Telehealth and Telecare: A Real-Life Integrated Experience in the COVID-19 Pandemic

Remote patient monitoring in patients with COVID-19 at home: literature review

BACKGROUND

During the pandemic healthcare providers implemented remote patient monitoring (RPM) for patients suffering from COVID-19. RPM is an interaction between healthcare professionals and patients who are in different locations, in which a certain number of patient's functioning parameters is assessed and followed up for a certain duration of time. By implementing RPM for these patients they obtained to reduce the strain on hospitals and primary care.

OBJECTIVE

With this literature review we aim at describing the characteristics of the RPM interventions, reporting on the patients with COVID-19 included in RPM, and providing an overview of outcome variables such as length of stay (LOS), hospital (re)admissions, and mortality.

METHODS

A combination of different searches in several database types (traditional databases, trial registers, daily (google) searches and daily Pubmed alerts) were run daily from March 2020 till December 2021. A search update for randomized clinical trials (RCT's) was done in April 2022.

RESULTS

The initial search yielded more than 4448 articles (not including daily searches). After deduplication and assessment for eligibility, 241 articles were retained describing 164 telemonitoring studies from 160 centres. None of the 164 studies covering 248,431 included patients reported on the presence of a randomized control group. Studies described a 'prehosp' group (96 studies) with patients who had a suspected or confirmed COVID-19 diagnosis and for whom it was decided not to hospitalize them yet, but closely monitor them at home, or a 'posthosp' group (32 studies) with patients who were monitored at home after hospitalization for COVID-19; 34 studies described both groups, in 2 studies it was unclear. There is a large variety in number of emergency department (ED) visits (0-36% and 0-16%) and no convincing evidence that RPM leads to less or more ED-visits as well as hospital (re)admissions (0-30% and 0-22%) in prehosp and posthosp, respectively. Mortality was generally low, and there is weak to no evidence that RPM is associated with lower mortality. There is neither evidence that RPM shortens previous LOS. A literature update detected three small scale RCT's which could not demonstrate statistically significant differences in these outcomes. Most papers claim savings, however the scientific base for these claims is doubtful. The overall patient experiences with RPM were positive, as patients felt more reassured, although many patients declined RPM for several reasons (eg, technological embarrassment, digital literacy, etc.).

CONCLUSIONS

Based on these results, there is no convincing evidence that RPM in COVID-19 patients could avoid ED-visits or hospital (re)admissions, could shorten LOS or reduce mortality, but neither is there evidence that RPM has adverse outcomes. Further research should focus on developing, implementing, and evaluating an RPM framework.

CLINICALTRIAL

Applications to augment patient care for Internal Medicine specialists: a position paper from the EFIM working group on telemedicine, innovative technologies & digital health

Telemedicine applications present virtually limitless prospects for innovating and enhancing established and new models of patient care in the field of Internal Medicine. Although there is a wide range of innovative technological solutions in Europe, there are overarching elements associated with such technologies when applied to the practices of Internal Medicine specialists. The European Federation of Internal Medicine (EFIM) strongly advocates for active leadership and influence from the Internal Medicine societies and specialist physicians across Europe in the development and application of telemedicine and digital technologies in healthcare. This position paper's conclusions were drawn via Delphi method, which was developed collaboratively from July 2021 to December 2023. The panel, consisting of experts in clinical medicine, public health, health economics and statistics, assessed various aspects related to telemedicine. Participants assigned scores on a Likert scale reflecting perceived value and potential risks. The findings were consolidated in a comprehensive checklist aligning with relevant literature and a SWOT analysis. Specifically, key issues that need to be addressed include promoting the professional development of e-health competencies in the healthcare and medical workforce, using educational campaigns to promote digital literacy among patients and caregivers, designing and implementing telemedicine applications tailored to local conditions and needs and considering the ethical and legal contexts under which these applications are employed. Importantly, there is currently no consensus on care models or standardized protocols among European Internal Medicine specialists regarding the utilization of telemedicine. This position paper aims to outline the opportunities and challenges associated with the application of telemedicine in Internal Medical practice in Europe.

Telenursing: How do caregivers treat and prevent pressure injury in bedridden patients during the COVID-19 pandemic in Thailand? Using an embedded approach

OBJECTIVE

To evaluate telenursing for caregivers (CGs) to treat and prevent pressure injury (PI) in bedridden patients (BPs) during the COVID-19 pandemic in Thailand.

