In mid-March, as the shadow of the coronavirus threat stretched across the nation, Erika Ibuado quickly retreated to safety. The 34-year-old stepped away from her job as a hair stylist and quarantined herself and 2-year-old daughter Scarlett in their Evans, Colorado home. Erika had another vulnerable companion to protect: her unborn child, then about 22 weeks old.
Erika and her husband, Sergio, did everything they could to shield their home from the SARS-CoV-2 virus, which causes COVID-19. She had no contact with any of her other family members. Sergio continued to work with his small crew on a Weld County oil patch – which was essential with Erika no longer working – but when he came home, he left his shoes in the garage, removed his work clothes in the laundry room to be washed, and immediately showered. He took care of the shopping and disinfected groceries and other items before putting them away.
Despite their efforts, the virus found its way into the Ibuado home. Erika experienced the first symptoms – sinus headaches and a runny nose – on Easter Sunday, April 12. Shortly thereafter, she noticed she’d lost her sense of taste and smell, and she became short of breath.
By Thursday, April 16, Erika’s primary care provider, nurse practitioner Lydia Pyle, ordered a COVID-19 test for her and recommended that she go to the emergency room at UCHealth Greeley Hospital, which she did. After her examination, Erika called her sister to catch her up. As they chatted, Erika checked My Health Connection, the Epic electronic health record patient portal, for her test results and saw she had tested positive for the virus.
She was prepared for the news, but the threat to her baby sunk in, as did the suddenness of the potentially life-changing diagnosis. Sergio and Scarlett had just dropped off Erika at the ER, expecting to return later that evening. They hadn’t really said good-bye to one another. How soon would they see each other again? And what lay ahead for the life inside her?
“It got serious very quickly because of the doctors’ concerns about my pregnancy,” Erika said. “You could feel it, that this is really serious. This could go wrong very quickly.”
The good news is that many things went right very quickly for Erika. Her providers in Greeley hastily transferred her by ambulance to UCHealth University of Colorado Hospital on the Anschutz Medical Campus, where the Neonatal Intensive Care Unit is equipped to care for infants born earlier than 28 weeks. She arrived at University of Colorado Hospital at 2 a.m. Friday, went into isolation and initially spent restless hours worrying about the rest of her pregnancy. Erika briefly received oxygen support to ensure the safety of her baby, but was able to leave the hospital on Sunday, April 19, to return to Greeley. She considered herself lucky.
An at-home companion
Erika didn’t go home alone. Toward the end of her hospital stay, she received an FDA-approved remote monitoring device that fits on the wrist and finger. Patients download an app to their smartphone, enabling them to transmit biometric data, including oxygen levels, respiratory rates and heart rates, to a cloud server. At UCHealth, providers in Aurora at the Virtual Health Center – a project launched in 2018 to provide remote monitoring of ICU and other at-risk patients – monitor the data in real time, around the clock, and take steps to protect the patient if a problem like a drop in oxygen levels crops up.
“We want to ensure that each patient has a safe transition and is watched safely at home,” said Amy Hassell, a critical-care nurse and director of patient services for the Virtual Health Center. “Our goal is to provide interventions that keep patients out of the emergency department and urgent care settings and avoid hospitalizations.”
That work requires a strong infrastructure. The Virtual Health Center, led by medical director Dr. Chris Davis, has support from physicians, nurses, information technologists, project managers and UCHealth leadership.
Responding to risk
Erika was among a pilot group of 10 COVID-19 patients selected to test the device made by Masimo. These patients met a set of “key criteria” for risk of declining health after discharge, said Dr. Hemali Patel, a hospitalist at University of Colorado Hospital who worked with a group of hospitalists, pulmonologists and infectious disease specialists to identify those who might benefit most from remote patient monitoring.
They include patients who are 55 years and older; discharged on oxygen for the first time or on higher levels than they used before admission; are immunocompromised; have underlying medical conditions, like diabetes; or are pregnant, like Erika.
Patel said it’s particularly important that providers have a way to monitor patients’ oxygen levels continuously.
