Background: Night time hospital coverage presents persistent challenges in balancing provider workload, efficiency, and maintaining timely clinical response. Traditional onsite coverage limits flexibility, contributes to provider fatigue, delays task completion with variability in nurse to provider communication. To address these barriers, the Hospital Medicine (HM) service implemented a telehealth-connected care model to optimize after hours cross coverage operations while sustaining safety, quality, and reliability in patient care.
Methods: A 4-month structured remote cross cover pilot was launched on February 1, 2025, across two hospital sites; a third site was added June 1, 2025. The pilot implemented a combined remote and on-site advanced practice provider (APP) model for nighttime cross coverage across multiple hospital sites. Prior to initiation of the pilot, specific criteria were created for appropriate type of cross cover calls for remote vs. On-site APP to guide the nursing staff. Remote APPs managed low acuity clinical tasks from an offsite location while high acuity concerns were triaged to onsite providers to ensure timely bedside evaluation and intervention. If the remote APP was called for an on-site issue, the APP notified the on-site APP to minimize burden for nursing staff. If the on-site APP was called for an issue the remote team could manage, education was provided to the nurse, but the concern was immediately addressed. Coverage was provided 7 days a week for 12 hours (7P-7A). Education was provided to nursing staff leading into the start date. The primary outcome was operational efficiency, assessed through response timeliness and cross cover task completion rates. Secondary outcomes included nursing satisfaction, provider engagement, and preservation of high reliability and safety standards in patient care. To capture this data, surveys were distributed to team members during the pilot period. A 4-point Likert scale was used to determine satisfaction (0 – strongly disagree; 4 – strongly agree). Descriptive statistics were used to analyze data. The organizational IRB approved this project.
Results: The team logged 5,646 nursing calls and 849 patient care hours. The majority of requests were resolved by the remote APP without escalation: 97%. The median number of minutes to complete tasks was 8 (quartile range: 5-10 minutes). Providers actively participated in the survey: remote APPs – 86%, on-site providers – 100%. Survey completion by nursing was low, but in-person meeting feedback was favorable. Providers strongly agreed to satisfaction with the process (83% scores ≥ 3). There was no increase in safety events reported through the institutional event reporting system or by nursing, on-site providers or hospital leadership during the pilot period.
Conclusions: This pilot demonstrated that a remote APP model enhanced operational flexibility by reallocating workload, allowing onsite clinicians to focus on complex or rapidly evolving cases. The pilot’s seamless transition into a sustained operational model underscores its feasibility, safety, and scalability. Nursing feedback reflected timely communication and satisfaction, and provider engagement increased with more balanced workload distribution. This model can safely and reliably extend care capacity, strengthen interdisciplinary collaboration, and provide a replicable framework for HM programs seeking to optimize resource utilization and nighttime performance.