METHODS

Purposive sampling of 70 CGs [intervention group (i-group): n = 35 and control group (c-group): n = 35)] using an embedded approach was conducted from August 2020 to February 2021. The QUAN data were concurrently collected via online semi-structured interviews (OSIs) and video in-depth interviews (VIIs), then analysed using multivariate analysis of variance and thematic analysis.

RESULTS

The QUAN data showed that CGs treating and preventing PI in BPs has a significant and positive effect (p < 0.01). The qual data illustrates that telenursing for CGs treating and preventing PI in BPs is associated with training and education, skin cleaning, repositioning, monitoring, and assessment of PI during the COVID-19 pandemic.

CONCLUSION AND IMPLICATIONS

Telenursing for CGs treating and preventing PI in BPs is valuable to the professional consultation during the COVID-19 pandemic. Telenursing can reduce the CG burden, instructing them how to visually examine, clean, monitor, and risk assess the skin of BPs to prevent PIs.

Home-based exercise program for people with residual disability following hospitalization for COVID-19: Randomized control trial

BACKGROUND

The best exercise program for individuals with effort intolerance or hypoxia at rest and/or during exercise post-COVID-19 treatment who have already had in-hospital rehabilitation remains unknown.

OBJECTIVE

We evaluated the efficacy of a home-based rehabilitation exercise program intervention that included teleconsultations with a specialist nurse.

METHODS

This was a multicenter randomized controlled trial for individuals who had been diagnosed with, and treated for, COVID-19. Despite inpatient rehabilitation they still had effort intolerance; this was defined as being a) only able to walk <70 % of the predicted distance during the six-minute walking test (6MWT) and/or b) oxygen desaturation all day long/during effort. The primary outcome was effort tolerance, as evaluated by the 6MWT. Secondary outcomes were dyspnea, fatigue, spirometry, respiratory muscle evaluations, and oxygenation. The Intervention group performed 4 weeks of a self-directed exercise program with bi-weekly physiotherapist video calls; the Control group participated in physical activity howsoever they wished. Exercises were divided into 4 intensity levels according to disability and oxygen desaturation. The program progressively increased from low (walking, free-body exercise, sit-to-stand, and balance exercises) to high (speed walking with a pedometer, cycle ergometer, and strengthening exercises).

RESULTS

We included 79 participants: 40 in the Intervention and 39 in the Control group. Mean (SD) age was 67.1 (10.3) years; 72 % (n = 57) were male. No intergroup differences in effort tolerance were found [Intervention 77.6 (75.4)m vs Control 49.5 (73.3)m (p = 0.109)]. Participants with 6MWT distance results < lower limit of normality values showed best improvements in mean (SD) effort tolerance: Intervention, 120.1 (75.8)m vs Control, 59.1 (75.6)m (p = 0.035). After 2 months, mean (SD) 6MWT distances in the 2 groups were similar: Intervention, 475.9 (82.4)m vs Control, 469.2 (118.9)m (p = 0.807).

CONCLUSIONS

In individuals with residual disability post-COVID-19 and after inpatient rehabilitation, a home-based exercise program with teleconsultation significantly improves effort tolerance but only for people who had severe effort intolerance at baseline.

DATABASE REGISTRATION

ClinicalTrials.gov number, NCT04821934.

Quality of Life and Emotional Problems of COVID-19 Patients after Discharge: A One-Month Longitudinal Study

AIM

The first coronavirus disease 2019 (COVID-19) outbreak in Taiwan occurred in May 2021 and many individuals were infected. All COVID-19 patients were quarantined in designated facilities until they fully recovered to prevent the spread of the disease. Prolonged quarantine could adversely affect these patients. In this study, we focused on investigating changes in the quality of life and mental health of individuals discharged from hospital after recovering from COVID-19.

METHODS

This study employed a longitudinal design and surveyed individuals discharged from a teaching hospital in northern Taiwan in 2021 within one week of their discharge and again after one month. An online questionnaire comprising the participants' background, respiratory function (COPD Assessment Test), quality of life (WHOQoL-BREF), and emotional problems (DASS-21) was administered to the participants.

RESULTS

A total of 56 participants actively took part in both surveys. We observed that participants with abnormal respiratory function had a lower physical and psychological quality of life, especially those with severe symptoms requiring endotracheal intubation during the treatment period of COVID-19. Additionally, approximately 30% of participants experienced anxiety problems throughout this study period. Finally, patients with COVID-19 symptoms exhibited a lower quality of life and higher levels of severe emotional problems.

