The role of telehealth in sepsis care in rural

Full text

Turn on search term navigation

Introduction

Sepsis is a leading cause of hospitalization and in-hospital death in the U.S., and patients treated initially in low-volume hospitals have 38% higher mortality than those treated in high-volume centers [1–3]. Sepsis mortality has fallen over the last 25 years, but care in rural hospitals continues to offer opportunities for improvement [4–9]. The Surviving Sepsis Campaign publishes practice guidelines to recommend care for patients diagnosed with sepsis, but despite those recommendations being incorporated into publicly reported quality metrics, adherence remains imperfect [10–13].

Provider-to-provider telehealth has been seen as one strategy to provide expert recommendations at the point of care [14,15]. Sepsis telehealth applications have been developed for patients in intensive care units, inpatient wards, rural emergency departments (EDs), and post-acute care, and sepsis telehealth in some settings has been associated with improved clinical outcomes [16–19].

The TELEmedicine as a Virtual Intervention for Sepsis in Emergency Departments (TELEVISED) study was developed to understand how real-time video consultation is associated with improved guideline adherence and clinical outcomes in rural patients with sepsis [20,21]. An early study showed that telehealth in rural EDs was associated with higher sepsis bundle adherence (adjusted odds ratio [aOR] 17.3, 95% confidence interval [CI] 6.6 to 44.9) [22], but we subsequently found that one significant barrier to telehealth use was sepsis diagnosis and recognition [23]. In another multicenter study in telehealth-capable hospitals with contemporary controls (n=1,191), we found telehealth consultation was not associated with improved outcomes, but the subgroup of patients treated in the most remote hospitals by advanced practice providers demonstrated reduced mortality (aOR 0.11, 95% CI 0.02 to 0.73) [24]. Since these findings were unexpected, we conducted a qualitative study of rural hospital and hub healthcare staff to better understand and interpret the findings from our quantitative studies.

The objective of this study was to understand how and why provider-to-provider telehealth was used to care for patients with sepsis in rural EDs and how telehealth recommendations were incorporated into the care and clinical outcomes of rural sepsis patients.

Methods

This study was a qualitative analysis of a mixed-methods study using interviews from rural physicians and advanced practice providers (APPs, including physician assistants and nurse practitioners), rural nurses, and telehealth hub physicians from sites in the original TELEVISED cohort. Our mixed methods study used an explanatory sequential design, in which the qualitative interview guide was informed by the results of the quantitative study to add explanation and context to our findings [25]. For our qualitative design, we used inductive content analysis based on modified grounded theory to identify themes related to each interview topic from interview transcripts [26]. Grounded theory is a strategy of identifying themes and theories from the data, rather than from predetermined hypotheses. This study was approved by the University of Iowa Institutional Review Board (IRB-01, approval number 202111434, approved 12/13/2021), verbal informed consent was obtained, and our findings are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) [27]. Methodologic details are included S1 Appendix.

Intervention, participants, and interviews

We conducted our interviews among sites that participate in a single hub-and-spoke provider-to-provider emergency department-based telehealth (tele-ED) network based in Sioux Falls, South Dakota. That network provides on-demand high-definition video consultation to 214 rural EDs across 13 states, 24 hours daily with board-certified emergency physicians and experienced nurses at the hub. All participating hospital EDs were classified as rural by the Federal Office of Rural Health Policy [20,28]. Sites elected to consult tele-ED staff for sepsis patients when they felt additional guidance was necessary, to help achieve quality metrics, or to help arrange interhospital transfer[29]. No longitudinal relationship between the tele-ED provider and patient existed. Potential participants were identified by local medical staff. We aimed to select 1 provider and/or 1 nurse per site to maintain diverse perspectives, but we allowed up to 2 in a single category if responses were delayed. Interviews were conducted using a semi-structured interview guide (S2 Appendix) between March 1, 2022 and May 22, 2023.

