Dec 23, 2019, By: Clare Koning
Take Away Messages
- In a country with vast geographical health regions, nurses can leverage virtual technology as a way to connect patients and their health care teams.
- In cardiac care, use of virtual consultation has improved access to specialist care, time to consultation, patient and health care provider satisfaction, and health outcomes.
- Virtual consultation is a fiscally responsible way to reduce inter-facility transfers and provide a safe and secure solution to improving access to care.
How does geography present a barrier to health care access in a developed country like Canada?
The reasons for this are complex. Access to health care is a human right, yet barriers still exist, requiring new and innovative ideas to provide health services to all Canadians, no matter where they live.
This challenge could not be clearer than in Fraser Health, British Columbia, which stretches over 250 km east to west, and covers a population of over 1.8 million. There is a single cardiac care centre for this region located in New Westminster: Royal Columbian Hospital. This is the logical hub for the cardiac specialists.
However, while Royal Columbian is the oldest hospital in BC, it is surrounded by a relatively sparse population. In fact, over seven times the population of New Westminster surrounds Surrey Memorial Hospital, located 10 km southeast, and twice the population of New Westminster surrounds Abbotsford Memorial Hospital, 50 km to the east. A total of 11 outlying acute care hospitals surround the Royal Columbian, some as far away as 140 km, and rely on it for specialist cardiac consultation.
These geographical considerations contribute to limiting access to specialist care for the region. For a cardiac inpatient located at one of the outlying hospitals to access a cardiac specialist, a plethora of events needs to occur with precise alignment. An inter-facility transfer for a specialist consultation depends on collaborative relations within the health authority sites and with provincial services for transportation.
Additionally, several puzzle pieces need to fit together perfectly, including bed availability at the receiving facility, a cardiac-trained RN for monitored patient transport, a cardiac RN to assume care for the patient at the receiving facility, BC ambulance services, and cardiac physician availability. Although these consultations often take less than 30 minutes to complete, planning can take days and transportation delays are common. As a result, inter-facility trips can take more than 12 hours after leaving the host site.
An innovative solution to help mitigate the limited access to specialist consultation and disruption of nursing workflow is virtual consultation. Given that almost all cardiac inter-facility transfers require a skilled nurse escort, the referring facility is often left short-staffed, incurs overtime costs, or both. Virtual consultation offers various advantages, including reducing the frequency of inter-facility transports, reducing the time from referral to consultation, reducing length of hospital stay, and reducing the workload of the health care provider (Palen et al., 2012; Shaw et al., 2018)
Virtual consultation has also shown improved access to specialist clinicians, improved continuity of care, and improved patient and health care worker satisfaction (Greenhalgh et al., 2018; Palen et al., 2012). Additionally, Skype as a tool for virtual consultation has been found to be as effective as face-to-face sessions at maintaining a working relationship (Freeman et al., 2017) and showed improved patient care and outcomes (Greenhalgh et al., 2018). Skype is an application that most people are familiar with using, and service costs can be kept low (Palen et al., 2012; Shaw et al., 2018).
It is clear in the literature that the use of video technology can aid in patient care and reduce wait times, but there may be barriers to implementation found at the clinician level, as well as connectivity issues with the Internet and lag times. Even so, this approach is largely successful, as it requires little equipment.
This article will discuss the development, expansion, and evaluation of a virtual consultation program that occurs at the patient’s bedside involving the patient, the nurse, and the cardiac specialist. The program is led, driven, and facilitated by nurses, nurse practitioners, and nurse specialists. These nurses have embraced their new virtual health role, which has led to successful implementation, positive outcomes, and program expansion.
Program evaluation was conducted by the clinical nurse specialist, who tracked virtual versus in-person consultations, time to consultation, and a health economic assessment. Harder-to-measure outcomes were the anecdotal conversations with nurses and patients that showed an increase in nurse and patient satisfaction with the program and advocacy for its broader use.
Highlights and implementation
Fraser Health has invested in Skype4Business—a platform similar to Skype in which a secure call is made between two Fraser Health computers with live video and audio feed. Making a Skype4Business connection is as easy as searching for the person you want to connect with and then clicking “call.” Encryption at both ends ensures a secure environment for sharing clinical information within the inpatient setting.
The year 2016 marked the first virtual electrophysiology consultation, and was started at two referring sites. In 2019, with the addition of a new cardiac clinical nurse specialist covering the Fraser Health region, the program expanded to a further five referring sites. The clinical nurse expert, as the project lead, provided the resource materials and training for each site.
Currently, virtual consultation is operating out of 7 of the 11 acute care referring sites in Fraser Health. It is a nurse-facilitated process and is utilized by cardiac service specialists in electrophysiology, including the nurse practitioner, and the cardiac surgeons, who joined in May 2019.
Figure 1. Posters illustrating the virtual cardiac consultation program and process
The virtual consultation process requires the involvement of nursing staff, patients, and the specialist physician. For new referrals for cardiac specialties in electrophysiology and cardiac surgery at Fraser Health, the triage nurses assess the suitability of virtual consultation over in-person consultation.
After discussion with the specialist physician, the referring unit is notified by the triage nurse of the decision, and verbal consent is obtained from the patient. At an agreed time, the Skype call is initiated, the portable device (Fraser Health laptop or tablet) is placed in front of the patient, and the conversation occurs virtually between the specialist nurse practitioner or the specialist physician at Royal Columbian Hospital and the patient at the referring site.
The primary nurse stays with the patient and is available to answer clinical questions that the specialist nurse practitioner or physician may have during the consultation.
