e-Emergency Services Bring Specialists to Rural Patients with the Push of a Button

by Candi Helseth

One afternoon Leonard Hajek sat down to read the newspaper and got ambushed by crushing chest pain. His wife, Audrey, helped him into their car and sped to the local emergency room at St. Michael’s Hospital Avera, a 25-bed critical-access hospital (CAH) in Tyndall, SD. Still conscious in the ER, Hajek was astonished when an e-Emergency physician in Sioux Falls 75 miles away began talking to him from a screen that Hajek thought was a television.

St. Michael’s is among approximately 60 rural sites in South Dakota, Iowa, Minnesota and North Dakota that have signed up for Avera eEmergency Services, a hospital-based telemedicine emergency support service provided by Avera Health in Sioux Falls.

From an operations center at Avera McKennan Hospital and University Health Center, board certified emergency physicians and emergency-trained nurses assist rural ER staffs 24 hours a day, offering treatment advice, initiating diagnostic testing and streamlining the process if critically ill patients need to be transferred.

“I didn’t have any idea this existed,” Hajek said. “The nurse pushed a button and just like that this doctor is on a TV screen talking to me. He says, ‘Leonard, how are you feeling? Explain it to me.’ Then he talked to the doctor in ER about what they all were doing for me. It really got my attention. It was like I had this big-time cardiac surgeon standing right beside my bed. It’s pretty amazing.”

As telehealth expands, clinical applications are virtually placing emergency physicians, neurologists, intensivists (physicians board certified to provide critical care), pharmacists, cardiologists, dermatologists, psychologists, and wound and infectious disease specialists in rural community hospitals whenever their expertise is needed. Avera moved into the virtual world in the 1990s with eConsult, live doctor-patient consultations via closed circuit television. Avera eCARE Services, which began in 2003, include eICU, eEmergency, ePharmacy, eStroke, eConsult, eNursery and eUrgent Care.

Patient Outcomes Improve

Brian Skow

Dr. Brian Skow, a physician with Avera, consults with a patient in a distant hospital via his computer.

“eEmergency, Avera’s most highly requested eCARE service, has reduced patient length of stay, patient transfers to tertiary facilities and overall costs,” said Deanna Larson, Vice President of Quality Initiatives and eCARE Services. “Clinicians at the remote sites report high levels of satisfaction with the program.”

Northern California-based Sutter Health was the first health care organization on the West Coast to connect a rural hospital to eICU in 2003. Deaths related to sepsis have decreased 28 percent system-wide and ICU patients’ lengths of stay have decreased by 15 percent from 2007 to 2010, according to Sutter’s most recent documented data.

“More than 1,300 lives were saved,” said Teresa Rincon, Sutter Health eICU nurse director. “The eICU plays a vital role in our system-wide efforts to combat sepsis, a life-threatening illness that is triggered by an infection and can create a massive inflammation response that overwhelms the body. Medical staff, eICU nurses, and intensivists work together to more quickly detect and treat the infection and the cascade of life-threatening symptoms that occur in these critically ill patients.”

Sutter Health currently has more than 30,000 critically ill patients being monitored from eICU hubs in Sacramento and San Francisco. In Sutter’s eICU system, intensivists and ICU-trained nurses use early warning software and advanced video and remote monitoring to constantly check critical care patients for any sign of trouble. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) featured Sutter’s eICU barcoding and electronic health record system in a national videoconference report highlighting innovative telemedicine programs.

Hospital ICUs have the highest mortality rates but eICUs are saving lives, shortening ICU stays and enabling community hospitals to treat more patients because of improved efficiency, according to Critical Care, Critical Choices: The Case for Tele-ICUs in Intensive Care, a study published by NEHI and Massachusetts Technology Collaborative. The study also notes that the number of patients and severity of illness are increasing while intensivists are decreasing in number.

Support Strengthens Rural Providers

Dr. Jill Kruse, a family medicine physician at St. Michael’s Hospital, was on the verge of burnout prior to e-Emergency. Three years ago, fresh out of her medical residency, Kruse began working at St. Michael’s. She had more experience working in rural areas than most new family medicine graduates because she’d trained in a Rural Training Track. Still, she said, being the only physician on-call for emergencies was overwhelming.

