Effect of Virtual Nursing Implementation on Emergency Department Efficiency and Quality of Care

---

Saif Khairat, Jennifer Morelli, Qiyao Qin, Xiaoyu Wu, Randy Fakhreddin, Barbara S. Edson, Mauri Williams

• School of Nursing, University of North Carolina at Chapel Hill, NC, USA

• Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA

• UNC Health, Morrisville, NC, USA

• Carolina Health Informatics Program, University of North Carolina at Chapel Hill, NC 27514, USA

• Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC 27514, USA

Received 13 November 2024, Revised 13 February 2025, Accepted 15 February 2025, Available online 17 February 2025, Version of Record 22 February 2025.

---

Highlights

• Virtual nursing admission assessments were correlated with a reduced ED wait time.

• Virtual nursing admissions had fewer uncompleted admission documentation tasks.

• Virtual nursing admissions had fewer interruptions than in-person admissions.

Abstract

Importance

Nursing shortages lead to longer emergency department (ED) wait times and incomplete documentation. US health systems are rapidly implementing virtual nursing, a new care delivery model, to improve care and alleviate nursing burden by providing nursing care and expertise via telehealth.

Objective

To evaluate the association of using virtual nursing for patients admitted via the ED with quality outcomes, namely, wait time, admission assessment duration, documentation completeness, and number of interruptions.

Materials and methods

Non-randomized retrospective cohort study of adult patients over the age of 18 seen in the ED and subsequently admitted to one of six hospitals.

Results

Patients who had in-person admission assessments median wait time was 525.5 min (IQR: 332.9–969.8), while the median wait time for patients using virtual nursing for admission assessments was 429.5 min (IQR: 292.6–954.5). In-person admissions had a median duration of 24.0 min (IQR: 15.0–36.0), while virtual nursing admissions median duration was 29.0 min (IQR: 18.0–42.0). The average number of uncompleted documentation fields for in-person admissions was 0.4 ± 1.5, while the average for virtual nursing admissions was 0.2 ± 0.5. Finally, the average number of interruptions during admission for in-person was 1.8 ± 1.5 interruptions, while virtual nursing admissions averaged 1.4 ± 1.3 interruptions.

Discussion

Virtual nursing was associated with shorter wait times, more complete nursing documentation, and fewer interruptions during admission assessments for patients admitted via the ED.

Conclusion

Virtual nursing is a promising care delivery model that may lead to reduced nursing burnout and enhanced patient care coordination.

---

Introduction

A shortage of nurses directly contributes to longer ED wait times, as fewer staff are available to manage patient flow and provide timely care [1]. This leads to high patient-to-nurse ratios, and the resultant workload makes it challenging for nurses to maintain thorough documentation practices [2].

Emergency Departments (EDs) are critical components of the healthcare system. They provide immediate care for patients with urgent and emergent medical conditions. However, prolonged admission wait times and incomplete documentation have emerged as significant challenges, impacting patient outcomes, care quality, and operational efficiency [3,4]. Long ED wait times are associated with negative patient outcomes, such as increased mortality rates, higher risk of adverse events, and decreased patient satisfaction [5]. Delays in care can lead to deterioration in patient conditions, especially for those with time-sensitive medical emergencies [6]. In EDs, telemedicine consultations were able to improve the timeliness of ECG evaluation and increase the use of fibrinolytic reperfusion therapy for rural patients [7].

Complete and accurate documentation in EDs is crucial for ensuring continuity of care and high-quality care. Studies have shown that nurses' documentation in EDs often lacks completeness, with omissions in critical areas such as social determinants of health, patient history, and medication administration [[8], [9], [10]]. Incomplete documentation can lead to errors in patient care, including medication mistakes, miscommunication among healthcare providers, and inadequate follow-up care [11]. It can also impede the ability to perform accurate clinical audits and quality improvement initiatives [12].

Virtual nursing, an emerging care delivery model that provides access to remote nursing expertise to complete patient admissions from the ED to the unit, has emerged as a potential solution to these issues [19]. In theory, virtual nurses can augment the existing workforce, providing additional support without needing physical presence in the ED, which can address the high nurse-patient ratio challenge and help manage patient volume more effectively [13]. Nonetheless, there is a lack of evidence on the effectiveness of VN in the efficiency and documentation of patient encounters in the ED.

Theoretically, VN will ease the workload for bedside nurses by allowing virtual nurses to complete a portion of the required patient care tasks. This is especially helpful in a stressful and fast-paced environment like the ED. Additionally, VN may improve patient satisfaction and care outcomes as patients may not have to wait as long for their bedside nurse and their virtual nurse is responsible for only one patient at a time. This study examined the impact of virtual nursing on ED efficiency (wait time, admission assessment duration) and quality of care (documentation completeness, and interruptions) in a non-randomized cohort study.

