then send the vital signs through encrypted e-mail to our COVID-19 Outbreak response team to review before rounds. Virtual daily rounds were held through HIPAA-compliant Web-based video interface (WebEx). The virtual daily rounds were attended by our team, the primary care provider for each patient affected, and facility director of nursing (DON). Our hospital-based team included pulmonary/critical care specialist, geriatrician, and telemedicine nurse liaison, as was supported by our telemedicine team.

The structure of virtual daily rounds is shown in Table 1. DON would first highlight any residents of particular concern or significant changes overnight. The group would then review clinical status of each resident (vital signs, clinical change, or concerns) individually and identify any patients with signs of clinical decline (Table 2). Residents identified with signs of clinical decline would be discussed in detail and primary provider had the option to request a telemedicine pulmonary consultation. Next, our team would provide clinical updates of hospitalized residents, so as to facilitation anticipation of discharge to ensure facility would have adequate staffing to accept transfer and co-ordinate with hospital team. Final part of virtual daily rounds would serve as the opportunity for primary provider to ask any additional questions on COVID-19 care and for facility to highlight any particular needs for assistance (e.g., PPE, staffing, and testing co-ordination).

Virtual daily rounds were made possible by outreach efforts to connect long-term care facilities with community and clinical resources. The trust and familiarity established through prior interactions with the nurse liaison and specialists through Project ECHO improved the willingness of facilities to participate in virtual daily rounds. The combination of telementoring sessions, periodic check-ins with the nurse liaison and virtual daily rounds, was intended to increase PA/LTC facility staff resilience, recognize stress, and employ strategies to mitigate the negative effects of stress, recognize and reduce unnecessary stressors in the workplace so that team members could function optimally feeling supported and back stopped by hospital-based specialists.

Results

The outbreak remained active for 6 weeks, 82 of 136 (60.3%) residents were infected and 36 of the COVID-19 positive residents (43.9%) were seen by telemedicine pulmonary consultation. There were 57 COVID-19 positive residents (69.5%) who were able to remain in-facility for treatment. During the outbreak, 21 residents died (25.6%), with 10 deaths occurring in facility and 11 occurring in the hospital. Of the residents seen in telemedicine pulmonary consultation, 24 (68.5%) were able to actively remain on the treat-in-place protocol with symptomatic support and goal-concordant care from facility team in co-ordination with hospital pulmonary consultant. The hospitalization rate of 31.5% and mortality rate 25.6% seen in this outbreak are significantly lower than initial COVID-19 outbreaks at other facilities, 56.8% and 28%, respectively. ⁷

Virtual daily rounds were initiated 8 days into this outbreak. All COVID-19 positive residents were reviewed each day. Each session was attended by resident's primary care provider, our team, and facility DON. All virtual daily rounds concluded in <30 min.

From discussion during virtual daily rounds, telemedicine pulmonary consultation was requested for 36 residents with COVID-19 infection. Reasons for consultation and visit outcome are shown in Table 3. Of the patients seen through consultation, 24 (66.7%) were able to remain on the treat-in-place protocol with symptomatic support and goal-concordant care.

Discussion

Telemedicine is a useful tool for use in care of medically vulnerable residents of PA/LTC facilities experiencing COVID-19 outbreak. There has been no protocol to date for systematic identification of residents appropriate for telemedicine consultation. Our COVID-19 response team utilized telemedicine consultation as one component of an interprofessional response. Virtual daily rounds were found to be an effective and efficient way to bring providers and nursing staff together to discuss all COVID-19 affected residents in systematic manner. Virtual daily rounds allowed for identification of subtle signs of possible clinical deterioration, as well as improved transparent communication between care sites.

One of the main delays to the initiation of daily rounding was the facility nursing staffing and concern for an additional responsibility. Ultimately, however, staff found the virtual daily rounds a favorable experience to increase a sense of open communication for hospitalized residents as well as streamline communication with primary and specialty providers. However, moving forward, facility staffing during a COVID-19 outbreak remains a challenge and was the main barrier for residents who were unable to be seen by consultation.

Conclusions

Residents in PA/LTC facilities remain at high risk for poor outcomes of COVID-19 infection. Integrated care with facility clinical team and hospital-based specialty team can lead to lower hospitalization rates and increase of goal-concordant care. We are continuing to implement this model as needed for facility outbreaks. We believe this provides a systematic approach for communication and care co-ordination for residents in PA/LTC facilities during this COVID-19 pandemic and beyond.

Ethical Approval

The University of Virginia IRB deemed this program and evaluation not human subject research and not subject to IRB approval on April 23, 2020.