CONCLUSIONS

According to our findings, it is necessary to monitor and provide appropriate interventions for individuals who have recovered from COVID-19, especially those who experienced severe symptoms that required endotracheal intubation during COVID-19 treatment. These interventions, such as symptom management and psychological support, can help improve their quality of life and reduce emotional problems. Therefore, after the participants are discharged, hospitals should regularly track the patients' status and provide appropriate support or referrals to help these individuals. Otherwise, future research could include more participants and follow up with them for longer to investigate the longitudinal impact of COVID-19.

Patient-reported experiences and outcomes of virtual care during COVID-19: a systematic review

INTRODUCTION

The onset of COVID-19 has caused an international upheaval of traditional in-person approaches to care delivery. Rapid system-level transitions to virtual care provision restrict the ability of healthcare professionals to evaluate care quality from the patient's perspective. This poses challenges to ensuring that patient-centered care is upheld within virtual environments. To address this, the study's objective was to review how virtual care has impacted patient experiences and outcomes during COVID-19, through the use of patient-reported experience and outcome measures (PREMs and PROMs), respectively.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to evaluate patient responsiveness to virtual care during COVID-19. Using an exhaustive search strategy, relevant peer-reviewed articles published between January 2020 and 2022 were pulled from MEDLINE, CINAHL, EMBASE, and PsychInfo databases. Study quality was independently assessed by two reviewers using the Mixed Methods Appraisal Tool. A patient partner was consulted throughout the study to provide feedback and co-conduct the review.

RESULTS

After removing duplicates, 6048 articles underwent title and abstract review, from which 644 studies were included in the full-text review stage. Following this, 102 articles were included in the study. Studies were published in 20 different countries, were predominantly cross-sectional, and reported on the delivery of virtual care in specialized adult outpatient settings. This review identified 29 validated PREMs and 43 PROMs. Several advantages to virtual care were identified, with patients citing greater convenience, (such as saving travel time and cost, less waiting experienced to see care providers) and increased protection from viral spread. Some studies also reported challenges patients and caregivers faced with virtual care, including feeling rushed during the virtual care appointment, lack of physical contact or examination presenting barriers, difficulty with communicating symptoms, and technology issues.

CONCLUSION

This review provides supportive evidence of virtual care experiences during the COVID-19 pandemic from patient and caregiver perspectives. This research provides a comprehensive overview of what patient-reported measures can be used to record virtual care quality amid and following the pandemic. Further research into healthcare professionals' perspectives would offer a supportive lens toward a strong person-centered healthcare system.

Digital solutions and the future of recovery after critical illness

PURPOSE OF REVIEW

Digital technologies may address known physical and psychological barriers to recovery experienced by intensive care survivors following hospital discharge and provide solutions to care fragmentation and unmet needs. The review highlights recent examples of digital technologies designed to support recovery of survivors of critically illness.

RECENT FINDINGS

Despite proliferation of digital technologies supporting health in the community, there are relatively few examples for intensive care survivors. Those we identified included web-based, app-based or telemedicine-informed recovery clinics or pathways offering services, including informational resources, care planning and navigation support, medication reconciliation, and recovery goal setting. Digital interventions supporting psychological recovery included apps providing adaptive coping skills training, mindfulness, and cognitive behavioural therapy. Efficacy data are limited, although feasibility and acceptability have been established for some. Challenges include difficulties identifying participants most likely to benefit and delivery in a format easily accessible to all, with digital exclusion a resultant risk.

SUMMARY

Digital interventions supporting recovery comprise web or app-based recovery clinics or pathways and digital delivery of psychological interventions. Understanding of efficacy is relatively nascent, although several studies demonstrate feasibility and acceptability. Future research is needed but should be mindful of the risk of digital exclusion.

COVID-19 teleassistance and teleconsultation: a matched case-control study (MIRATO project, Lombardy, Italy)

Background

During the COVID-19 pandemic, telemedicine has been recognised as a powerful modality to shorten the length of hospital stay and to free up beds for the sicker patients. Lombardy, and in particular the areas of Bergamo, Brescia, and Milan, was one of the regions in Europe most hit by the COVID-19 pandemic. The primary aim of the MIRATO project was to compare the incidence of severe events (hospital readmissions and mortality) in the first three months after discharge between COVID-19 patients followed by a Home-Based Teleassistance and Teleconsultation (HBTT group) program and those discharged home without Telemedicine support (non-HBTT group).

Methods

The study was designed as a matched case-control study. The non-HBTT patients were matched with the HBTT patients for sex, age, presence of COVID-19 pneumonia and number of comorbidities. After discharge, the HBTT group underwent a telecare nursing and specialist teleconsultation program at home for three months, including monitoring of vital signs and symptoms. Further, in this group we analysed clinical data, patients' satisfaction with the program, and quality of life.

