​Congrat​​ulations!

The Guthrie Clinic (Sayre, PA) has been selected as the winner of ECRI's 17th Health Technology Excellence Award for its strategic approach to addressing staffing shortages exacerbated by the COVID-19 pandemic. The Guthrie Clinic's implementation of artificial intelligence (AI) and video technology to create a telesitting program led to immediate improvements in patient safety during a time of crisis, as well as demonstrable cost savings. Significantly, this initiative also served as the first phase and proof of concept for developing a virtual command center that is centralizing certain operational and patient care functions, with the goal of improving care—and improving access to care—in a variety of settings across the large geographic region that the health system serves.

The Health Technology Excellence Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. ECRI announced The Guthrie Clinic as the winner of the 17th award in May 2023. For details about the other submissions that achieved recognition, see The Health Technology Excellence Award: Recognizing Exceptional Health Technology Management.

ECRI congratulates Gail Strausser, Terri Couts, and the rest of the Guthrie Clinic team.

Jason Launders, ECRI's Director of Operations, Device Evaluation, presents the award to Terri Couts and the rest of the Guthr​​ie Clinic team.

To address staffing shortages exacerbated by the pandemic, while also positioning the rural health system to better serve future patients in a changing healthcare landscape.

The Guthrie Clinic's approach involved rapidly implementing a telesitting program to address the immediate need—a staffing crisis—but also to serve as the first phase and proof of concept for a virtual command center, based on an AI-enhanced video and communications platform. The vision for the command center is to consolidate resources in a centralized location, to standardize practices across care areas and facilities, and to expand the reach of providers to help improve care, including access to care, across the region served by the health system. Key components in the first years of implementation include virtual nursing, electronic intensive care unit (eICU) capabilities, and a central patient transfer center.

The C​ontext

The Guthrie Clinic is a rural integrated health system that serves patients in hospitals and clinics across a 9,000-square-mile region in the states of Pennsylvania and New York. The organization takes pride in meeting its quality, patient safety, and patient experience goals despite the challenges associated with rural healthcare.

During the pandemic, however, meeting those goals became a struggle. The health system's beds, emergency rooms, and clinics were becoming overwhelmed with patients. At the same time, many local nurses and other care providers were deciding to take positions in other regions or to leave healthcare altogether.

Quality and patient experience metrics declined as the organization contended with premium labor costs that were six times what was forecasted, staff-to-patient ratios that were undesirably high, long wait times in the emergency departments (EDs), and a shortage of inpatient beds for ED boarders. The health system needed to turn the tide.

The Guthrie Clinic team recognized a strategic opportunity both to address the immediate staffing shortage and to position the organization to provide optimal care in a changing healthcare environment. Anticipating a future in which care providers will need to meet patients where they are—whether that be at a community hospital or clinic, in a long-term care facility, or in the home—the team conceived of a virtual command center that would centralize certain operational and patient care functions. This would both ease the local staffing burden and provide greater access to clinical expertise regardless of where the patient was being treated. "We want to be able to provide the right care closest to where the patient resides, meeting patients where they are," explains Terri Couts, Chief Digital Officer at The Guthrie Clinic.

​​ ​The Gut​hrie Clinic's Sayre, PA, ​campus. (Image courtesy of The Guthrie Clinic.)

The Proc​​ess

With the stresses of the pandemic starting to overwhelm its facilities, The Guthrie Clinic developed—and immediately began executing—a five-year strategic plan to identify and implement the technologies that would form the backbone of the "Guthrie Pulse Center," the organization's name for the virtual command center. The team assessed the organization's needs, examined potential technology solutions, and identified use cases that would allow The Guthrie Clinic to achieve its short- and long-term goals despite financial constraints.

Phase 1: Telesitting

The team determined that establishing a telesitting program as the first phase of its project would have the greatest immediate impact:

• First, it would help alleviate the staffing shortage. The Guthrie Clinic had a continuous need for sitters due to high-fall-risk and behavioral health concerns with its patient population, but did not have enough staff that it could dedicate to this task. This led to overqualified staff performing the sitting function and thus being unavailable to perform higher-level duties, thereby exacerbating the staffing challenges, or to patients going unwatched and thus being at risk. A telesitting program would allow better patient coverage using fewer staff, and it would free up skilled nurses to perform other patient care duties.
• Second, a telesitting program would provide an opportunity for a quick win. It could be implemented more rapidly than other aspects of the proposed virtual command center, and it held the promise of showing a return on investment almost immediately. If successful, the telesitting program would build confidence in the technology and create excitement and support.

When assessing potential technology solutions for the program, The Guthrie Clinic knew that it needed to look beyond just telesitting capabilities. With its broad vision of establishing a central command center that would serve as a digital hub for care model redesigns, the team focused on vendors that could be agile, that could deliver results quickly, and that could scale services over a span of time. The team selected a system centered on the use of video technology wrapped with AI.

For the telesitting program, The Guthrie Clinic deployed 50 cameras across the five hospitals in its system. Two staff members per shift perform the telesitter role, providing coverage for up to 50 patients. Previously, covering that same load would have required 50 individual staff members.

The technology functions as follows: Cameras in the patient rooms allow the telesitters to provide fall coverage from a central location for dozens of patients across the health system, thereby freeing up dozens of patient care staff to perform other care tasks. The AI functionality built into the system provides an added layer of safety by interpreting the images in real time and highlighting circumstances that require the sitter's attention. For instance, the system is trained to distinguish a patient from a non-patient by learning features such as Guthrie's room layouts, beds, and patient gowns, and the system has learned to identify circumstances associated with a higher risk of falls based on factors such as positioning and movements.

