Contemporary nursing must continue to evolve to meet the ever-changing needs of healthcare delivery and patient care. Aiken and colleagues1 authored the seminal paper demonstrating that a 1:4 nurse-to-patient ratio provided the safest environment for patients in the acute care setting, with a meta-analysis of 35 articles on nurse-to-patient ratios reporting that many patient outcomes, including in-hospital mortality, are positively impacted when this ratio can be maintained.2 Unfortunately, the United States is struggling to maintain the prepandemic status quo, with insufficient numbers of nurses available to fill the more than 200 000 open nursing positions nationwide. Although acute care units might optimally have one nurse to every four patients, the nursing shortage has forced many to run at high ratios (1:5 or 1:6 nursing-to-patient ratios), and throughout the pandemic, many ran at extremely high ratios (1:8 nursing-to-patient ratios). The nursing shortage is also projected to worsen as retirements occur through 2031.3 The impact of this nursing shortage on patient care is extreme; for each 10% reduction in nursing hours of care available per patient, there is an associated 11% increase in the odds of patients dying.4

From 2020 to 2021, the total number of nurses in the United States dropped by 100 000, with the majority of these nurses employed in the hospital setting.5 In addition, 50% of nurses recently surveyed are considering leaving the profession because of insufficient staffing, burnout, and inability to deliver quality care.6 Nurses report that insufficient staffing and excessive documentation required through the electronic health records (EHRs) are key reasons for burnout and intention to leave their employment.7,8 And, although the travel nurse industry was a necessity for mitigating staff shortages during COVID, recent literature has demonstrated that even travel nurses are “burned out” in the acute care environment.9

The amount of time nurses spend in direct contact with patients is central to ensuring quality care. Unfortunately, the requirements for extensive clinical documentation in EHRs also take time away from bedside nursing. Documentation has been shown to take up nearly 30% of a nurse's time; coupled with the 55% time spent on verbal communication, indirect care, and other activities, less than 15% remains for direct patient care activities.10 Bedside nursing mitigation strategies that have been implemented nationally include hiring travel nurses,11 hiring less skilled and unregistered staff (eg, licensed vocational nurses, patient care assistants [PCAs]), and stretching ratios at the bedside.12

For decades, telehealth services have also been used to offset workforce shortages, most commonly in remote locations, when in-person care is not available. For chronic conditions requiring frequent monitoring such as heart failure, hypertension, and diabetes, telehealth has been shown to improve quality care and healthcare spending with high patient satisfaction rates.13,14 Expanding telehealth services to inpatients in acute care settings may provide another innovative solution to reduce nursing staffing challenges, with multiple tele–critical care (TCC) models within the hospital setting showing promise.

The TCC model typically involves a single, fixed remote site providing simultaneous services such as expert consultation, adherence to guidelines, and facilitating end-of-life care planning to support the workflow of nurses and physicians at multiple locations.15 More than 35% of hospitals have a TCC program; that is more than double the expected 2014 growth predictions from the Society of Critical Care Medicine's ICU Telemedicine Committee.15,16 With TCC's expansion, there is growing evidence of reduced ICU and hospital mortality, length of stay, and rates of preventable complications such as catheter-related infections and deep vein thrombosis, due in part to support by TCC services.16–18

Centralized on-site TCC had been previously implemented at our hospital system in March 2020 servicing 350+ ICU beds during the hours of 7 pm to 7 am. The TCC program utilizes contracted physicians and hospital-employed nurses. On a typical shift, three virtual intensivists and six to seven TCC nurses staff the program. The program has grown to servicing the entire healthcare system and supporting surge areas including ICU and intermediate care unit boarder patients in various emergency departments and affiliated emergency care centers. Our positive experiences with TCC motivated us to explore telenursing for acute care.

Preliminary Nursing Time Study

To better inform program design for acute care telenursing (ACTN), a nursing time study was conducted in March 2022 to evaluate the amount of time that acute care nurses spend on non–direct care–related tasks. Four nonstudy unit nurses observed the time spent undertaking 60 possible nursing activities (for examples, see Table, Supplemental Digital Content 1, https://links.lww.com/CIN/A318), and four PCAs observed unlicensed staff activities on a 28-bed pre–liver transplant and medicine overflow unit. Both day and night shifts over a 4-day period were included. Overall, 60 common nursing tasks were monitored, with 19 of these identified as nonnursing such as specimen collection, patient assistance and gathering and delivering supplies. Forty-five PCA tasks were monitored such as patient assistance and mobility activities.

