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1 – Cross Coverage: responding to the calls from hospital nurses across five hospitals. 

The team receives all the messages into a special email folder that is updated real-time. 

The RN would take the easiest calls: prn sleep meds, prn laxatives, ordering morning labs, etc. A lot of the orders were by default, so she would not need to discuss them with an MD or NP. 

Our RN would also help with admin stuff, e.g., getting ahold of a certain floor or a particular service department in the hospital: e.g., lab, microbiology, blood back, etc.

The MD and NP took care of all the other more complicated calls, although the MD was responsible for ICU calls most of the time.

What were the most common calls/messages we would see?

Hypotension, low H&H, other critical lab results, tachycardia/bradycardia, pain meds, patient requesting to leave AMA (my favorite: Really? At 2 am? Don’t you want to sleep?).

Volume:

The average number of calls the telehospitalist team would “process” was close to 300.

Interestingly enough, there were a few very busy times at night: 

Evenings when RNs changed shifts, then 4-5 am when morning labs were back, with a third peak around 7-8 am when morning shifts started.

The time between 1-3 am was a little slow, so I managed to take short naps.

Liability and documentation:

Of course, the liability part is there even if you cover patients virtually.

Think about it: as a telemedicine hospitalist, I was covering almost 500+ very sick patients, some of them in ICU’s.

I came up with my own strategy to provide better “virtual” patient care for the patients and to minimize the liability:

First of all, almost every time I got a message, I picked up a phone and talked to the nurse to clarify the patient’s status and ask questions. I would also glance at the last hospitalist progress note to get a better understanding of what was going on with the patient.

This approach made a big difference, as I caught myself changing my orders after talking to the nurse and reviewing the chart multiple times.

Second, I would also put a note in the chart, documenting what info I’d gotten from the nurse and what new orders or changes I’d made.

These notes were also important for day hospitalists to make sense of what actually happened with the patient overnight.

Now, you may be wondering what if a patient were too sick and needed to be evaluated? 

When this situation came up, I would call an in-house doc and ask him to lay eyes and hands on the patient.