Qualitative analysis

After interviews, two coders independently reviewed all transcripts and developed a qualitative codebook based upon the themes that emerged in the interviews. Themes were identified in domains based on discussion within the study team, and disagreements were planned to be resolved by discussion with a third qualitative analyst (this resolution was never required for this analysis). We conducted coding and analysis in parallel with interviews, and we reviewed new codes every three interviews to determine whether thematic saturation had been reached. The codebook and coding were performed using Microsoft Word and Microsoft Excel (Microsoft Corporation, Redmond, Washington), and codes and themes were not shared with participants. The development of new concepts or qualitative theories was not within the scope of this study design. The major domains and themes were presented with illustrative quotations, and the study team discussed data interpretation iteratively to ensure consistency. The research team has conducted over 20 prior projects using similar methods.

Results

We enrolled a total of 27 participants from 13 hospitals: five hub physicians, eight rural ED providers (four physicians and four APPs, from eight unique hospitals), and 14 rural nurses (from 11 unique hospitals). Rural participants varied in use of tele-ED based on scope of practice, experience, and comfort with both telehealth and sepsis care (Table 1). A description of participating hospitals was previously published[20].

[Figure omitted. See PDF.]

Interview responses were organized into three main domains: (1) facilitators and benefits to using tele-ED; (2) barriers and factors that mitigate potential benefits of tele-ED use; and (3) other considerations associated with tele-ED use for sepsis. Within the first two domains, we identified themes focused on (1) hospital/facility factors, (2) staff factors, and (3) patient factors. Fig 1 presents the conceptual model of our qualitative findings, and Table 2 describes themes with exemplary quotes. All themes were mentioned by at least 2 participants.

[Figure omitted. See PDF.]

We identified 9 themes from our qualitative data that grouped into 3 main domains: facilitators and benefits of tele-emergency (tele-ED) use, barriers and factors mitigating clinical benefits of tele-ED use, and other considerations. Within the first 2 categories, we considered themes according to three categories: facility-based, staff-based, and patient-based themes.

Facilitators and benefits to using Tele-ED in rural ED sepsis

Factors driving tele-ED use or tele-ED benefits in rural sepsis care include facility factors (interhospital transfer; surge capacity for small teams), staffing and provider factors (provider scope of practice; inexperience), and patient factors (severity of illness and comorbidities).

Facility factor: Interhospital transfer.

Interfacility transfer plays a critical role in whether rural providers activate tele-ED, but reasons for transfer can vary according to local context. Many small rural hospitals have limited inpatient capacity, procedural capabilities, or staffing that preclude local admission, and most hospitals in our study did not have intensive care units. Many participants shared that the need for interhospital transfer was the primary reasons that tele-ED was consulted. Tele-ED providers often completed the administrative tasks for interhospital transfer to free up local ED staff for other work.

In most cases, hub physicians did not determine the need for transfer—this was usually done before tele-ED activation. That factor also contributed to timing of tele-ED use because local staff often waited for diagnostic test results and the assessment of the initial response to therapy before deciding whether transfer was necessary; thus, much of the early medical care was provided prior to tele-ED activation, which contributed to consultation delays.

As part of helping with transfer, however, medical guidance was often provided. Participants varied on their perception of the extent to which treatment recommendations were made—some interactions led to detailed conversations about patient management and others focused mostly on the administrative aspects of transfer themselves, and the character of this conversation was determined by local staff preference. In many cases, however, both hub staff and rural staff highlighted that suggestions, recommendations, and tips were informally provided while they were still in rural EDs.

Facility factor: Surge capacity for small teams.

Many participating rural EDs were staffed with small teams: sometimes only a single provider and two nurses who may also be caring for hospital inpatients. While that was often sufficient for routine care, teams were shorthanded when critically ill patients were being treated—and few EDs had a mechanism to marshal additional staff for periods of workload surge. For nurses specifically, tele-ED was often used for documentation or to consult medical references (e.g., drug compatibility, etc.), which was one way to expand the effectiveness of a small clinical team by offloading administrative tasks to hub nurses.

Even during these tele-ED activations, hub staff provided guidance and checked for errors, which improved timeliness of care for sepsis patients. They were able to enter electronic orders and track completion of bundle elements for local staff who continued bedside treatment.

Staff factors: Provider scope of practice.