---

Section snippets

Methods

This study is a retrospective cohort analysis involving approximately 40,000 patients who visited emergency departments (ED) at six hospitals affiliated with a major Southeastern health system between August 2022 and December 2023. Virtual nursing outcomes were examined at four hospitals within the same health system using the same institutional EHR. At these hospitals, virtual nursing is offered by a patient's ED nurse primarily for admission assessments and patient education.

Using a phased

Results

Of 15,435 patient encounters, 11,343 (73.5 %) were in-person encounters and 4092 (26.5 %) were virtual encounters (Table 1). Overall, the average (SD) age was 62.4 (18.7) years, 7833 (51 %) were females, 11,297 (73 %) were White, 14,550 (94 %) were neither Hispanic nor Latino, and 14,907 (97 %) reported English as their preferred language.

The overall median for patient assessment duration was 25.0 min (interquartile range [IQR]: 15.0–38.0), Fig. 1a. For virtual nursing sessions, the median

Discussion

This is the first-of-its-kind study to evaluate the effect of virtual nursing on wait times, nursing documentation, and interruptions using retrospective cohort analysis of EHR data in six hospitals. We found that EDs that the wait times from triage to admission were about 90 min shorter in EDs that implemented virtual nursing than EDs that did not offer VN, suggesting virtual nursing sessions could offer a more efficient patient flow through the ED than in-person visits. The availability of

Conclusion

This retrospective cohort analysis compares the outcomes of EDs that used virtual nursing with ED that do not to demonstrate the potential benefits of virtual nursing in improving the efficiency and quality of care. The use of virtual nursing was associated with shorter wait times from triage to admission, increased completeness of nursing documentation, and fewer interruptions during patient assessment. While we observed that virtual nursing led to longer admission assessment durations, this

Funding

This study was supported by the Health Resources and Services Administration (HRSA), (Grant No. 6 U3GRH40003-01-01) and the National Center For Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Number RC2TR004380, and the UNC School of Nursing. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of HRSA or NIH, nor does mention of department or agency names imply endorsement by the US

CRediT authorship contribution statement

Saif Khairat: Writing – original draft, Supervision, Project administration, Methodology, Funding acquisition, Formal analysis, Data curation, Conceptualization. Jennifer Morelli: Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Qiyao Qin: Writing – original draft, Validation, Formal analysis, Data curation. Xiaoyu Wu: Writing – review & editing, Writing – original draft, Visualization, Validation,

Declaration of competing interest

Saif Khairat reports financial support was provided by Health Resources and Services Administration. Saif Khairat reports financial support was provided by National Center for Advancing Translational Sciences. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The team would like to thank Shiyi Yang and Shiyu Wan for their assistance and insights provided during this study.

---

References (27)

• L.I. Horwitz et al.

  US emergency department performance on wait time and length of visit

  Ann Emerg Med

  (2010)

• P. Carayon et al.

  Advances in patient safety nursing workload and patient safety—A human factors engineering perspective

• J.E. Ball et al.

  ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care

  BMJ Qual Saf

  (2014)

• S. Calder-Sprackman et al.

  Availability of emergency department wait times information: a patient-centered needs assessment

  Emerg Med Int

  (2021)

• Y. Shen et al.

  Improving the wait time to consultation at the emergency department

  BMJ Open Qual

  (2018)

• R. Knopp et al.

  Physician-patient communication in the emergency department, part 1

  Acad Emerg Med

  (1996)

• A.C. Miller et al.

  Emergency department telemedicine consults are associated with faster time-to-electrocardiogram and time-to-fibrinolysis for myocardial infarction patients

  Telemed J E Health

  (2020)

• M. Franco et al.

  Electronic medical record in the ED: a cross-sectional survey of resuscitation documentation practices and perceptions among emergency department clinicians

  Pediatr Emerg Care

  (2018)

• J. Bunting et al.

  Strategies to improve compliance with clinical nursing documentation guidelines in the acute hospital setting: a systematic review and analysis

  SAGE Open Nursing

  (2022)

• K. De Groot et al.

  Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses

  BMC Nurs

  (2022)

• A. Shahbodaghi et al.

  Documentation errors and deficiencies in medical records: a systematic review

  J Health Manag

  (2024)

• U.M. Kinnunen et al.

  Register-based research of adverse events revealing incomplete records threatening patient safety

  Stud Health Technol Inform

  (2020)

• C.M. Rutledge et al.

  Telehealth: preparing advanced practice nurses to address healthcare needs in rural and underserved populations

  Int J Nurs Educ Scholarsh

  (2014)

There are more references available in the full text version of this article.