JOURNAL OF MEDICAL INTERNET RESEARCH Bruce et al

Original Paper

Impacts of an Acute Care Telenursing Program on Discharge,

Patient Experience, and Nursing Experience: Retrospective Cohort
Comparison Study

Courtenay R Bruce, MA, JD; Steve Klahn, RN, MBA; Lindsay Randle, MBA; Xin Li, BS; Kelkar Sayali, BS; Barbara
Johnson, BSN, MBA, DNP; Melissa Gomez, MBA; Meagan Howard, MHA; Roberta Schwartz, PhD; Farzan
Sasangohar, PhD
Houston Methodist, Houston, TX, United States

Corresponding Author:
Courtenay R Bruce, MA, JD
Houston Methodist
8100 Greenbriar Drive
Houston, TX, 77030
United States
Phone: 1 281 620 9040
Email: [email protected]

Abstract
Background: Despite widespread growth of televisits and telemedicine, it is unclear how telenursing could be applied to augment
nurse labor and support nursing.
Objective: This study evaluated a large-scale acute care telenurse (ACTN) program to support web-based admission and
discharge processes for hospitalized patients.
Methods: A retrospective, observational cohort comparison was performed in a large academic hospital system (approximately
2100 beds) in Houston, Texas, comparing patients in our pilot units for the ACTN program (telenursing cohort) between June
15, 2022, and December 31, 2022, with patients who did not participate (nontelenursing cohort) in the same units and timeframe.
We used a case mix index analysis to confirm comparable patient cases between groups. The outcomes investigated were patient
experience, measured using the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHCPS) survey;
nursing experience, measured by a web-based questionnaire with quantitative multiple-choice and qualitative open-ended questions;
time of discharge during the day (from electronic health record data); and duration of discharge education processes.
Results: Case mix index analysis found no significant case differences between cohorts (P=.75). For the first 4 units that rolled
out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHCPS domains. Scores for “communication with
doctors” and “would recommend hospital” were improved significantly (P=.03 and P=.04, respectively) in 1 unit in phase 1. The
impact of telenursing in phases 2 and 3 was mixed. However, “communication with doctors” was significantly improved in 2
units (P=.049 and P=.002), and the overall rating of the hospital and the ”would recommend hospital” scores were significantly
improved in 1 unit (P=.02 and P=04, respectively). Of 289 nurses who were invited to participate in the survey, 106 completed
the nursing experience survey (response rate 106/289, 36.7%). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program
was very helpful or somewhat helpful to them as bedside nurses. The only noticeable difference between the telenursing and
nontelenursing cohorts for the time of day discharge was a shift in the volume of patients discharged before 2 PM compared to
those discharged after 2 PM at a hospital-wide level. The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and
29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was
13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice (nontelenursing cohort) of a bedside nurse
engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation time study.
Conclusions: This study shows that ACTN programs are feasible and associated with improved outcomes for patient and nursing
experience and reducing time allocated to admission and discharge education.

(J Med Internet Res 2024;26:e54330) doi: 10.2196/54330

KEYWORDS
telenursing; telemedicine; patient discharge; health personnel; surveys and questionnaires; patient outcome assessment
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preimplementation methods are reported more extensively in