Both day- and night-shift data (12 hours per shift) demonstrated that a nurse's time was primarily spent on documentation (30%) and medication administration (24%), whereas 17% or 10 minutes each hour of a 12-hour shift was spent on nonnursing activities. The admission and discharge processes averaged 45 minutes per patient. The majority of a PCA's time is spent on various patient assistance activities (25%), vital sign capture (14%), and patient mobility (11%). Thirteen percent or 8 minutes per each hour of a 12-hour shift of a PCA's time was spent idle.

Preliminary Nursing Workload Survey

In conjunction with the nursing time study, a nursing workload survey was sent out in May 2022 to 155 acute care nursing staff (Table, Supplemental Digital Content 1, https://links.lww.com/CIN/A318). From a list of 19 nursing tasks, the survey asked nurses to choose the top four tasks in which they believed that receiving additional help would reduce their workload. Thirty-seven (18 day-shift and 19 night-shift) nurses responded to the survey (24% response rate). Overall, the top four tasks included completing the nursing admission profile assessment, providing patient discharge instructions, answering patient and family questions, and sending inpatient text updates to patient-designated family members. Nurses commented that the admission and discharge processes could take up to an hour to complete because of other interruptions and the extensive documentation required. Although conclusions drawn from these individuals may not fully describe the actual conditions because of a lower response rate, we found these answers instructive.

In summary, both the nursing time study and survey suggested that nurses were spending extensive time with documentation and doing tasks that nonlicensed staff can perform. As a result of these findings, hospital administrators worked to implement strategies to reduce the amount of time nurses spent on nursing documentation and nonnursing activities. First, the PCAs' role was redefined and standardized to add greater accountability for their work, along with phlebotomy training to assist nurses with patient blood draws. To overcome nurses' documentation burden, a nursing scribe program was initiated showing promising preliminary results. Finally, an ACTN pilot program was administratively approved for implementation in May 2022. Program evaluation of this project was determined not to be regulated human subjects research by the Houston Methodist Research Institute institutional review board.

In the acute care setting, two important time-consuming areas of nursing are patient admission and discharge, both requiring uninterrupted attention to patients along with significant documentation in the EHR.19,20 Thus, a pilot study was conducted to evaluate the feasibility of implementing a large-scale ACTN program, where a hospital-employed telenurse would complete admission and discharge processes for hospitalized patients virtually, and the program could be scaled with a reasonable number of people and cost and in a short time period to meet the urgent needs for additional staff. During the 7-month pilot, we examined patient satisfaction with the quality of telenurse-to-patient communication, time spent on admission and discharge, and EHR documentation completion by telenurses compared with the traditional bedside nursing process.

METHODS

From June 2022 to December 2022, a feasibility ACTN quality and operational improvement study was conducted at a large tertiary academic medical center in the Southwest region of the United States. The study hospital is the largest in a system of eight hospitals with more than 1000 beds and more than 40 000 patient admissions per year. The hospital has five ICUs totaling 154 beds, two intermediate care units (37 beds), 12 medical acute care units (328 beds), and 13 surgical acute care units (396 beds). The five-time Magnet-designated hospital employs more than 1550 inpatient nurses, 850 of whom in an acute care area. From 2021 through 2022, the average turnover rate for nursing was 25%, significantly increased from the prepandemic average rate of 15%.

Acute Care Telenursing Pilot Program

Four units were chosen to participate in the ACTN pilot program. The units were chosen because of their challenges in recruitment and retainment of nurses leading to staffing that was lower than budgeted levels on all shifts or closure of beds due to lack of staffing. The study pilot units included a stroke unit (36 beds), a neurosurgery unit (36 beds), a medicine unit (37 beds), and a transplant unit (28 beds), totaling 137 beds. A description of preliminary program implementation has been previously described.18

Twelve ACTN positions were posted, and 2.7 full-time equivalents (FTEs) were allocated for initial program launch in June 2022. This allowed for telenurse support Monday through Friday from 7 am to 7 pm. An additional 2.3 FTEs were hired in July 2022, allowing for 24-hour coverage Monday through Friday. The FTEs were allocated from the hospital's acute care nursing budget by adjusting budgeted nurse ratios on the four pilot units from 1 to 4.0 to 1 to 4.3. No nurse postings were removed, and hiring continued for these units as there were substantial needs to achieve a 1:4.3 ratio. To prevent further reduction in bedside staffing, ACTNs were hired from outside the organization. Acute care telenurses were selected for hire as previously employed, high-performing bedside nurses; those who had previous interest in TCC or virtual nurse positions; and those not interested in open bedside positions. Based on the favorable impressions by staff at the outset, eight units were added to the ACTN program in September 2022, bringing the total number of telenurse-supported beds to 365. Acute care telenursing FTEs increased from 5 to 11.1 FTEs.