​Within three months of the project's initiation in late 2020, the telesitting program was up and running. Since then, The Guthrie Clinic has leveraged the technology for other use cases.

Phase 2 a​nd Beyond: Virtual RNs and Other Capabilities

The second phase to be implemented—virtual registered nurses (RNs) in the ICUs—likewise helped address a pandemic-driven staffing issue: high turnover among their critical care nursing staff. The virtual RN functionality allows experienced critical care nurses, sitting behind the video screen, to support the newer nurses who are staffing the health system's ICUs, regardless of location.

Subsequent phases have included, or will include, establishing eICU capabilities, setting up a central transfer center, and implementing centralized telemetry monitoring. Additional use cases that are being considered for the AI-driven platform include its use to aid with pressure ulcer reduction (e.g., recognizing whether a patient has been turned and alerting staff when this action is needed), automatic documentation, handwashing audits, and security alerts, to name a few.

Making the Fi​​n​​​ancial Case

To justify the implementation financially, the team assessed the budgetary implications of the system's expected impact on quality, patient safety, and patient experience. This analysis considered factors such as the cost saving associated with telesitters being able to monitor multiple patients compared with a one-to-one sitting model, and reductions in length of stay that could be achieved by having the virtual RN streamline the discharge process.

The R​​​esults

The financial impact of the telesitting program was immediate and significant: The Guthrie Clinic estimates that the program reduces labor costs by more than $7 million per year, based on a pay rate of $19 per hour for these staff members (leading to a savings of $10,944 per 12-hour shift). While implementing the technology required a significant investment, "the system paid for itself almost immediately," notes Couts. "The ability to show a quick return on investment helped sell the program to leadership."

Further, the program had an immediate and significant impact on patient safety and patient care. Before the system was implemented, staffing limitations meant that some patients weren't monitored at all for fall prevention. Now, all patients can be covered either through the telesitter or through one-to-one in-room observation. Additionally, the telesitting program allows staff members who might otherwise have had to sit with a patient to be deployed for other patient care activities, alleviating some of the nursing load.

The implementation did meet with some initial skepticism and concern from staff about the presence of cameras and the effectiveness of relying on remote staff. Rigorous change management efforts and frequent communications helped in this regard, but attitudes really started to change once staff saw the system in action and how it improved their workflow and their ability to care for patients. Soon, staff were requesting more cameras.

Finally, feedback from families and patients has also been positive. The technology is explained to them and consent is obtained. "We haven't gotten much pushback," notes Gail Strausser, Senior Director for Epic Systems at The Guthrie Clinic. "Most families are grateful to learn that the system provides additional assurance that their loved one will not fall."

The overwhelming success of the telesitter program facilitated the second phase, the implementation of virtual critical care nursing. As noted, a shortage of critical care nurses had the potential to severely compromise patient care, creating an urgent need for The Guthrie Clinic to identify ways to maximize the impact of the experienced critical care nurses on staff.

The virtual RN implementation makes use of the same AI-driven platform, along with the Epic electronic health record system and technology from another vendor that can stream hemodynamic waveforms and data, regardless of vendor, to a central location. This functionality allows a central team of nurses to support those nurses who are staffing the ICUs across the health system. It provides an additive level of care that supports the bedside nurses in several ways: for example, by giving them the ability to reach out for assistance, by creating opportunities for them to gain insight from more experienced staff who are remotely monitoring the patient's condition, and by allowing some tasks (e.g., second sign-off for high-risk drugs) to be offloaded to the central team.

Other functions that are now operational include an eICU program, in which tele-intensivists support facilities where only hospitalists are on-site, and a central transfer center, which manages transfers into and out of the health system's various facilities. The Guthrie Clinic reports that centralized telemetry is also in development and should soon be operational; that program is expected to help maximize staff resources and improve care—for example, by standardizing alarm management practices.

Key Takea​​​​ways

Couts and Strausser shared some insights that might help other organizations choosing a similar path:

• A project of this size requires a fair amount of change management. The key is to communicate early, to communicate often, and to involve as many of the users who will be impacted as possible.
• As Couts observed: "In many ways, the change management aspects of the project were more challenging than the technology piece, largely because of the need to redesign care models in order to support care differently."
• Strausser concurred, adding: "There were negative supporters at the beginning of the process. By involving those same individuals in the workflow designs and discussions, we both empowered them and helped them see firsthand the positive impact that the project will have on them and on the patients we serve."

• To gain staff trust, it's also important to clearly establish the boundaries defining how the technology will and, importantly, will not be used. For instance, the team recommends against using the system to audit a nurse's care, noting that it could ultimately be counterproductive, eroding trust and creating a "Big Brother" scenario in which staff worry about being watched. The point of the technology needs to be about supporting nurses and other providers in caring for the patient.
• AI implementations are not just plug-and-play. The technology needs to learn the local situation, which requires a training period. Similarly, the healthcare organization will learn the capabilities of the technology over time; eventually, the team can begin branching out and investigating other use cases.
• The organization has already begun planning ways to extend these capabilities into the home or other care environments. Such efforts require assessing the "digital determinants" of health for the patients in their region—such as what technologies patients can access, whether and how well they can use those technologies, and whether they have Wi-Fi or cell service—and building care pathways that take those limitations into account.