Introduction the studies by Hehman et al [12] and Schwartz et al [13].
Telemedicine, particularly video televisits, has greatly expanded Program implementation was first informed by nursing time
in the wake of the COVID-19 pandemic [1,2]. Televisits have and workload surveys and pilot implementation in 4
shown promise as a robust, practical, efficacious, and scalable comparatively understaffed units. The chief innovation officer,
alternative to in-person office visits that could ameliorate labor along with nursing leaders and ACTN program administrators,
supply shortages [3,4]. The published evidence suggests a met with the bedside nursing staff of these 4 understaffed units
generally positive attitude toward televisit appointments for to solicit their input on where and how ACTN would add value
chronic care, focused on addressing financial and transportation to their workflow. Bedside nursing staff provided critical input
barriers and improving patients’ access to care [5-7]. Despite on admission processes that could be delegated to individuals
the promise shown by televisits, limited attention has been paid working remotely with no perceived negative impact on patient
to applying this method in the acute care setting and, in experience. We conducted participatory workflow design
particular, on how this promising technology can be leveraged sessions with bedside nursing staff on the ACTN program to
to support nurses. cocreate workflow integration points where the remote team
could assist [13].
Estimates suggest that approximately 200,000 open nursing
positions will become available each year between 2021 and Pilot Implementation and Procedures
2031 [8]. Telenursing can augment nursing labor supply, Before implementation, the ACTN administrators trained
decrease nursing workload, maintain patient and nurse safety, bedside nurses in pilot units by demonstrating the use of
and positively impact nursing and patient experiences [9]. technology during shift huddles. Then, the trainers presented
However, the impact of telenursing on outcomes in acute care slides on contact information and available support and provided
settings remains a research gap. a role demarcation process map, showing what the remote
telenurse staff would be doing compared to what the bedside
To address this gap, this study aimed to evaluate the outcomes
nurses needed to do to launch and conduct discharge education.
associated with a large-scale acute care telenurse (ACTN)
Furthermore, the trainers invited the nursing staff to observe
program to support web-based admission and discharge
several discharges to learn how to conduct them. A software
processes for hospitalized patients compared to patients who
with Health Insurance Portability and Accountability Act
did not undergo the ACTN program intervention. Admission
compliance was uploaded to iPads (Apple Inc) and stored on
and discharge are 2 substantive and time-consuming acute care
each unit. Handheld iPads were available, and roaming iPads
nursing tasks that involve tedious documentation in the
were made available for patients who could not hold an iPad.
electronic health record (EHR) and extensive interaction with
patients and families to gather history and provide patient The pilot implementation was staggered in a phased rollout,
education [10,11]. We aimed to develop an ACTN program to consisting of 3 sequenced phases, as shown in Figure 1. Upon
augment nursing care by conducting admission and discharge admission, the acute care bedside nurse contextualized the
processes through telenursing in a large health system. ACTN program with patients and families by handing the patient
Subsequently, we discuss the impacts on 4 end points: patient an iPad with a preloaded remote program app (Caregility) and
experience, nursing experience, time of discharge during the then pressing a soft key to allow the ACTN to enter the patient’s
day, and length of time for discharge education processes. We room via the iPad screen. The ACTN introduced themselves,
hypothesized that the ACTN program would be associated with completed the nursing admission profile in the EHR, placed a
higher patient experience scores and improved nursing request for a consultation, and notified the bedside nurse that
experience compared to standard admission and discharge the admission was completed using secure SMS text messaging
practices. [13]. A similar process was followed for discharge workflow
processes, where the ACTN completed patient education on
Methods discharge instructions, confirmed the patient’s pharmacy details,
confirmed discharge transportation, and arranged for departure.
Overview
This study was conducted in a large academic hospital system
(approximately 2100 beds) in Houston, Texas. The

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Figure 1. Overview of the 3-phase pilot implementation in 12 units. CV: cardiovascular; CVIMU: cardiovascular intermediate unit; GI: gastrointestinal.

Bedside nurses used their discretion regarding which patients which represented 8 aspects (called dimensions) of patient
would be appropriate for the ACTN program. They based this satisfaction. Each dimension was measured using a continuous
determination principally on whether documentation was needed variable (0 to 100 points).
and whether the patient could benefit from the undivided
For the telenursing cohort, we analyzed bedside nurses’
attention the ACTN program could afford. Furthermore, they
collective responses using a Forms (Microsoft Corp) survey
excluded patients from the ACTN program if the patients
conducted in April 2023. The survey consisted of 5 questions,
expressed discomfort using an iPad. After the initial rollout,
asking them to indicate whether the ACTN program was helpful
patients’ input was sought on their experience with the ACTN
using a Likert scale with 5 items (very helpful to very
program to identify where and how improvements could be
unhelpful). Nurses were asked to provide open-ended comments
made, and this feedback was incorporated into iterative revisions
to explain the reasons for their evaluation. At the end of the
in subsequent rollouts.
survey, we included 2 open-ended fields for nurses to describe
Pilot Outcomes Monitoring opportunities for improvement in future rollouts and provide
A retrospective, observational cohort comparison was any additional comments.
performed, in which all patients in our pilot units for the ACTN Furthermore, we explored the time at which discharge occurred
program (telenursing cohort) between June 15, 2022, and using the EHR admission, discharge, and transfer date and time.
December 31, 2022, were compared with all patients who did We compared the hour of the day the patient was discharged in
not participate (nontelenursing cohort) in the same units in the the telenursing cohort with the hour of the day the patient was
same timeframe. discharged in the nontelenursing cohort, hypothesizing a priori
Our primary outcomes were patient experience and nursing that patients might be discharged earlier in the day in the
experience. Patient experience scope was any process observable telenursing cohort. Finally, we analyzed the duration of
by patients [14]. We compared patient experiences in the discharge education for both cohorts, measured in minutes.
telenursing and nontelenursing cohorts by evaluating patients’
responses to the widely used Hospital Consumer Assessment
of Health Care Providers and Systems (HCAHPS) survey [15],

