As the Commonwealth of Pennsylvania prepares to disperse Rural Health Transformation program grant funding, one model that has shown promise is the Guthrie Clinic’s Pulse Center, which integrates experienced virtual clinical teams with bedside caregivers across multiple Guthrie hospitals. Debra Raupers, M.S.N., R.N., Guthrie’s  chief nurse executive, recently spoke with Healthcare Innovation about the center’s growth and next steps. 

The six-hospital Guthrie Clinic is a nonprofit health system serving over 700,000 patients across 11,000 square miles of Pennsylvania and New York, with a strong focus on expanding access to care in rural communities. Guthrie Clinic says that since its launch, the Pulse Center has delivered quantifiable systemwide results, including millions of dollars in annual savings, more than 10,000 hours of bedside nurse time returned and an average 135-minute reduction in emergency department–to–inpatient bed placement time. Tele-sitting contributed to an 87.5% reduction in major-injury falls, while virtual nursing reduced pressure injuries by 20.3%, shortened length of stay and helped ensure more than 45% of patients are discharged within 75 minutes systemwide.  

Healthcare Innovation: Did Guthrie have some issues in rural areas that innovations such as tele-sitting and virtual nursing tools have helped it address?

Raupers: In rural settings, in some of our smaller hospitals, they don't have the technology available to provide care in an integrated platform. Some facilities are so small they don't even have enough need to have 24/7 observation. When you can do a clinically integrated model centrally, it takes away the burden of small critical access hospitals, because you're able to centralize the resources to monitor more and more patients.

HCI: And do the virtual tools allow those patients to stay in those smaller rural hospitals rather than having to be transferred to a larger health center for observation? 

Raupers: Yes. One of the things that was really important was that we could care for patients in their community at the hospitals locally, with the advanced practice of the integrated system. With clinicians providing care virtually for those patients, as well as the nursing team constantly monitoring the patients, they were able to take care of higher level of acuity of patients locally, rather than moving all of the patients to a large tertiary center. What we realized during the pandemic is that's no longer possible. We overburdened the large tertiary hospitals, and we knew we could provide care locally, so we worked really hard at that model of care.

HCI: Did you work with certain vendors or did you develop some of it in house?

Raupers: We did develop some things in house. We did site surveys, and we went to other healthcare systems to see how they were utilizing the platform and virtual nurses. We saw a lot of things we liked, and we saw a lot of things that we would like the opportunity to improve. We also decided that we wanted to do a clinically integrated platform in a center, and that we wanted the team to all work together monitoring all of our patients, so that if one of the clinicians sees an issue with a patient, they immediately have help from nursing or from a provider to jump in and assist with clinical care. 

The vendor question is interesting, because I think you need to decide what's the problem you're solving for and then look for the technology that supports that problem. An easy example of that is the tele-sitter program. With tele-sitters, we had all of these unlicensed personnel, like an aide, sitting one on one with patients to prevent them from harm and falling, but that took away a lot of our caregivers who were giving hands-on care, helping patients go to the bathroom and assisting them with their needs. With the use of technology, we can centralize and have one person monitoring multiple patients. That allowed those bedside clinicians to go back to direct clinical care. We monitor the patients virtually with the use of technology and AI that helps identify increased movement of patients and allows for redirection and prevention of fall with injury.

HCI: You mentioned that the vendor part was interesting. So was there a solution that fit perfectly, or did you have to customize a solution or develop something in house?

Raupers: There were tele-center programs out there. Guthrie had not utilized them before we started this platform. We went with a vendor that was going to work with us and help us achieve better outcomes and we actually partnered with them, and we're constantly developing the AI platform in partnership with them, so that we know we can prevent injury to our patients with redirection, better cameras, a two-way interface. Those clinicians can go right in and say, “It looks like you're starting to move. Could you please wait? I have a nurse on their way. They'll assist you with going to the restroom.”

HCI: What was the timeline for the creation of the Pulse Center itself?

Raupers: We started the concept at the end of 2021 and in 2022 we started with a pilot for the tele-center program. We wanted to see how that was going to work, so we started with that, and we saw great results. Very quickly, our virtual clinician was able to monitor multiple patients — in the range of 12. Then we decided we were going to move it into a central platform in the fall of 2022 and we added the virtual nurses as well as cardiac monitoring centrally.

HCI: Do you have to recruit and train for those virtual nursing positions? Is it a different kind of position than the nurses are used to?

Raupers: You need a coach and mentor mentality. You never want them to seem to be criticizing or not assisting the bedside nurses in the clinical care. It's a partnership.

HCI: Did you look for ways to measure ROI of making this investment? Were there certain use cases like fall prevention where you said you were going to measure the impact across the health system?

Raupers: There were lots of reasons why it was valuable to do. I think we have to start with the fact that we're able to catch de-escalation of patients. If a patient has a physical change in their condition, we're able to quickly identify it, because we're physiologically monitoring them. We can actually call and say, ‘Hey, would you take a look at this patient? It doesn't look like things are going well,’ or ‘it looks like their blood work is coming back abnormal. We think somebody should see this patient right away.’ Right there is a huge return on investment — catching people before they're compromised. We have used it with our nurse vacancy and turnover for newly licensed personnel. This is the reason we actually started our virtual nursing platform was for them to be coaches and mentors for those newly licensed, because their turnover was highest at year one. We wanted to make sure that they always had a a friend available to them, and it has shown fantastic results. That's probably the best return on investment that we had was a complete reduction of agency and travelers in our workforce in those key areas. 

We also saw improvements in patient safety. The risk of fall with injury — we saw those numbers completely decrease. We use it for throughput —  patients who are held in the emergency room, we can actually prioritize their admission and if we know what floor they're going to be going to, we can prioritize discharges virtually, so we get those done and as soon as the discharge occurs, we can get a patient up there and their admission is already done and we can begin giving clinical care. This has decreased our length of stay. It's decreased time in the emergency room. We decreased the number of people leaving without being seen, because we don’t have huge numbers of patients in our waiting rooms, because we're able to prioritize the way care is given and get them moved into a bed quickly.

Overall, we've had high employee satisfaction with our whole virtual platform. The clinicians can now spend more time doing hands-on patient care, and it's augmented with these virtual nurses who assist in the clinical care. I think that's huge. It leads to satisfaction, not only for the nursing and other personnel at the bedside, but it also increases patient satisfaction. We have loved ones who now will leave and go home and go to bed at night because they're not afraid their loved one's going to fall when they're in the room alone.

HCI: Do you think that the virtual nurses themselves find the work satisfying?

Raupers: It saves nurses from retirement. If a nurse had a back injury and was no longer able to do a 12-hour shift in clinical care, that nurse is still a clinical resource and an expert clinician. We mandate five years of experience and certifications, so that's a nurse who has valuable knowledge to share with clinicians. We’re keeping them in the profession. 

HCI: I understand that the Pulse Center was highlighted by the Commonwealth in talking about the Rural Health Transformation Program. Is it possible that this model could be replicated in other communities in Pennsylvania, through that grant funding?

Raupers: That’s what we're hoping for. If there are critical access hospitals or small community hospitals that don't have the technological advancement to do this, we can support them through mobile cameras and through our clinicians being able to pop in and out of rooms. We're really excited to partner and try to provide this to other hospitals within the Commonwealth. There's no reason we can't continue to grow this across healthcare organizations.

HCI: Has the Commonwealth started announcing funding of things yet or is that still in the works?

Raupers: It’s in the works. Actually, all of the grant applications had to be in  last week. We put in our full proposal, and we're hoping to come up with some partners and some monies so that we can begin this work and assist other hospitals and organizations change the way they deliver clinical care.