Many participants felt that tele-ED consultation was used very differently by different provider groups—partially for formal supervision or because of state or institutional policies. Some observed that APPs were more likely to use tele-ED, and participants thought that was because they valued the experience and training of the tele-ED provider, were more accustomed to talking through care pathways for critically ill patients or were required by institutional or state policy. APPs acknowledged their comfort with the technology and the interactions with the hub. Supervision requirements sometimes applied to specific types of patients (e.g., critically ill patients, transfer patients), which drove tele-ED use.

Tele-ED was also sometimes activated because no physician or APP was present in the ED. In those cases, a tele-ED physician functioned as the primary individual guiding care without a local provider—usually until a local provider arrived from clinic, elsewhere in the hospital, or from home.

Staff factors: Inexperience with medications or procedures.

Several participants highlighted that staff in the most remote facilities were more likely to activate tele-ED sooner because they see sepsis cases less frequently—often to provide guidance for rarely used medications or for uncommon procedures. This use was especially frequent for sepsis patients who required endotracheal intubation, in which procedural guidance is a well-established tele-ED practice.

Medication guidance was reported to focus principally on drug selection and dosing. This use was most common for antibiotics, vasopressors, or practical aspects like drug compatibility and infusion rates. Some participants also discussed the frequency of using tele-ED for providing pediatric sepsis care, which was a particularly rare event in all our participants’ hospitals. In these scenarios, tele-ED providers were able to provide a broader experience related to drug selection and dosing, risk stratification, and consulting reference materials as required.

Patient factors: Severity of illness and comorbidities.

Another theme that persisted about both use and timing of tele-ED activation was the role of illness severity and comorbidities in deciding when to use tele-ED. Those with more severe disease may have more acute medical needs and often required specific or unique medications and procedures less familiar to treating staff. For instance, the most severely ill patients with multiple organ failure more often required complex management that local providers consulted with tele-ED staff to co-manage.

The other situation that encouraged tele-ED use were patients with multiple competing comorbidities—especially congestive heart failure or end-stage renal disease. Several participants also noted that patients with the most severe illness or who had multiple complex conditions were the patients in which they thought that tele-ED recommendations could have the most impact.

Barriers and factors that mitigate benefits in rural ED sepsis

We identified three themes focused on barriers preventing tele-ED use and factors that mitigate potential benefits of tele-ED in rural sepsis patients: standardization of protocols, provider reluctance, and diagnostic uncertainty.

Facility factor: Sepsis standardization reduces variation in non-tele-ED care.

Several rural staff members highlighted the important role that sepsis care standardization has played in attenuating beneficial effects of tele-ED. In many cases, this standardization has been reflected in extensive educational initiatives, standard screening protocols, treatment order sets, and performance feedback. Many of our participants felt overall sepsis care had improved over the past 10 years on account of these activities, even without tele-ED use. These initiatives, in their opinion, translated to increased comfort and effectiveness for local staff to manage sepsis cases effectively.

That increased comfort also translated into later tele-ED consultations. Many of the local ED staff felt that following protocols usurped tele-ED consultation, which could be an explanation for the limited tele-ED impact in our quantitative results. Several staff suggested that in a system without the substantial focus on sepsis quality of care, the benefit from tele-ED consultation may have been greater.

Staff factor: Provider reluctance to use tele-ED.

One of the consistent themes identified as a barrier to tele-ED use was the reluctance to use a platform in front of staff or patients, because it was viewed as a threat to a rural provider’s professional credibility. This factor was described by rural providers, nurses, and hub physicians, and each group had examples of individual cases where they had seen this as a barrier. Several nurses related stories when they wanted to activate tele-ED and a physician asked them not to do so. Participants explained this behavior as providers feeling confident about their care, not wanting another provider to threaten their professional autonomy, or being concerned about perceptions of inadequacy, but this was a prominent theme.

A factor that many rural providers cited was the importance of respectful and collegial interactions in encouraging future tele-ED use. Few participants had examples of conflict between tele-ED and hub staff, but this seemed to be a concern that several suggested could affect rural staff willingness to use the tele-ED service. Several rural nurses had examples of cases in which rural providers chose to leave the patient room and initiate a telephone consultation (instead of using the video platform), presumably to maintain credibility with local staff, patients, and family members.

Patient factor: Sepsis diagnostic uncertainty.