Hardware and Software

Technology was essential for the feasibility study, and a variety of technological solutions were studied, including use of bedside iPad (Apple Inc., Cupertino, CA, USA) devices with Caregility Cloud technology (Caregility, Eatontown, NJ, USA) loaded on the iPad, which was implemented during the COVID pandemic, wheeled carts with higher-resolution cameras placed on each study unit, or cameras hard-wired at the bedside. After consideration of timing and cost of the pilot, a decision was made to use the iPads at bedside along with the Caregility application (Figure 1). This technology allowed for utilization of bidirectional AV connections into and out of every patient room. Although the iPads were available, there was low utilization (66%) initially. Thus, all iPads were checked to make sure that they were in working order. Additional images of this technology in action have been published.18

FIGURE 1:

Image of implemented bedside iPads. Note: No actual patient or identifiable information appears in this demonstration image.

Acute Care Telenursing Telenurse Workflow

Prior to the ACTN program launch, the role was formally defined within the nursing clinical workflow design process. In these workflow design sessions, the teams codefined integration points where the remote team could best provide assistance. Special care was given not to require traditional lengthy handoffs, while still efficiently sharing pertinent information in the most seamless manner. For patient admissions, the acute care bedside nurse would settle the patient in the room, hand the patient and/or the family the iPad, and press the soft key requesting the ACTN to virtually enter the room on the screen. The ACTN would welcome the patient, complete the nursing admission profile in the EHR, and place any necessary consults. After admission was complete, the ACTN would notify the bedside nurse that paperwork is complete via EHR secure messaging. The patient would retain access to the iPad for entertainment and meal ordering but could not reach out to the ACTN after this time.

For patient discharges, the ACTN would complete the discharge instructions, confirm patient's preferred pharmacy, inquire about the patient's ride home, call transportation, and arrange for departure of the patient as needed. If the ACTN found discrepancies in any aspect of the admission or discharge process, or if the patient or family had additional questions that could not be resolved by the ACTN, the ACTN would contact the provider or bedside team for clarification. When necessary, the ACTN could also conference in a family or interpreter (or both) to provide complete information. The ACTN program did not apply to discharges to higher-level care or other nontraditional discharge, for example, to skilled nursing facilities.

RESULTS

In June 2022, a total of 256 remotely supported patient admissions and discharges were completed over the four pilot units. Of these, the ACTN completed 107 admissions (42%) and 149 discharges (58%) (Figure 2). In quarter 4 (Q4) of 2022, there were 12 998 total admissions and discharges on the pilot units, of which 8730 (67%) were completed by the ACTN.

FIGURE 2:

Monthly and total patient admissions and discharges completed over the four pilot units of the ACTN pilot program with associated pilot milestones, May 2022 to February 2023. Abbreviations: HD, hemodialysis; Obs, observational unit; Ortho, orthopedic; Surg, surgery.

During the first 90 days, ACTN activity trended by time of day and staffing levels. Acute care telenursing activity existed throughout the 24-hour day, with the lowest activity occurring during the 12 am to 8 am, and the highest activity occurring during the 11 am to 6 pm. Using this information, ACTN staffing hours were adjusted to meet the admission and discharge demands. Figure 3 demonstrates the bell curve for the first 90-day ACTN activity trending and ACTN staffing required for the activity.

FIGURE 3:

Ninety-day activity trends (telenurse call volume and number of nurses on shift) by time of day.

Once a patient admission or discharge was identified and placed in the ACTN queue by the acute care nurse, the average wait time was 1 minute 56 seconds, with 89% of calls answered in less than 5 minutes. Average ACTN call time with a patient was 13 minutes 28 seconds. Acute care telenurses used translation services over 250 times in Q4 of 2022 and were able to remotely connect families as needed. On average, ACTNs completed 114 admissions and discharges per day, with a range of 40 to 163 admissions occurring daily. During the calls, ACTNs also corrected pharmacy locations on discharges, reconciled discrepancies on discharge medication dosages and missing prescriptions, provided additional discharge education, and addressed patient and family concerns on plan of care.

Although not specifically tracked for the pilot study, there is preliminary evidence of reduced time from discharge order to actual discharge of up to 9.5% and reduced time to complete admission paperwork of up to 25%. There is also evidence of improvements in the comprehensiveness of documentation. For example, when comparing prepilot and postpilot data for the study units, the completion of malnutrition screening documentation increased an average of 25.5% during the study period.

Preliminary Patient and Family Feedback

Study units had an average improvement of 5.6% in the discharge section of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey during the study period. When asked by unit leadership during daily rounds about the ACTN program used for admissions and discharges, patients and families gave positive responses. A sample of comments include “I like this, and you took the time to personalize it about me,” and “This hospital is high tech and advanced.”

