When Virtual Becomes Vital—A Conversation With Deb Raupers of the Guthrie Clinic

Debra “Deb” Raupers, MSN, RN, is the enterprise chief nurse executive for the Guthrie Clinic, based in Sayre, Pennsylvania.

Q: To start us off, can you talk us through your career progression as a nursing professional and how you came to your current role at Guthrie?

A: I have been in nursing for over 30 years, and it's been a wonderful career within the Guthrie Healthcare System. I worked in many different clinical areas throughout my career. I became certified in medical-surgical (med-surg) nursing, critical care and executive nursing practice. I eventually jumped into professional development because I love helping develop nurses and assisting with advancing careers. I then led efforts to attain Magnet accreditation at one of our flagship hospitals, which lead to me becoming a CNO and vice president at a small community hospital within the system. Guthrie then committed to building a new replacement hospital, which became an exciting project to help oversee.

After opening that hospital successfully, I was recruited to take a two-hospital system CNO role. In that role I really learned a lot about running the operations of a hospital, surgical services and ambulatory care. That's when my eyes were opened to managing integration across the full care continuum.

I eventually returned to the Guthrie Clinic in the role of EVP, chief nurse executive. This was post-pandemic, and we needed to move forward and rebuild our clinical staff. I firmly believe in not going backward with how nursing was performed in the past and designing a future state with the help of technology. I was very blessed because when I walked in the door, I had a chief digital officer who was also a nurse, and we wanted to take advantage of everything that's available within our Epic EHR and new advancements with technology. We started touring other systems to see what was available and what type of care was being given virtually. The first thing we walked away with was that we wanted virtual teams to augment our clinical teams at the bedside. The virtual staff would be employed and licensed where we give care in our organization, and they would feel like part of the clinical care team. That was our vision, and I wanted to make sure whatever we did with virtual care was creating the future of nursing.

Q: So that brings us to Guthrie’s Pulse Center, which is the organization’s virtual care center that has been operating for a few years now. Tell me about the center’s structure in terms of staffing, the technology you use, and managing the interactions between the bedside and virtual care teams.

A: We wanted the virtual clinicians to be in a room together so they could easily collaborate and care for patients collectively as a team. They can literally talk to each other and get help and pull in the necessary resources quickly. We started brainstorming roles for the center, and we began with virtual critical care nurses. We recruited critical care nurses with five years of experience who would oversee clinical practice in all our critical care units across the system. One of the reasons we created this center is that we became overly reliant on travelers during the pandemic, and in our critical care units we needed to rebuild with staff employed by us.

Inside our Pulse Center we have many virtual roles: intensivists, virtual RNs (critical care, med-surg), telemetry technicians, telesitters, and a case manager nurse who can identify and support high-risk patients during discharge. The Pulse Center also manages all our transfers, including helicopter or ground transport across six facilities and two states. They also handle our placement of patients, so actually knowing the right bed to place a patient in, where we have capacity and where they receive the right level of care.

In terms of technology, our chief digital officer came upon Artisight’s camera system. We started with some mobile units while cameras were installed in every acute care room. We hardwired cameras in the ED, critical care and med-surg beds across the system.

Once we had everything set up, we decided to call this space the Pulse Center because it’s the “pulse” of our organization. We believe we are, “Imagining Tomorrow, Today.” That's how it was born.

Q: What is the return on investment so far? What are some metrics that you've been tracking?

A: We’ve had great outcomes with the Pulse Center. Quality and safety outcomes are our primary focus and looking at our quality indicators we’ve drastically reduced patient harm. We track all high-risk areas like falls and hospital-acquired infections as we strive to reduce those to zero. We want to make sure that patients feel safe in our care, knowing that there are cameras, and they have the ability to call a nurse or physician at any time. We’ve also had success at improving patient flow and throughput. For example, we've been able to not only decrease overall length of stay and have faster discharges, but we’ve also decreased the hours in a critical care bed because virtual clinicians are facilitating patient care along with bedside clinicians.

There are many improvements with our transfer center with centralized bed placement and care coordination. We've been able to keep more patients in their local hospitals with oversight from the Pulse Center. You can have a community hospital that doesn't have an intensivist in house, but now they have access to one because they have our virtual intensivist who can round on those patients twice a day—this allows patients to stay in the community hospital rather than always being transferred to the larger tertiary hospital.

The Pulse Center also impacted recruitment. We had newly licensed nurses who were coming in post-pandemic who didn't get a lot of clinical experience because the schools weren't doing full clinical rotations. Now, at any given time they can call a virtual nurse and say, “Would you help me walk through this?” We see newly licensed nurses are not afraid to go into our critical care areas or ED settings because they always have clinical support in a room with them. We were able to better recruit and retain staff and decrease our reduction of travelers, which resulted in millions of dollars in savings.

Also, keep in mind nursing requires many two-people sign-offs, like when handling high-risk medications or blood products. With cameras in every room, Pulse Center nurses can go in virtually and support those steps. They can see anything in the room—your pump, your pinpoint pupil, your wristband. So now a virtual nurse is available to sign off instead of needing to physically find another nurse on the unit and pull them away from their patient care. We did a time study on this and estimated it can take around 35 minutes to go physically find another nurse to do these sign-offs—using a virtual nurse it’s done in 90 seconds.

Q: I know AI is being used as part of the computer vision capabilities within those room cameras. Are there any other additional AI-related efforts that Guthrie Clinic is currently evaluating?