This treatment-oriented tele-ED intervention sometimes prevented tele-ED from being consulted, because sepsis often presents with vague symptoms and the diagnosis was sometimes unclear early in the clinical course. Rural participants did not routinely view tele-ED consultation as helping identify patients with sepsis, because they viewed the tele-ED network focused primarily on treatment recommendations. In fact, they viewed that diagnosis was the rural provider’s role prior to tele-ED activation. Consequently, most of our rural participants did not feel that the tele-ED service contributed significantly to sepsis recognition or diagnosis.

This area was one where rural and hub clinicians held different perspectives. Some hub physicians felt that tele-ED consultation delays were common because of delayed recognition, and that these delays adversely affected the ability for tele-ED to positively influence sepsis treatment.

Other considerations related to tele-ED in rural ED sepsis

We identified one additional consideration that was not cited as a reason for or against tele-ED use, but it was identified by multiple providers as a potential secondary benefit: real-time sepsis education and training.

Real-time sepsis education and training.

Some providers noted that learning from having consulted tele-ED in the past contributed to improved future performance. Because of that observation, cases in which tele-ED was not consulted received care more similar to that recommended by tele-ED (from real-time experiential learning). This experiential learning was particularly impactful, because recommendations were provided in a rural staff member’s care context—making it easily transferable to future patients. That method of learning was distinct from didactic lectures, online training modules, continuing education programs, or other alternative methods of ongoing learning: walking through a case in real-time with an expert uniquely contributed to understanding because it allowed local staff to translate knowledge into practical action. When tele-ED was not used, some rural staff indicated that was because local providers were confident with the care they were providing—and that confidence sometimes came from prior tele-ED use.

Discussion

In this qualitative follow-up to the original TELEVISED quantitative analysis [24], we found that telehealth was used most frequently—and was perceived to have the greatest value—in very discrete clinical scenarios. Patients requiring interhospital transfer, those treated by less experienced providers or who had regulatory requirement-mandated supervision were those for whom tele-ED was used most often. Additionally, we identified that standardization of sepsis care, ongoing professional education, and diagnostic uncertainty may have mitigated potential tele-ED benefits in our primary analysis. These findings are valuable, because they highlight that the utility of an acute care telehealth intervention is less a function of the utility of the technology or the telehealth team and more a function of the infrastructure and context surrounding provider-to-provider tele-ED use.

Prior studies have examined the perceived utility of provider-to-provider telehealth, and they have largely found telehealth to add perceived value to care [30]. In a qualitative study of physicians who experienced an ED-based pediatric tele-resuscitation program, physicians found value in the ability of a telehealth provider to help integrate findings, communicate expectations, and address a local lack of trained staff—based partially on the reputation of the remote hospital providing tele-consultation [31]. Like our study, the authors identified the importance of collegial interactions, but consultations in their network were more frequent for medical consultation, rather than to facilitate administrative or technical aspects of care. A similar study in the Veterans Health Administration identified apprehension about the use of a new process as a potential barrier to use of an emergency tele-psychiatry program, but the perceived value of consultation was the most important factor driving telehealth use [32]. Real-time learning was previously identified as an ancillary benefit of telehealth consultation in EDs, and we previously demonstrated that care in tele-ED hospitals changes over time in response to telehealth provider recommendations—suggesting that real-time learning may be one of the mechanisms of telehealth benefits [33–35]. Our findings reinforce that this specific benefit of telehealth may leverage recommendations so that they impact the treatment not only for an individual patient, but also as a vehicle for disseminating changes in care. Finally, a systematic review demonstrated that telehealth may improve outcomes for sepsis patients, which could be a message that drives tele-ED use [16]. Our findings corroborate that benefits of telehealth consultation may be attenuated in a health system with significant institutional focus on sepsis quality of care.

The findings from this study reinforce something that sepsis researchers already know: a standardized approach to sepsis care is associated with better sepsis outcomes. Participation in a sepsis quality improvement program improves sepsis outcomes [36,37]. Care bundles, provider feedback, education, and nurse-initiated order sets can all improve sepsis standardization [11,38–40]. In that context, telehealth may be an additional strategy that can effectively standardize treatment, but in a health system with other performance improvement activities ongoing, the incremental impact may be limited. The benefits of telehealth in such a system may even be observable with structured audio-only consultation, because video technology may be less critical than the relationship upon which such communication is based.