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Data Analysis domains (Table S1 in Multimedia Appendix 1). On average, 6

The patient demographic data were available for all patients. out of 8 HCAHPS domains were improved for patients in the
To confirm that the telenursing cohort had similar patient telenursing cohort. All 4 units experienced improvements in
demographics as the nontelenursing cohort (and therefore to the “overall rating” domain, and 3 of the 4 units experienced
confirm that nurse biases in patient selection for the ACTN improvements in “likelihood to recommend” domain for patients
program were unlikely), we conducted a case mix index (CMI) in the telenursing cohort compared to those in the nontelenursing
evaluation. We first isolated the population of both cohorts into cohort within the same units. The improvement scores ranged
adults (aged ≥18 y). We compared only those patients who were from 1.4% for the neurosurgery unit (36 beds) to 11.6% for the
discharged home and excluded those who were on medical unit (37 beds). Furthermore, all 4 units in the first phase
extracorporeal membrane oxygenation or those who underwent of roll out experienced improved scores in the “responsiveness”
a tracheostomy. The remaining population was evaluated to domain by >4 points (ranging from 5% to 10.1%). A total of 2
determine whether there was a difference in patient acuity and out of the 4 units also experienced improvements in the
severity. After confirming that patient acuity and severity were “communication with nurses” (ranging from 1.7% to 3%) and
of no significant difference, we included the inpatient and “communication about medicines” (ranging from 3.3% to
observation populations to evaluate the intervention results. 11.7%) domains. The 2 units that did not experience
improvement in the communication domains were the combined
For the patient experience data, independent sample t tests medical and surgery neurology and neurosurgical units (36
(2-tailed) were used to compare the telenursing and beds). Only the neurosurgical unit showed statistically
nontelenursing cohorts across different HCAHPS dimensions significant improvements in 2 dimensions: “communication
and units. Analysis was conducted using R software (R with doctors” (P=.03) and “would recommend hospital” (P=.04).
Foundation for Statistical Computing). For the nursing
experience survey data, we used Excel (Microsoft Corp) to For the 7 units that rolled out during phase 2, only 1 orthopedic
analyze the responses to multiple-choice, discrete questions and surgery unit (28 beds) experienced improvements in every
thematic analysis to evaluate the open-text fields. Thematic domain (ranging from 0.9% to 12.5%). Medical observation
analysis allows for eliciting key themes that emerge based on unit 1 also improved in 5 areas. However, only improvements
recurring statements [16]. The analysis followed an inductive in “communication with doctors” (P=.002), “overall rating of
approach. This approach uses open-ended questions, allowing hospital” (P=.02), and “would recommend hospital” (P=.04)
themes to emerge with a few previously articulated assumptions were statistically significant. The remaining units experienced
on responses. Given the limited content, CRB served as the improvements in some domains for the telenursing cohort
primary coder. Coding labels were used for data contextualizing, compared to the nontelenursing cohort, with no improvement
allowing for new themes to emerge throughout the coding in other domains. However, the scores for “communication with
process, using a codebook [16,17]. We stored emergent patterns nurses” and “communication with doctors” domains were
and themes in an electronic format. improved for most of the units that rolled out in phase 2 (Table
S2 in Multimedia Appendix 1).
Ethical Considerations
For the 2 units that rolled out in phase 3, both of which were
The hospital’s review board determined that the ACTN pilot surgical cardiac units with 36 beds, 1 unit experienced
would not be considered regulated human subjects research. improvement in every domain except “responsiveness” (ranging
All data reported in this study were aggregated and deidentified. from 1% to 12%). The other unit only experienced improvement
in the “communication with doctors” (4.9%) and “care
Results transitions” domains (1.1%). However, none of these
improvements were statistically significant (Table S3 in
Overview Multimedia Appendix 1).
The demographics of the telenursing and nontelenursing cohorts
were relatively similar. Both cohorts had an average age of 60 Nursing Experience
years with an SD of 16.91; had a similar distribution in race Of the 289 nurses who were invited to participate in the survey,
and ethnicity (approximately 92/2319, 3.96% Asian; 525/2319, 106 completed the survey (36.7% response rate). Of the 106
22.64% Black; 425/2319, 18.33% Hispanic; 70/2319, 3.02% nurses, 101 (95.3%) indicated that the ACTN program was
Native American, declined to identify, or other categories; and “very helpful” or “somewhat helpful” to them as bedside nurses.
1202/2319, 51.83% White); and had a similar distribution in
female participants versus male participants (1249/2319, 53.86%
Quantitative Findings
vs 1070/2319, 46.14%). To further understand the population, The main reasons nurses gave for the program’s helpfulness
the CMI analysis for acuity and severity showed that the CMI included that it saved them time (94/106, 88.7%), allowed them
was slightly higher in the telenursing cohort than in the to focus on more urgent clinical needs (90/106, 84.9%), allowed
nontelenursing cohort, but the difference was not statistically them to focus on activities they felt were more in line with their
significant (P=.75). skill level (55/106, 51.9%), and allowed patients to have
undivided attention for their discharge education (52/106,
Patient Experience 49.1%). Among the 5 nurses who indicated that the ACTN
Among the first 4 units that rolled out in phase 1, all units program was somewhat unhelpful or very unhelpful, 3 (60%)
experienced improvement in at least 4 and up to 7 HCAHPS indicated that workflows were not clear or needed further