Preliminary Staff Feedback

Anecdotal comments from acute care nurses provided to unit leadership during the study period were overwhelmingly supportive of the ACTN pilot and its expansion. A selection of those anecdotal comments included “I'm new and this is very helpful,” “Please expand this to other units,” “Thank you for saving me a lot of work today,” and “Yesterday I discharged and admitted four patients, which would not have been possible without the virtual nurse.” Nurse enthusiasm continued to grow throughout the study period.

DISCUSSION

Early indications demonstrate that an ACTN program can support bedside nurses, save time with admission and discharge for patients, and improve the patient experience. To our knowledge, this is the first study to report successful implementation of an ACTN pilot program to more than 9000 patients as well as the first to report a 5.6% increase in the discharge section of an HCAHPS survey using this service. By using existing technology, ACTN implementation and coordination between bedside and virtual nurses in acute care settings were shown to be successful, with almost 90% of admissions and discharges occurring by the end of the pilot by the ACTN. Improvements in patient satisfaction, speed of discharge, and reduced nurse workload provided the opportunity for bedside nurses to focus on direct patient care activities.

The pandemic accelerated public acceptance of telehealth services,21 which likely contributed to the success of the ACTN program. Patients and families who were exposed to the ACTN were pleased with the interaction. Patients reported that their admission and discharge process were quick but thorough. One patient was especially pleased with the discharge process, which allowed him to “leave the hospital sooner.” It is possible that our incidental finding of reduced time to discharge will prove significant in future studies.

Although not fully conclusive, these patient anecdotal comments may translate to a trend toward improvements in patient satisfaction scores. It stands to reason that if virtual nurses can provide their undivided attention to a comprehensive patient admission and discharge process and bedside nurses can spend time on critical patient care activities, then the quality and satisfaction of the entire patient experience will be enhanced. In addition, reducing frequent interruptions on a primary task (eg, patient admission) can also reduce the risk for medical errors.22

It is encouraging that pilot units showed improvements in the comprehensiveness of nurse documentation in one area. This is a promising finding from a healthcare regulatory perspective where clinician documentation is a roadmap to the patient's plan of care and a repository for the care provided. It also suggests that the quality of patient health information entered in the EHR by the ACTN during admission is more extensive and thorough, thereby mitigating patient safety risks during hospitalization.23

The quality and level of detail ascertained during the admission and discharge process further indicated improved patient safety and quality outcomes. The patient admission and discharge processes are complex activities requiring significant workload and cognitive demand.24 Patient admission and discharge activities happen in the context of multiple interruptions such as patient care demands and phone calls, typically occurring during busy daytime hours. With this, acute care nurse enthusiasm for the ACTN program grew shortly after initial implementation. Once nurses found the use of ACTNs to be functional and efficient, they quickly integrated the process into their practice. Nurse satisfaction grew with increased demands to implement the ACTN program on other units.

Our findings should be interpreted in light of the project scope and limitations. The observational nature and unit-based implementation of this study limited our ability to compare different intake and discharge approaches. Although all patients on the floor were originally offered telenurses at admission, patients found to be confused or unable to provide us with feedback themselves are not represented. We also did not assess the satisfaction of patients of different races/ethnicities or primary languages after participating in telenursing in an inpatient setting. Future studies to test the uptake of telenursing in inpatient environments continue to be needed in healthcare environments that are less technology-enabled and with different groups of patients including children, patients discharged to skilled nursing facilities, and those who require more assistance from a caregiver.

In 2023, the ACTN program was expanded to more than 600 beds across the hospital system employing 7.0 ACTN staff FTEs in the virtual center. Additional research is underway to evaluate improvements in patient length of stay, readmission rates, and satisfaction.

CONCLUSION

Our hospital data support the feasibility of a telenursing program as an aid to bedside nursing in acute care settings. Technology to bring the ACTN to the bedside worked with minimal hardware and software requirements (iPad and Caregility); workflow to support nursing was remarkably easy to implement and gained great support from bedside nurses; and hiring for ACTN nurses was easier than hiring bedside nurses. We continue to mature the ACTN program and in 2023 anticipate reaching remote admission and discharge volumes of greater than 20 000. We are also implementing more advanced hardware at the bedside and shared nursing staff between ACTN and bedside. The ACTN program has provided a new direction for future staffing of hospitals in an era of reduced numbers of bedside nurses that can still maintain high levels of quality care and patient satisfaction.

Acknowledgments

The authors thank Jacob M. Kolman, MA, ISMPP CMPP, of the Houston Methodist Academic Institute, for critical review and editing on this article.

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