The issue of context, though, may be relevant. With health systems experiencing decreased experienced long-term staff after the COVID-19 pandemic, regional approaches to sepsis care that can endure despite staffing turnover are valuable [41,42]. This observation may also highlight the importance of real-time learning from telehealth providers [33]. Disseminating practice change is difficult, and it may be even more challenging in rural hospitals across large geographic areas [43–45]. Changing practice requires applying new knowledge to a local care context, which telehealth-enabled collaborative medical care may be particularly adept at facilitating [46]. Having reliable systems to disseminate new guidelines, ensure standardization of care for high-risk conditions, and maintain quality during periods of staffing turbulence could be additional roles acute care provider-to-provider telehealth might play. Opportunities exist to enhance both the targeting of tele-ED interventions and the design of such networks to improve the utility to the end-user. Future work should focus on the role of hospital incentives to maintain telehealth-based quality improvement programs and reimbursement strategies to enable provider-to-provider telehealth use from rural hospitals when such use has perceived patient-oriented benefits.

This study has several limitations. First, the COVID-19 public health emergency significantly affected operations in participating hospitals. Our quantitative data was from prior to COVID-19, but our interviews were conducted after the pandemic began. We prompted participants to respond based on their experience separate from the public health emergency, but the COVID-19 experience could still have affected their perspectives. Second, our rural participants work in different sizes of hospitals in different types of communities, but they used a single tele-ED service, so the findings may not be fully generalizable to telehealth providers with different structures, functions, or procedures. Third, some themes may relate to tele-ED broadly, and although they were also true for sepsis tele-ED care, they may not be unique to sepsis alone. Fourth, the lack of participant verification of themes was a limitation of our methodology. Fifth, our use of standard software instead of dedicated qualitative analysis software may have introduced analytic constraints. Sixth, all interviews were conducted by a single interviewer, which could have introduced bias. Seventh, our reliance on recalled experiences of self-reported data may have led to recall or social desirability bias. Finally, the health system from which our participants were recruited has put significant effort into sepsis training and quality improvement over the last 10 years. Some of that effort may have influenced the perceived use and utility of the tele-ED intervention, which may not reflect the experience in other health systems.

In conclusion, provider-to-provider telehealth use in rural EDs for patients with sepsis was viewed by local staff as valuable, but many consultations were initiated to facilitate administrative and technical aspects of care. Further, the focus on sepsis treatment after diagnosis and ongoing professional training in a health system with significant sepsis focus may have attenuated the benefits of sepsis treatment we expected to see. Future work will focus on the context in which telehealth consultation may be most valuable and the structure and process of telehealth-augmented care that can maximize the impact on patient outcomes.

Supporting information

S1 Appendix. This file includes detailed information about the intervention, participants, and interviews.

https://doi.org/10.1371/journal.pone.0321299.s001

S2 Appendix. This file is the qualitative interview guide that was used in the conduct of the study.

https://doi.org/10.1371/journal.pone.0321299.s002

Acknowledgments

The authors acknowledge Tera Shea, BS for her editorial assistance in the preparation of this manuscript.

References

1. 1. Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90–2. pmid:24838355

* View Article

* PubMed/NCBI

* Google Scholar

2. 2. Kocher KE, Haggins AN, Sabbatini AK, Sauser K, Sharp AL. Emergency department hospitalization volume and mortality in the United States. Ann Emerg Med. 2014;64(5):446-457.e6. pmid:25041705

* View Article

* PubMed/NCBI

* Google Scholar

3. 3. Gaieski DF, Edwards JM, Kallan MJ, Mikkelsen ME, Goyal M, Carr BG. The relationship between hospital volume and mortality in severe sepsis. Am J Respir Crit Care Med. 2014;190(6):665–74. pmid:25117723

* View Article

* PubMed/NCBI

* Google Scholar

4. 4. Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012. JAMA. 2014;311(13):1308–16.

* View Article

* Google Scholar

5. 5. Rhee C, Klompas M. Sepsis trends: increasing incidence and decreasing mortality, or changing denominator? J Thorac Dis. 2020:S89-S100.