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refinement or clarification. Furthermore, the nurse respondents Being in such a fast-paced unit, it can be a bit
shared several barriers and provided opportunities for stressful with so many discharges and admissions.
improvement, with 91 (85.8%) out of 106 nurses offering Having a helpful hand is beneficial.
suggestions.
Improved Patient Safety
Qualitative Findings Finally, the third theme was perceived improvement in patient
Overview safety by having a telenurse who could “catch missed” issues
(eg, an incorrectly identified pharmacy details), simultaneously
For the free-text explanation fields, all but 3 nurses (103/106, allowing the primary bedside nurse to focus more intensely on
97.2%) provided additional comments on the ACTN program other needs, essentially creating a 2-fold safety promotion. Some
helpfulness. Three themes emerged from the qualitative analysis nurses noted that they could begin carrying out orders while the
of the free-text comments: (1) most of the nurses’ comments telenurses began completing the admission, facilitating quicker
reflected that telenurses help bedside nurses save time, (2) treatment and resolution of care needs, thereby improving the
respondents indicated that extra hands provided emotional and safety and quality of care. One nurse mentioned the following:
physical support in providing patient care, and (3) respondents
perceived an improvement in patient safety by having a telenurse Allows [telenurses] to take on thorough and accurate
who could “catch missed” issues. admissions, while also preventing any rushing the
patient might experience from the primary RN.
Time Saving
When asked for areas of improvement, the most recurring theme
One of the perceived benefits of the telenursing program was was having 24 hours of support during the weekend and during
saving time. One nurse said the following: the week. The second theme for improvement was the reduced
... Just putting in home medications alone takes up time to connect to a telenurse. The third theme was the
so much time. This new telenurse service helps [save availability of iPads. Nurses mentioned that iPads could
time] sometimes be unavailable in patients’ rooms or they may not
Several nurses highlighted that admission and discharge be fully charged.
processes are so complex and time-consuming that shifting this Time of Discharge
work to the ACTN program freed nurses to perform other
The time of day distribution is presented in Figure 2. The only
activities, as reflected by this nurse:
noticeable difference between the telenursing and nontelenursing
The tele RN is able to spend as much time possible cohorts was a shift in the volume of patients discharged before
sufficiently educating an admission or discharge while 2 PM compared with those discharged after 2 PM at a
allowing me time to respond to the needs of my other hospital-wide level (Table 1). At an individual unit level, these
patients saving me time on one patient especially results were not consistent and could be further explored by
charting. patient population and their needs to discharge. The variation
was further illustrated when reviewing the length of stay of
Emotional and Physical Support
patients in the telenursing and nontelenursing cohorts. Only 5
For the second theme, several responses focused less on time out of the 12 units showed a decrease in the average inpatient
management and perceived efficiencies and instead centered length of stay.
more on the emotional appeal and support in having an extra
hand, as one nurse mentioned:

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Figure 2. Comparison of percentage distribution of discharge by time of the day.

Table 1. Time of the day distributions for the nontelenursing cohort compared to the telenursing cohort.
Hour of day Nontelenursing (n=4220), n (%) Telenursing (n=3907), n (%)
Before and up to 2 PM 1837 (43.53) 1766 (45.2)
After 2 PM 2383 (56.47) 2141 (54.8)

At the time of writing this paper, the United States was

Discharge Length experiencing a critical nursing shortage that will likely reach
The ACTN admissions averaged 12 minutes and 6 seconds (SD an epidemic level in the next few decades [8]. Despite the
7 min and 29 s), and the discharges averaged 14 minutes and promise shown by telenursing, to our knowledge, only 1 existing
51 seconds (SD 8 min and 10 s). The average duration for ACTN paper documents the impact of ACTN programs on
calls was 13 minutes and 17 seconds (SD 7 min and 52 s). HCAHPS-measured patient satisfaction using a small cohort of
Traditional cohort standard practice of a bedside nurse engaging patients in a single, time-limited pre- and posttelenursing
in discharge and admission processes was 45 minutes, consistent analysis [18]. A study by Schuelke et al [18] revealed a 6.2%
with our preimplementation nursing time study. increase in “communication with meds” and 12.7% increase in
“communication with nursing” domain scores; other HCAHPS
Discussion domains were not evaluated. This research builds upon the
promising work of Schuelke et al [18], evaluating the impact
Principal Findings of an ACTN program on several units with a much larger cohort
Our results suggest that the ACTN program was associated with of patients using a staggered rollout and comparing all HCAHPS
positive nursing experiences because it saved time. Furthermore, domains between telenursing and nontelenursing cohorts within
the ACTN program was associated with higher HCAHPS scores the same time frame and in the same units.
in several domains but only in the first series of units that piloted
By conducting granular HCAHPS analyses, we identified what
the intervention. In phase 1, the improvement in
we believed to be a time sequence variability in that units that
“communication with doctors” and “would recommend hospital”
rolled out in phase 1 performed considerably stronger in
scores in 1 unit was statistically significant. In phase 2, the
HCAHPS impacts than units that rolled out in later phases. An
improvement in “communication with doctors” score was
explanation for this sequence effect might be that some later
significant in 2 units and that in “overall rating of hospital” and
adopters had less potential for high effect size, given that the
“would recommend hospital” scores were significant in 1 unit.
first 4 units of the rollout were specifically chosen for their
The time of day discharge was nearly the same in both the
staffing problems compared to later units. ACTN support might
telenursing and nontelenursing cohorts. The duration for
have augmented the staffing support to such a degree that
discharge processes was less than half in the ACTN cohort
allowed the impacts of the program to be more salient. An
compared to the nonintervention cohort.
alternative explanation is that the early adopters and promoters
tend to have greater diffusion uptake, greater saturation and

