Expanding ED Observation to Community Hospitals with Telemedicine

Rebekah Mckelvey MSN, FNP-BC
Carilion Clinic, ED Observation, Roanoke, VA

When access, efficiency, and patient experience align, meaningful change happens. This past fall, our organization celebrated 10 years of ED Observation Medicine. We have recently strengthened our Observation program by the integration of telemedicine to better serve our rural communities.

What began in 2015 as a small, 6‑bed unit has grown into a systemwide program managing 40 ED Observation beds daily across five of our emergency departments. Our newest innovation, telemedicine, has allowed us to extend observation services to our rural, critical access EDs. At a time when admission holds and transfer delays strain hospital systems, incorporating telemedicine in ED Observation improves throughput, reduces unnecessary transfers, and offers shorter lengths of stay for appropriate observation diagnoses.

Our staffing model is creative and efficient. For 12 hours each day, an Advanced Practice Provider (APP) is onsite at one of our community ED with a dedicated 5‑bed Observation Unit. Here, they provide routine in person Observation care. During that same shift, the APP also supports two rural, community EDs via telemedicine, collaborating closely with the local attending physicians and nursing teams. Outside of these hours, ED providers at each site continue observation management within the ED. This hybrid model extends ED Observation support to 3 hospitals by a single provider and ensures consistent patient flow around the clock.

In the past year alone, this approach supported more than 1,300 ED Observation patients in our Community EDs and prevented 522 potential hospital admissions or transfers. The average length of stay for this group was 16.3 hours, with a conversion‑to‑inpatient rate of just 11.4%. This data reflects both efficient care delivery and appropriate patient selection.

While much of our ED Observation Telemedicine program is functioning well, it is important to reflect on the challenges encountered. Providers have occasionally experienced brief connectivity interruptions during virtual visits. Additionally, during periods such as shift changes or times of high patient acuity, staff may not always be immediately available to initiate the virtual encounter.  More significant challenges include the lack of dedicated observation bed space within busy community emergency departments and the need to support staff in adapting to the cultural shift associated with ED Observation and telemedicine. These minor operational challenges are manageable and can be addressed with flexibility and ongoing process refinement.

Consider an older adult arriving at a rural southwestern Virginia ED with symptoms of a TIA. In the past, this patient would face prolonged waits and a hospital transfer far from home. Today, that same patient can remain locally, receive a full diagnostic workup—including MRI, telemetry, echocardiogram, and neurology consultation—all through ED Observation and telemedicine. Care is delivered efficiently, patient satisfaction is high, and both time and resources are preserved. A win for the patient and the hospital system.

This is the future of ED Observation: innovative, patient‑centered, and designed to bring high‑quality care closer to home.