“You’re really alone out here a lot of the time,” she said. “I went from my residency where I was supervised and always had a colleague or attending physician to consult with to my first weekend on-call here when I was completely alone. As a brand new grad, I had no one to turn to or ask questions because the other two doctors in my practice were both out of town. Our ER isn’t staffed 24/7. Having e-Emergency has helped when I’m on ER call now. It means there is another doctor instantly available who I can consult and who is going to be helping if I need it. It makes me feel like I’m not as isolated practicing here.”

e-Emergency also offers a valuable second opinion, Kruse said. Late one Friday in June, a mother brought her child to Kruse, saying the four-year-old cried in pain when she tried to walk. A physical exam and X-rays didn’t reveal any breaks or fractures. Reluctant to send the child home over the weekend, Kruse turned to e-Emergency for a second opinion.

“When they say a picture is worth a thousand words, these videos are worth a million,” Kruse said. “I’m not a critical-care pediatrician but that child had access to one with this technology.” The e-Emergency physician confirmed that the child’s problem needed further evaluation and initiated a transfer to a nearby hospital pediatric specialist who treated the child and discharged her the following day.
Most rural communities don’t have a physician in the hospital 24 hours a day, Larson said. e-Emergency physicians fill the gap while nurses wait for the local doctor to arrive.

A 20-bed CAH owned by Catholic Health Initiatives, Oakes Community Hospital was the first North Dakota facility to add Avera’s eEmergency service.

“Having e-Emergency has made our staff a hundred times more comfortable,” Oakes Community Hospital Administrator Lee Boyles said. “When you’re out in the middle of nowhere and you have board certified physicians at your finger tips any time of the day, it makes everyone working here more comfortable. It can be the middle of the night and there is no doctor in house. All our nurses have to do is push a button and they can talk to a doctor immediately.”

“The decision to make the investment was a no-brainer,” Boyles said. “We’re keeping patients closer to home and we’re reducing travel, duplicated tests, additional diagnostics and patient transfers. eEmergency gives us the ability to extend and enhance the level of health care in our community.”

Geographic Barriers Diminish

Six hundred miles from Sioux Falls in western North Dakota, McKenzie County Hospital in Watford City recently implemented e-Emergency. Located in the heart of North Dakota’s booming oil territory, the 24-bed CAH has seen a 40 percent increase in ER patients in the last year. Patients also have more serious injuries, said CEO Dan Kelly.

Staffing the hospital is an ongoing nightmare. “With the significant salaries that are offered by oil companies, many individuals that would historically accept employment with the health care system are going to work for oil-related employers,” Kelly said. “Some families have oil-related income, creating the scenario where family members no longer need or want to work. And our community has a deficiency in homes and rental units so housing is an issue when hiring.”

Currently, the hospital has no staff pharmacist, but will add ePharmacy this fall, which will give hospital staff access to a hospital-trained pharmacist who will review and approve every medication order before it is administered to a patient.

Sreenivas Ravuri

Dr. Sreenivas Ravuri communicates with a patient in northern California through Sutter Health’s advanced eICU technology.

Like Avera, Sutter Health’s network extends to rural communities far from the network hub, such as Sutter Coast Hospital in Crescent City, 425 miles away. Sutter also offers ePharmacy; its system was developed by staff professionals and recognized by the ASHP Foundation for its “outstanding contribution to biomedical literature describing an innovation in pharmacy practice.”

Overall, telehealth hospital-based services improve access and quality care for patients in rural areas, reduce medication errors and patient transfers, and minimize rural workforce shortages, according to Larson.

“Medicine isn’t meant to be practiced in isolation,” she asserted. “There are physicians who want to practice in rural areas but all of a sudden, they’re everything to everyone and it’s impossible to know every facet of medicine. They need access to peers for support. They also need time to sleep and see their families. They can’t work 24 hours a day. eCARE services help with that.”

A year and a half after his heart attack, Leonard Hajek, 84, looks back on his eCARE experience and says he believes his care was equivalent to what he would have received if Audrey had driven him to Sioux Falls—except that he probably wouldn’t have survived long enough to get to Sioux Falls.

“I’d tell people you can be absolutely comfortable with what they can do with this setup,” he said. “I was definitely in good hands.”


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