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adoptability, and greater impacts compared to late adopters or time-of-day discharge savings. One explanation for this
those resistant to adoption [19,20]. Our anecdotal evidence discrepancy may be that many factors beyond nursing impact
suggests that early adopters might have wanted the telenursing the time of the day a patient is discharged; therefore, while the
program to succeed; therefore, they applied consistent bedside nurses’ time is saved, the remaining discharge processes
implementation practices to ensure success. Adopters in later beyond nurses remain unaffected. Specifically, there are 3
stages were more aware of barriers and potential downsides and segments of time during discharge processes: (1) the time for
might have been more ambivalent about telenursing and, the discharge order and medication reconciliation [21] to the
therefore, less likely to modify their behaviors to promote the time the after-visit summary (AVS) is populated and printed
telenursing program’s success. [22]; (2) the time the AVS is completed and printed to the time
the discharge instructions are provided; and (3) the time from
Another interesting finding was that the ACTN program seemed
providing the discharge instructions to the actual discharge
to be effective for both medical and surgical units of all
(Figure 3). Notably, telenurses’ involvement is currently limited
specialties. Phase 1 was a mix of medical and surgical units;
to only the second segment of time. Specifically, telenurses’
however, all units experienced increases in scores. Phases 2 and
involvement is not initiated until the AVS is printed by the
3 experienced mixed results, without a clear lead for one
nurse, which means that telenurses cannot positively impact
specialty over the other. This may suggest that ACTN programs
any discharge activity that occurs between the time the discharge
are broadly applicable across acute settings and that success
order is written and the time the AVS is printed. However, there
depends most crucially on the need and desire of unit leaders.
are inefficiencies and bottlenecks in discharge processes that
Our time of day discharge findings showed only a few occur well before the AVS is printed [23,24]. For instance, the
quantitative positive efficiencies. However, our discharge discharging physician may write a conditional discharge order
duration analysis and nursing experience survey results showed early in the morning, listing conditions that cannot be fulfilled
that ACTN has major time-saving benefits for nurses, suggesting within a few hours or it may take bedside nursing longer than
a discrepancy between perceived and actual time savings versus anticipated time to print the AVS.
Figure 3. Overview of the discharge process in our health system. AVS: after-visit summary.

To create a wider cascade effect for positively impacting the study, we did not control for other factors that could impact
discharge processes for all segments of time, we are currently patient and provider satisfaction as well as discharge times;
trying to obtain greater transparency through EHR reporting in telenursing can only improve upon one component in a complex
what occurs for segments 1 and 3. For instance, at present, we set of factors limiting discharge efficiency and satisfaction
know that at least 2 hospitals in our 8-hospital system have high outcomes. Finally, participating nurses were aware of the
incidence rates of conditional discharge orders that should be ongoing study, and this knowledge might have affected their
reduced. One hospital anecdotally reports that the discharging behavior [28].
physician identifies incorrect pharmacies, which requires a nurse
to send the scripts back to the discharging pharmacist to
Future Directions
reconcile before discharge education can occur [25]; however, After the completion of this pilot study, the ACTN admission
the prevalence and location of these issues remain speculative. and discharge program has been rolled out to pilot medical units
Segment 3 is a black box of time [26]—the time it takes for and all surgical and observation units. Our rationale for
hospital transport or an ambulance to arrive and move the patient expansion rested on the premise that nursing experience is
to their destination and the time it takes for the family to pick important to maintain and strengthen, particularly at a time
up the patient. All these factors impact the discharge processes when turnover is high in the health care industry in general. It
and need to be fully elucidated, explored, and streamlined. is important to reduce staff inefficiencies in workload as a means
Furthermore, we hope to facilitate processes that enable of preserving or strengthening organizational morale and cost
telenurses to print the AVS, to remove the dependency on saving. Because our nursing experience findings for the ACTN
bedside nurses to begin the discharge education process. program heavily supported the program, this served as the
primary motivation for expansion. The nursing experience
Limitations findings, coupled with the findings related to time-savings in
This study has several noteworthy limitations. First, the study discharge education and modest improvement, though not
was conducted in 1 health system and the results may not be negative, in the HCAHPS findings for the ACTN program
generalizable to other settings with different patient populations, compared to the nontelenursing cohort, further supported
processes, and implementation strategies [27]. Second, in this expansion.