* View Article

* Google Scholar

6. 6. Gaieski DF, Edwards JM, Kallan MJ, Carr BG. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med. 2013;41(5):1167-74.

* View Article

* Google Scholar

7. 7. Rubens M, Saxena A, Ramamoorthy V, Das S, Khera R, Hong J, et al. Increasing sepsis rates in the United States: results from national inpatient sample, 2005 to 2014. J Intensive Care Med. 2020;35(9):858–68. pmid:30175649

* View Article

* PubMed/NCBI

* Google Scholar

8. 8. Luhr R, Cao Y, Söderquist B, Cajander S. Trends in sepsis mortality over time in randomised sepsis trials: a systematic literature review and meta-analysis of mortality in the control arm, 2002-2016. Critical Care. 2019;23(1):241.

* View Article

* Google Scholar

9. 9. Greenwood-Ericksen MB, Rothenberg C, Mohr N, Andrea SD, Slesinger T, Osborn T, et al. Urban and rural emergency department performance on national quality metrics for sepsis care in the United States. J Rural Health. 2019;35(4):490–7. pmid:30488590

* View Article

* PubMed/NCBI

* Google Scholar

10. 10. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063–143. pmid:34605781

* View Article

* PubMed/NCBI

* Google Scholar

11. 11. Townsend SR, Phillips GS, Duseja R, Tefera L, Cruikshank D, Dickerson R, et al. Effects of compliance with the early management bundle (SEP-1) on mortality changes among medicare beneficiaries with sepsis: a propensity score matched cohort study. Chest. 2022;161(2):392–406. pmid:34364867

* View Article

* PubMed/NCBI

* Google Scholar

12. 12. Barbash IJ, Davis B, Kahn JM. National performance on the medicare SEP-1 sepsis quality measure. Crit Care Med. 2019;47(8):1026–32. pmid:30585827

* View Article

* PubMed/NCBI

* Google Scholar

13. 13. Venkatesh AK, Slesinger T, Whittle J, Osborn T, Aaronson E, Rothenberg C, et al. Preliminary performance on the new CMS Sepsis-1 national quality measure: early insights from the emergency quality network (E-QUAL). Ann Emerg Med. 2018;71(1):10-15.e1. pmid:28789803

* View Article

* PubMed/NCBI

* Google Scholar

14. 14. Mohr NM, Hurst EK, MacKinney AC, Nash EC, Carr BG, Skow B. Telemedicine for early treatment of sepsis. In: Koenig MA, editor. Telemedicine in the ICU. Cham: Springer International Publishing; 2019. p. 255-80. https://doi.org/10.1007/978-3-030-11569-2_15

15. 15. Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care?. J Am Coll Emerg Physicians Open. 2022;3(1):e12631. pmid:35024689

* View Article

* PubMed/NCBI

* Google Scholar

16. 16. Tu KJ, Wymore C, Tchangalova N, Fuller BM, Mohr NM. The impact of telehealth in sepsis care: A systematic review. J Telemed Telecare. 2025;31(1):3–13. pmid:37093782

* View Article

* PubMed/NCBI

* Google Scholar

17. 17. Deisz R, Rademacher S, Gilger K, Jegen R, Sauerzapfe B, Fitzner C, et al. Additional telemedicine rounds as a successful performance-improvement strategy for sepsis management: observational multicenter study. J Med Internet Res. 2019;21(1):e11161. pmid:30664476

* View Article

* PubMed/NCBI

* Google Scholar

18. 18. Scott B, Hassell A, Davis C, Huntley N, Pierce R. 1333: Impact of a system-wide virtual sepsis response program on the volume of actionable alerts. Critical Care Medicine. 2020;48(1):643–643.