“We know that drops in oxygen levels can be one of the earliest signs of deterioration,” she said. However, the drops could easily go unnoticed without the electronic eyes housed in the Virtual Health Center.
Patel’s observation played out in real life in the Ibuado home. During Erika’s first night back from the hospital, a phone call awakened her. A nurse from the Virtual Health Center tracking the device data noticed that her blood oxygen level had dipped below the 94% that is ideal during pregnancy.
At the nurse’s direction, Erika sat up and took some deep breaths to help boost her oxygen. The following day her obstetrician, who had been alerted to the potential issue, ordered home oxygen for Erika. The Virtual Health Center kept regular tabs on her throughout the eight days that she wore the monitoring device, and called her each morning to ask if she’d experienced any potentially dangerous symptoms, like shortness of breath, fever or diarrhea.
The experience with the device was both a revelation and a comfort, Erika said.
“I thought, ‘Oh, my gosh, they really are monitoring me,” she said. “I felt secure, and it was nice to know that if something does go wrong, they are monitoring you. They are on top of it and really keeping track of their patients. You are not just forgotten once you go home.”
Erika no longer wears the device and is out of quarantine, although she continues to put on a mask when she is within six feet of Sergio and Scarlett. She and other patients in the groundbreaking first group will not be the last to push the boundaries of remote patient monitoring at UCHealth. Additional COVID-19 patients who are at highest risk for clinical deterioration are now at home under the watchful eye of the Virtual Health Center. On the horizon is a “phase two” move to open up monitoring to all COVID-19 patients after they leave the hospital, Hassell said.
Multiple monitoring options
The Virtual Health Center is also evaluating additional remote monitoring options, notably the FDA-approved BioSticker, developed by Denver-based technology company BioIntelliSense in partnership with the UCHealth Care Innovation Center. The small device, affixed to the patient’s body, transmits not only heart and respiratory rates, but also readings on skin temperature, activity levels, body position and more. The device collects and continuously transmits data for 30 days. The goal, again, is to help providers manage patients proactively rather than hurriedly address problems after they’ve worsened.
Patients would leave the hospital with the BioSticker after receiving instructions on using it and understanding its benefits. Dr. Patel stressed that the key consideration for any remote monitoring device is to ensure that it delivers accurate data and that patients feel comfortable using it.
“The most important piece of all of this is that we provide quality care that is patient-centered,” Dr. Patel said.
COVID-19 has helped shine a brighter light on the benefits of virtual care, but it is only one piece of a movement that was well underway at UCHealth before the pandemic hit. Virtual Visits and Virtual Urgent Care were available at more than 90 clinics prior to the pandemic and is now available at more than 800 clinics. That preparation paid off as the virus shuttered clinics and sharply curtailed personal contact between patients and physicians. UCHealth Chief Information Officer Steve Hess pegs the number of virtual visits in April at about 88,000 across all of UCHealth and affiliates. Prior to the pandemic, the number of monthly virtual visits was just 400, Hess reported.
Only the beginning
Those numbers suggest that remote patient monitoring devices will continue to play an important role at UCHealth, regardless of how the COVID-19 pandemic plays out. Dr. Patel acknowledged that remote monitoring and virtual visits represent change, “and change is always hard.” But she strongly believes that patients will receive the same level of care, even when their provider is miles away.
“I see it becoming part of the usual patient care we provide,” Dr. Patel said. “A lot of patients come to us from far away. How do we think about providing care for them in a smooth and seamless fashion? These devices will allow us to gather information and data that will help us to provide care from a distance. I think that will be an important part of care in the future. I don’t think that is going away.”
That future very likely also includes remotely monitoring non-COVID-19 patients with chronic diseases like diabetes, Hassell said. The results of the pilot project with patients like Erika Ibuado offer early support for moving forward, she added.
“Virtual care is an exciting new frontier,” Hassell said. “Patients [in the pilot] were supportive of the process. They were overwhelmingly grateful and liked the idea that the hospital is keeping an eye on them and that they could reach out if there was an issue.”