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The initial scope for expansion included a complete system-wide direct communication with staff on medications and patient
implementation for all admissions and discharges. Furthermore, training can happen through virtual means; infection control,
we are planning to expand the ACTN program beyond in which room environments can be reviewed through virtual
admissions and discharges. Responsive to qualitative feedback audits, moving quickly from floor to floor; and guest relations
reported earlier, the next phase of the ACTN program will add and spiritual care, in which patients can be visited virtually upon
safeguards on high-risk medications by having telenurses patient request. Furthermore, physicians who wish to either
conduct double-checks, skin assessments, hourly rounding virtually enter inpatient rooms during their clinic days or from
assistance, and auditing of safety functions and educational home can quickly drop in to see patients using the virtual
activities. These activities were chosen because they are program. For these groups to further develop advanced inpatient
time-intensive for nursing staff on the patient floors. Additional telemedicine programs, additional technology will be required,
support in these areas would be a staff morale booster in addition including cameras that can zoom into various portions of the
to improved efficiencies for bedside nursing. Conducting hourly room and advanced sound capabilities. Future work could
rounding using the ACTN program will require more time and expand programs similar to ACTN to specialties such as
resources; however, conducting high-quality, uninterrupted respiratory therapy, pharmacy, infection prevention, and spiritual
hourly rounds is known to be effective at improving patient care.
safety and patient experience outcomes [29]. Therefore, we
suspect that the ACTN program will have some positive impacts
Conclusions
if rounds are consistently conducted, even if conducted virtually. This study provides preliminary evidence suggesting that
telenursing may effectively address nursing shortages in acute
In addition, the ACTNs have been motivating other specialties care settings and positively impact patient and provider
to adopt or consider a similar program as the ACTN program satisfaction as well as admission and discharge times. More
to support stretched staffing. These specialties include work is needed to validate the findings in other settings, use
respiratory care, in which virtual support can quickly identify other satisfaction metrics, and investigate the impact of
patients in need of intensive on-site support; pharmacy, in which telenursing on the quality of care and cost.

Acknowledgments
The authors would like to thank Jacob M Kolman, MA, ISMPP CMPP, senior scientific writer, Houston Methodist Academic
Institute, for the critical review and for providing formatting feedback on this manuscript. The authors would also like to thank
Amir Hossein Javid for his help with statistical analysis.

Data Availability
Data sharing is not applicable as no data sets were generated during this study.

Authors' Contributions
All authors were involved in the conceptualization, review and approval, and writing of the manuscript. LR, BJ, MG, RS, SK,
and MH were extensively involved in the implementation of the project. BJ, MH, SK, and MG conducted the training. SK and
XL conducted the analyses. CRB wrote and edited the manuscript, inserted and refined the citations, and provided critical feedback
during implementation and analyses. CRB and FS were involved in all stages of writing and publication. All authors meaningfully
contributed to the drafting, writing, brainstorming, executing, finalizing, and approving of the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Additional outcome information for Hospital Consumer Assessment of Health Care Providers and Systems, time of day discharges,
and discharge education processes.
[DOCX File , 34 KB-Multimedia Appendix 1]

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Abbreviations
ACTN: acute care telenurse
AVS: after-visit summary
CMI: case mix index
EHR: electronic health record
HCAHPS: Hospital Consumer Assessment of Health Care Providers and Systems

Edited by T de Azevedo Cardoso, G Eysenbach; submitted 06.11.23; peer-reviewed by C Jensen; comments to author 08.12.23; revised
version received 16.01.24; accepted 17.02.24; published 04.04.24
Please cite as:
Bruce CR, Klahn S, Randle L, Li X, Sayali K, Johnson B, Gomez M, Howard M, Schwartz R, Sasangohar F
Impacts of an Acute Care Telenursing Program on Discharge, Patient Experience, and Nursing Experience: Retrospective Cohort
Comparison Study
J Med Internet Res 2024;26:e54330
URL: https://www.jmir.org/2024/1/e54330
doi: 10.2196/54330
PMID: 38573753

©Courtenay R Bruce, Steve Klahn, Lindsay Randle, Xin Li, Kelkar Sayali, Barbara Johnson, Melissa Gomez, Meagan Howard,
Roberta Schwartz, Farzan Sasangohar. Originally published in the Journal of Medical Internet Research (https://www.jmir.org),
04.04.2024. This is an open-access article distributed under the terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic
information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must
be included.

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