* View Article

* Google Scholar

19. 19. Taylor SP, Murphy S, Rios A, McWilliams A, McCurdy L, Chou S-H, et al. Effect of a multicomponent sepsis transition and recovery program on mortality and readmissions after sepsis: the improving morbidity during post-acute care transitions for sepsis randomized clinical trial. Crit Care Med. 2022;50(3):469–79. pmid:34534130

* View Article

* PubMed/NCBI

* Google Scholar

20. 20. Mohr NM, Harland KK, Okoro UE, Fuller BM, Campbell K, Swanson MB, et al. TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study). J Comp Eff Res. 2021;10(2):77–91. pmid:33470848

* View Article

* PubMed/NCBI

* Google Scholar

21. 21. Mohr NM, Schuette AR, Ullrich F, Mack LJ, DeJong K, Camargo CA Jr, et al. An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study. J Comp Eff Res. 2022;11(10):703–16. pmid:35608080

* View Article

* PubMed/NCBI

* Google Scholar

22. 22. Mohr NM, Campbell KD, Swanson MB, Ullrich F, Merchant KA, Ward MM. Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments. J Telemed Telecare. 2021;27(8):518–26. pmid:31903840

* View Article

* PubMed/NCBI

* Google Scholar

23. 23. Kaldjian AM, Vakkalanka JP, Okoro U, Wymore C, Harland KK, Campbell K, et al. The effect of sepsis recognition on telemedicine use and bundle completion in rural emergency department sepsis treatment. medRxiv. 2023.

* View Article

* Google Scholar

24. 24. Mohr NM, Okoro U, Harland KK, Fuller BM, Campbell K, Swanson MB, et al. Outcomes associated with rural emergency department provider-to-provider telehealth for sepsis care: a multicenter cohort study. Ann Emerg Med. 2023;81(1):1–13. pmid:36253295

* View Article

* PubMed/NCBI

* Google Scholar

25. 25. Shorten A, Smith J. Mixed methods research: expanding the evidence base. Evid Based Nurs. 2017;20(3):74–5. pmid:28615184

* View Article

* PubMed/NCBI

* Google Scholar

26. 26. Strauss AL, Corbin JM. Grounded theory in practice. Thousand Oaks, CA, US: Sage Publications, Inc; 1997. p. viii, 280-viii.

27. 27. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. pmid:17872937

* View Article

* PubMed/NCBI

* Google Scholar

28. 28. HRSA. Defining Rural Population; 2024. Available from: https://www.hrsa.gov/rural-health/about-us/what-is-rural.

* View Article

* Google Scholar

29. 29. Mohr NM, Skow B, Wittrock A, Bell A, McDanel J, Fuller BM, Simpson S, Ward M. Improving acess to high quality sepsis care in south dakota emergency telemedicine network. In: HHS, editor. RTRC, 2017. p. 1-4.

30. 30. Totten AM, Womack DM, Griffin JC, McDonagh MS, Davis-O’Reilly C, Blazina I, et al. Telehealth-guided provider-to-provider communication to improve rural health: A systematic review. J Telemed Telecare. 2024;30(8):1209–29. pmid:36567431

* View Article

* PubMed/NCBI

* Google Scholar

31. 31. Mateus LA, Law MP, Khowaja AR, Orlando E, Pace A, Roy M, et al. Examining perceptions of a telemedicine network for pediatric emergency medicine: a mixed-methods pilot study. Front Digit Health. 2023;5:1181059. pmid:37304179

* View Article

* PubMed/NCBI

* Google Scholar

32. 32. Ward MJ, Shuster JL, , Mohr NM, Kaboli PJ, Mixon AS, Kemmer J, et al. Implementation of telehealth for psychiatric care in VA emergency departments and urgent care clinics. Telemed J E Health. 2022;28(7):985–93. pmid:34788149

* View Article

* PubMed/NCBI

* Google Scholar

33. 33. Zhu X, Merchant KAS, Mohr NM, Wittrock AJ, Bell AL, Ward MM. Real-time learning through telemedicine enhances professional training in rural emergency departments. Telemed J E Health. 2021;27(4):441–7. pmid:32552479

* View Article

* PubMed/NCBI

* Google Scholar

34. 34. Mohr NM, Vakkalanka JP, Harland KK, Bell A, Skow B, Shane DM, et al. Telemedicine use decreases rural emergency department length of stay for transferred north dakota trauma patients. Telemed J E Health. 2018;24(3):194–202. pmid:28731843

