The Virtual Hospitalist: A Single-Site Implementation Bringing Hospitalist Coverage to Critical Access Hospitals.

BACKGROUND: On-site hospitalist care can improve patient care, but it is economically infeasible for small critical access hospitals (CAHs). A telemedicine "virtual hospitalist" may expand CAH capabilities at a fractional cost of an on"site provider.

OBJECTIVE: To evaluate the impact of a virtual hospitalist on transfers from a CAH to outside hospitals.

DESIGN, SETTING, PATIENTS: A 6-month pilot program providing "virtual hospitalist" coverage to patients at a CAH in rural Iowa.

MEASUREMENTS: The primary outcome was the rate of outside transfers from the CAH Emergency Department (ED). The secondary outcomes included transfer from either the ED or the inpatient wards, daily census, length of stay, transfers after admission, virtual hospitalist time commitment, and patient and staff satisfaction. The preceding 24-week baseline was compared with 24 weeks after implementation, excluding a 2-week transition period.

RESULTS: At baseline, there were 947 ED visits and 176 combined inpatient and observation encounters, compared to 930 and 176 after implementation, respectively. Outside transfers from the ED decreased from 16.6% to 10.5% (157/947 to 98/930, P < .001), and transfers at any time decreased from 17.3% to 11.9% (164/947 to 111/930, P < .001). Daily census, length of stay, and transfers after admission were unchanged. Time commitment for a virtual hospitalist was 35 minutes per patient per day. The intervention was well received by the CAH staff and patients.

CONCLUSIONS: The virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally. A single virtual hospitalist may be able to cover multiple CAHs simultaneously.

FUNDING: Development of this project was funded through the University of Iowa Hospitalist group and the Signal Center for Health Innovations at UI Health Ventures. Virtual hospitalist clinical time was paid for by the CAH on a fractional basis of a traditional hospitalist based on projected patient volumes through analysis of baseline data. Patients were not directly billed for virtual hospitalist service but were charged for the services provided by CAH providers.