Both the patient and family are encouraged to ask questions during this virtual meeting and are provided with educational materials to guide the process. Family involvement is encouraged and appreciated, something that is often not possible with in-person consultations requiring inter-facility transfers. This patient- and family-centred care model promoted by Fraser Health provides a broader focus to care that is more holistic.
Barriers to implementation
While the program has shown great success, there were some obstacles to overcome. At some Fraser Health sites, equipment needs were challenging: sites had to invest in portable devices, Wi-Fi connections needed to be stable, and there was an assessment of unit culture and competing projects that could inhibit end-user uptake and engagement in a new project. Some sites without corporate Wi-Fi were unable to participate in the program.
In addition, not all cardiac patients are good candidates for virtual consultation at their bedside. Unfortunately, the majority of patients, especially those who need cardiac surgery consultations, still need to be transferred to the cardiac centre at Royal Columbian Hospital for functional testing, specialist imaging, or diagnostic procedures.
Privacy and risk assessment
Prior to implementing this program, a Fraser Health privacy impact assessment (PIA) was conducted and passed in addition to a terms-of-use agreement for virtual technologies. This privacy and risk assessment is an extensive evaluation process undertaken by legal, privacy, and security departments, and can take several months to complete. The review includes ensuring that no confidential information is released without patient consent, that the virtual platform is sufficiently encrypted, and that the devices used are also encrypted and are Fraser Health property.
An evaluation of risk was completed including level of security risk, risk of harm, and sensitivity of information. An incident cost score was generated using the Risk Grid Evaluation Matrix with a result of 30, representing very low risk, where the maximum risk impact score is 225. This assessment was conducted to ensure that the conversation that occurs virtually via Skype4Business is no different in privacy and security impact than a physician standing at the patient’s bedside and having the same conversation in person.
This program could not have been successfully implemented, sustained, or expanded without the cardiac services team, the front-line leadership and nurses, and the patients’ direct involvement and support of this program. In most cases, this is the first virtual consultation that a patient and family may experience; to date, there have been no reports of a patient refusing a virtual consultation and requesting an inter-facility transfer instead.
As the virtual consultation program has gained traction, nurses have been advocating for its use, and the results are significant. In 2018, data from the two referring sites showed that 23% of the electrophysiology consultations were done virtually, or 28 virtual consults out of 124 total consults. Reflecting on the program cost analysis, each virtual consultation is estimated to save the health system $5894 per patient; this equates to $165 032 saved in 2018. In addition, the data showed an average reduction in time to consult of 50%: from 3 to 5 days for an in-person consult, down to 1 to 2 days for a virtual consult to take place. Some virtual consults even occur on the same day that the referral is entered.
With the expansion to a further 5 referring sites and the addition of cardiac surgery services, the data from the first 6 months of 2019 show increased significance, with 28 virtual consults having already been conducted. The anticipated upward trend is double the virtual consults in 2019 compared to 2018. In the first half of 2019, 4% of patients referred for cardiac surgery consultations were seen virtually, and 20% of patients referred for electrophysiology consultation from sites outside of Royal Columbian were seen virtually. The estimated cost saving in the first half of 2019 matches that for all of 2018, and totals over $330 000 for the last 18 months.
Beyond the fiscal, logistical, and time advantages, there are benefits that are harder to measure. These surface during conversations with patients and staff members participating in the virtual program. There is a reported improvement in patient experience and satisfaction, as well as increased family involvement in consultation and care planning.
The benefits extend to nursing staff, who voice improved satisfaction with a reduction in nursing shortages related to inter-facility transports. In addition, referring physicians are seeing their specialist consultations reported in half the time, an improvement that can have positive impacts on care planning and health outcomes.
Figure 2. Trend in number of virtual consultations in Fraser Health: January 2018 – June 2019
What can be expected in the future?
With growing limitations in physical space and human resources, seeking innovative solutions in the virtual realm is the obvious direction to pursue. The increased use of technology in health care has provided a safe and secure means of improving health outcomes and nurses’ work environment, as well as ensuring fiscally responsible access to specialty care services.
This initiative has required a simple creative idea, utilization of existing platforms, the investment of a clinical nurse specialist, the enthusiasm of nursing end-users, and imagination in order to expand the concept and solve ongoing problems in health care access and geographical barriers in the Fraser Health region. Because of its clear benefits, this project has gained interest beyond Fraser Health region: Interior Health, the Lower Mainland cardiac surgery group, and Provincial Health Services have all requested information and collaboration.
Finally, this program would not be possible without the investment of nurses. Expansion of health care into the virtual realm is inevitable, and limited only by our imagination.
Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., & Slater, M. (2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 47(14), 2393–2400. https://doi.org/10.1017/s003329171700040x
Greenhalgh, T., Shaw, S., Wherton, J., Vijayaraghavan, S., Morris, J., Bhattacharya, S., … Hodkinson, I. (2018). Real-world implementation of video outpatient consultations at macro, meso, and micro levels: Mixed-method study. Journal of Medical Internet Research, 20(4). https://doi.org/10.2196/jmir.9897
Palen, T. E., Price, D., Shetterly, S., & Wallace, K. (2012). Comparing virtual consults to traditional consults using an electronic health record: an observational case–control study. BMC Medical Informatics and Decision Making, 12(65).
Shaw, S., Wherton, J., Vijayaraghavan, S., Morris, J., Bhattacharya, S., Hanson, P., et al. (2018).Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. Health Serv Deliv Res 6(21). DOI: 10.3310/hsdr06210
Clare Koning is the regional cardiac clinical nurse specialist for Fraser Health, British Columbia. Clare has 15 years experience in cardiac nursing and has practiced in several different countries and health authorities in Canada.