* View Article

* PubMed/NCBI

* Google Scholar

35. 35. Mohr NM, Harland KK, Chrischilles EA, Bell A, Shane DM, Ward MM. Emergency department telemedicine is used for more severely injured rural trauma patients, but does not decrease transfer: a cohort study. Acad Emerg Med. 2017;24(2):177–85. pmid:28187248

* View Article

* PubMed/NCBI

* Google Scholar

36. 36. Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al. The surviving sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med. 2010;36(2):222–31. pmid:20069275

* View Article

* PubMed/NCBI

* Google Scholar

37. 37. Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, et al. Surviving sepsis campaign: association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014;40(11):1623–33. pmid:25270221

* View Article

* PubMed/NCBI

* Google Scholar

38. 38. Schinkel M, Nanayakkara PWB, Wiersinga WJ. Sepsis performance improvement programs: from evidence toward clinical implementation. Crit Care. 2022;26(1):77. pmid:35337358

* View Article

* PubMed/NCBI

* Google Scholar

39. 39. Trent SA, Havranek EP, Ginde AA, Haukoos JS. Effect of audit and feedback on physician adherence to clinical practice guidelines for pneumonia and sepsis. Am J Med Qual. 2019;34(3):217–25. pmid:30205697

* View Article

* PubMed/NCBI

* Google Scholar

40. 40. Bruce HR, Maiden J, Fedullo PF, Kim SC. Impact of nurse-initiated ED sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality. J Emerg Nurs. 2015;41(2):130–7. pmid:25612516

* View Article

* PubMed/NCBI

* Google Scholar

41. 41. Auerbach DI, Buerhaus PI, Donelan K, Staiger DO. Projecting the future registered nurse workforce after the COVID-19 pandemic. JAMA Health Forum. 2024;5(2):e235389. pmid:38363560

* View Article

* PubMed/NCBI

* Google Scholar

42. 42. NCSBN Research Projects Significant Nursing Workforce Shortages and Crisis. National council of council of state boards of nursing. 2023.

43. 43. Greco P, Eisenberg J. Changing physicians’ practices. New England Journal of Medicine. 1993;329(17):1271–4.

* View Article

* Google Scholar

44. 44. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–30. pmid:14568747

* View Article

* PubMed/NCBI

* Google Scholar

45. 45. Ward MM, Baloh J, Zhu X, Stewart GL. Promoting action on research implementation in health services framework applied to TeamSTEPPS implementation in small rural hospitals. Health Care Manage Rev. 2017;42(1):2–13. pmid:26415078

* View Article

* PubMed/NCBI

* Google Scholar

46. 46. Gupta DM, Boland RJ Jr, Aron DC. The physician’s experience of changing clinical practice: a struggle to unlearn. Implement Sci. 2017;12(1):28. pmid:28245849

* View Article

* PubMed/NCBI

* Google Scholar

Citation: Mohr NM, Merchant KA, Fuller BM, Faine B, Mack L, Bell A, et al. (2025) The role of telehealth in sepsis care in rural emergency departments: A qualitative study of emergency department sepsis telehealth user perspectives. PLoS ONE 20(4): e0321299. https://doi.org/10.1371/journal.pone.0321299

About the Authors:

Nicholas M. Mohr

Roles: Conceptualization, Data curation, Formal analysis, Funding acquisition, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

E-mail: [email protected]

Affiliations: Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America, Department of Anesthesia Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America, Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, United States of America

ORICD: https://orcid.org/0000-0003-0497-5828

Kimberly A.S. Merchant

Roles: Data curation, Formal analysis, Investigation, Writing – original draft

Affiliation: Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, United States of America

Brian M. Fuller

Roles: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing

Affiliation: Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, United States of America

Brett Faine

Roles: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing

Affiliations: Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America, Department of Pharmaceutical Practice, University of Iowa College of Pharmacy, Iowa City, Iowa, United States of America

Luke Mack

Roles: Conceptualization, Data curation, Writing – review & editing

Affiliation: Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, United States of America

Amanda Bell

Roles: Conceptualization, Data curation, Writing – review & editing

Affiliation: Avel eCARE, Sioux Falls, South Dakota, United States of America

Katie DeJong

Roles: Conceptualization, Data curation, Writing – review & editing

Affiliation: Avel eCARE, Sioux Falls, South Dakota, United States of America

Edith A. Parker