A: Quite a few actually. We started with clinical monitoring of all our patients. We use a product called Sickbay that uses AI to monitor clinical vital signs, conditions, labs, etc, puts it all together, and as you're being monitored, there’s an indicator on our system that turns a color (red, yellow, green) to indicate if you have a change in patient condition. Our nurses are always monitoring patients, but with this we are now preventing incidences from occurring, and that product is getting better over time.

We're adding more AI into many of our Epic applications, such as for monitoring sepsis alerts, patient triage, timing of antibiotics and helping with decision-making in clinical practice. We're also using some devices to monitor patients in their homes.

With our telemetry and sitter programs, AI can operate continuously to review our patients and give notifications for clinicians to act on. These AI applications do critical and predictive analysis for us so that our clinicians aren't overwhelmed with everything that they're doing, which is fabulous.

Q: Technology brings opportunity, but I have also seen my share of headlines around clinician pushback, particularly from nurses who are asking to be more involved in the oversight of digital investment related to patient care. Yet given your role, and the fact that your chief digital officer is also an RN, do you find that the influence of nursing within Guthrie’s leadership has given you an advantage in getting staff bought in to these changes?

A: Absolutely. I think you have to get bedside clinicians involved in the right conversations to get the right engagement. What's in it for them? What’s going to be the benefit? And there are other concerns, like they don't want “Big Brother” watching over them. Some of the pushback you're hearing is also related to concerns about job replacement, but we are not replacing clinicians. We're supporting them to give higher levels of clinical care.

To get that buy-in, we asked them directly what they need help with, and they would often highlight task-related duties. What a difference it has made when our staff tell us directly what they would like help with. Instead of us just directing and saying we need you to do this, we have engaged them. Our virtual team also participates in rounds and are assigned groups, so they're there for them and they know who their clinicians are that day. That team approach is key and important to get the buy-in and avoid pushback.

Q: Focusing further on telehealth, one of the issues that has been a bit of a stumbling block has been the continued uncertainty around pandemic era Medicare waivers, and if they are going to continue. Do you find these regulations are impacting the work of the Pulse Center or have you been somewhat insulated from that?

A: It's not insulated because they're licensed clinicians giving care in two states, so they do get regulatory visits, and we do have to explain how they're part of the care team. This is work in progress—most of the work I'm doing right now is around advocacy for virtual nursing.

What I share with legislators is: do you want better access for people? This does that. We're rural, and we're doing it. We're providing better access to patients for clinical care using virtual platforms. Why take that away? I have been involved in meetings with legislators because we need to help them understand the future. This is the future, and we must support this because it's going to improve overall quality of health and access to care, which our communities need.

It’s important that we don't forget there is a return on investment, even if it’s not around reimbursement. I'm not reimbursed right now for any of those virtual clinical care hours, yet I have a virtual critical care nurse who comes into any code or any rapid response on a patient who is decompensating—they do all the documentation, they record everything in the medical record, yet their time is not counted toward any clinical care. We'll get people there, but the real return on investment is all the great care outcomes, saving lives and the other improvements around throughput allowing us to care for more patients. We're seeing great benefits, and we're not giving up.

Q: Looking ahead, any future expansion or continued iteration on the Pulse Center?

A: Yes, we would love to continue to add more disciplines. For example, we'd like to add 24/7 respiratory therapy where they can monitor all our ventilators and our most critical patients. I think there is also a huge need for pharmacy to review adverse events, drug reconciliations and assist with patient education. We also are looking at on-call—we’re finding many clinicians don't love taking jobs that take call services overnight, so we're looking at how to automate those into one center to triage. How can we have a clinician who can make decisions with algorithms to answer those calls and prevent multiple sites from having on-call services?

We’re also looking into matters of staff safety and addressing workplace violence to help our clinicians feel safer behind closed doors. For example, we’re testing a feature where staff can say specific phrases into the speakers embedded in our virtual cameras to notify security to get to that room immediately without needing to explicitly say that there’s an escalated situation going on.

We didn't even talk about ambient documentation, which we’re using in our outpatient settings and just starting with inpatient. My goal is that we no longer have to document with a keyboard—wouldn’t that be fabulous? Applications like these are going to save our clinicians time. We're already reducing bedside nurses' documentation requirements, which gives them more time for clinical care at the bedside.

Q: We're always talking about the digital transformation of health care. How do you envision the nursing role continuing to evolve alongside this transformation?

A: Technology is only going to help us advance clinical care—and seeing the new products and how fast they're evolving, it's just unbelievable. I firmly believe we're going to save lives and people are going to live longer because of technological advancements that detect, treat and assist us with clinical care.

I believe technology gives us more time for the essence of nursing: our hands-on care and connecting with our patients. I believe nursing is still fundamentally the most trusted profession because of how we interact and care for our patients. That's still really important. Let technology do monitoring and surveillance to help us while we're working at the top of our license to provide bedside clinical care. We want this to be our future.

This blog post is part of an ongoing Q&A series with digital health leaders at organizations across the US. These in-depth interviews aim to provide real-world perspective and insights in this rapidly evolving space. Don’t miss the other blogs in the series, found here.

Sg2 members are encouraged to check out the full library of digital health and AI resources in our online resource kit. Not a member? Email learnmore@sg2.com for information on the expert intelligence, data-driven insights and strategic perspective we offer to health systems nationwide.