Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Telehealth and More: 11 Timely Healthcare Lessons From a Rural State

10/12/2016 11:08:35 AM | 1 comments

Emergency physicians tend to gravitate toward urban centers after residency. But some of CEP America's newest Partners are living proof that practicing in a smaller city can be equally exciting, challenging, and rewarding.
Welcome to Idaho, the 14th largest U.S. state — which also ranks 44th in population density. Of its 40 hospitals, 27 are designated as Critical Access Hospitals. Rural Idahoans regularly travel hundreds of miles to access specialty healthcare. A common destination is the Saint Alphonsus Health System of Boise.
When Saint Alphonsus' long-time ED partners merged with CEP America on April 1, the physicians were excited about the possibilities. "We're looking forward to exploring areas like vertical delivery systems, SNF partnerships, and ED-hospitalist integration," says new partner Po Huang, MD.
But the new group also brought many assets to CEP, including a passion for outreach and community involvement. Here are just a few of the lessons we're learning from our newest Partners:

1. Smaller cities can offer rich career opportunities.

Saint Alphonsus' four Boise-area EDs offer something to suit every practitioner. On one end of the spectrum, there's Saint Alphonsus Medical Center, a tertiary facility that's home to certified stroke and cardiac centers as well as a Level II Trauma Center (the highest designation in Idaho). On the other are two stand-alone EDs located in residential neighborhoods. "These lower-acuity facilities offer emergency physicians a rare opportunity to sit down and spend some time with patients," says Huang, who practices throughout the system.

2. Small doesn't have to be stuffy.

At just over 200,000 residents, Boise may not be a mega metropolis. But it does attract providers from all over the country. "We have a surprising number of residency programs represented among our partners," Huang says. "There's a huge diversity of ideas and experience to draw from."

3. Sometimes the Acute Care Continuum stretches hundreds of miles.

Saint Alphonsus' patients come from all across Idaho and Oregon, so it's probably no surprise that the system is a telehealth powerhouse. Here are just a few innovative ways the hospital is using the technology:
  • Providing post-operative care to orthopedic patients discharged to rural areas.
  • Creating a regional telestroke network that ensures 24-7 access to specialists and advanced treatments.
  • Keeping families connected with infants who are hospitalized in the NICU. (The service is also used for neonatology consults.)

4. The opportunities for outreach are endless.

"In rural Idaho, it's not unusual for EDs to be staffed by advanced providers," Huang says. "We also see a lot of single coverage where the attending physician is fresh out of residency."
As former Director of Telehealth Services for the ED group, Huang oversaw several grant-based programs aimed at connecting Saint Alphonsus emergency providers with their compatriots in remote areas. Through secure video conferencing, they provided real-time support for complicated cases as well as skills and disaster preparedness training.

5. Help everyone heed the "golden hour."

"Certain interventions within the first hour after a trauma can make a real difference in mortality and morbidity," Huang says. "But because most rural providers only see trauma occasionally, it's easy to miss certain kinds of injuries." One of the group's most successful telehealth education programs simulated the pre-transfer assessment and stabilization of trauma patients.

6. There are infinite ways to teach and learn.

On the day I talked to Huang, he and colleagues were preparing to fly to the ski town of Coeur D’Alene to train the local emergency providers on chest tube placements, central line placements, advanced airway techniques, and other bioskills. The team has also produced a bioskills video series in partnership with Idaho State University and the Idaho Simulation Network.

7. Never stop looking for new ways to help.

During their forays into telehealth, the ED team stumbled on a valuable application: end-of-life care. "Once they understand their choices, some patients with poor prognosis decide against transfer to a distant hospital," Huang said. "They choose to receive palliative care in their home communities, which can greatly improve their quality of life."

8. Leadership opportunities and career growth can be found throughout the community.

Saint Alphonsus ED partners serve as medical directors for a variety of local programs, including two county EMS services and Saint Alphonsus Life Flight.

9. Not in a heathcare hot spot? Bring the world-class educators straight to you.

The Saint Alphonsus ED physicians hold a quarterly grand rounds and journal club that's attended by healthcare professionals across the state. And they've done a great job in enticing emergency medicine luminaries to present. Upcoming speakers include Corey Slovis, MD, Emergency Medicine Chair at Vanderbilt University, and Ronald Kirchner, MD, Medical Director of the Nebraska Regional Poison Center. Talks are broadcast via webinar for those who can't attend in person.

10. All that open space can be a lot of fun.

While living in a largely rural state presents certain challenges for emergency medicine, it also has its advantages. "Our team tends to attract outdoorsy types," Huang says. "We go on mountain bike rides together, kayak together, fish together." And for vacation? "A group of us are planning to fly into the Canadian backcountry and spend a week skiing on glaciers." Now that's some serious team bonding.

11. No matter if you're big or small, care should be personal.

On one of Huang's ED shifts, a man in his 70s was rushed to the hospital with profound weakness in his left side that left him unable to move his arm or leg. Thanks to the quick action of the onsite team and telestroke network, the patient was diagnosed and underwent a successful interventional procedure for clot retrieval. "He was actually able to start moving again on the table, which was a vast relief for everyone," Huang says.
The next day, Huang visited the patient on the telemetry unit and found the patient up and walking around. Huang knew the local American Stroke Association was meeting nearby, which gave him an idea. He chatted with the hospitalist, who granted the patient temporary leave from the hospital.
A few hours later, the patient addressed the ASA meeting and told the story of the previous night's clot retrieval. "It was really a great moment," Huang says. "The patient felt empowered. The doctors were inspired. It came together by luck, but that's also the kind of thing that happens in a tight-knit community like this one."

Tamara Longo
Thank you for sharing your experiences associated with telehealth, Dr. Huang and Sarah. Your endorsement of the many benefits associated with improving care delivery for patients, expansive provider education opportunities is very inspiring. I am currently working with CEP Telepsychiatry. We we are preparing to launch our pilot in Roseburg, OR hoping, too, for impressive results in delivering timely care for our patients residing in a rural community.
10/17/2016 8:01:07 AM