Results

Four hundred twenty-two patients per group were identified for comparison. The median age in both groups was 70 ± 11 years (62% males). One or more comorbidities were present in 86% of the HBTT patients and 89% in the non-HBTT group (p = ns). The total number of severe events was 17 (14 hospitalizations and 3 deaths) in the HBTT group and 40 (26 hospitalizations and 16 deaths) in the non-HBTT group (p = 0.0007). The risk of hospital readmission or death after hospital discharge was significantly lower in HBTT patients (Log-rank Test p = 0.0002). In the HBTT group, during the 3-month follow-up, 5,355 teleassistance contacts (13 ± 4 per patient) were performed. The number of patients with one or more symptoms declined significantly: from 338 (78%) to 183 (45%) (p < 0.00001). Both the physical (ΔPCS12: 5.9 ± 11.4) component and the mental (ΔMCS12: 4.4 ± 12.7) component of SF-12 improved significantly (p < 0.0001). Patient satisfaction with the program was very high in all participants.

Conclusions

Compared to usual care, an HBTT program can reduce severe events (hospital admissions/mortality) at 3-months from discharge and improve symptoms and quality of life.

Clinical trial registration

www.ClinicalTrials.gov, NCT04898179.

Technologies in Home-Based Digital Rehabilitation: Scoping Review

BACKGROUND

Due to growing pressure on the health care system, a shift in rehabilitation to home settings is essential. However, efficient support for home-based rehabilitation is lacking. The COVID-19 pandemic has further exacerbated these challenges and has affected individuals and health care professionals during rehabilitation. Digital rehabilitation (DR) could support home-based rehabilitation. To develop and implement DR solutions that meet clients' needs and ease the growing pressure on the health care system, it is necessary to provide an overview of existing, relevant, and future solutions shaping the constantly evolving market of technologies for home-based DR.

OBJECTIVE

In this scoping review, we aimed to identify digital technologies for home-based DR, predict new or emerging DR trends, and report on the influences of the COVID-19 pandemic on DR.

METHODS

The scoping review followed the framework of Arksey and O'Malley, with improvements made by Levac et al. A literature search was performed in PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library. The search spanned January 2015 to January 2022. A bibliometric analysis was performed to provide an overview of the included references, and a co-occurrence analysis identified the technologies for home-based DR. A full-text analysis of all included reviews filtered the trends for home-based DR. A gray literature search supplemented the results of the review analysis and revealed the influences of the COVID-19 pandemic on the development of DR.

RESULTS

A total of 2437 records were included in the bibliometric analysis and 95 in the full-text analysis, and 40 records were included as a result of the gray literature search. Sensors, robotic devices, gamification, virtual and augmented reality, and digital and mobile apps are already used in home-based DR; however, artificial intelligence and machine learning, exoskeletons, and digital and mobile apps represent new and emerging trends. Advantages and disadvantages were displayed for all technologies. The COVID-19 pandemic has led to an increased use of digital technologies as remote approaches but has not led to the development of new technologies.

CONCLUSIONS

Multiple tools are available and implemented for home-based DR; however, some technologies face limitations in the application of home-based rehabilitation. However, artificial intelligence and machine learning could be instrumental in redesigning rehabilitation and addressing future challenges of the health care system, and the rehabilitation sector in particular. The results show the need for feasible and effective approaches to implement DR that meet clients' needs and adhere to framework conditions, regardless of exceptional situations such as the COVID-19 pandemic.

Tele Homecare in Premature Infants’ Post-Discharge Early Follow-Up: A Narrative Review

The study was conducted to review, categorize and organize early tele-homecare follow-up research in premature infants based on research type, the focus of tele-homecare, and measured outcomes. This narrative review was conducted in 2021 through international databases, including PubMed, Scopus, ProQuest, and Web of Science databases. Studies selected for this purpose included original articles on premature infants. We reviewed 16 out of 267 identified articles. These studies were analyzed according to general characteristics, elements, and characteristics of tele-homecare intervention. Based on the obtained data, most studies had been conducted in Nordic countries as the pioneer in tele homecare. Also, most of them were on the psychological status of premature infants’ parents. Phone calls, video consultation, and applications were considered dominant tele-homecare communication tools. Overall, the qualitative studies on parents’ and health providers’ views about tele homecare revealed its hidden aspects as a supportive tool. The tele-homecare studies were distributed across different fields and countries, resulting in positive outcomes for infants and parents. However, further studies in the long-term periods are recommended to follow up on premature infants.

Usability of a continuous oxygen saturation device for home telemonitoring

Background

The emergency for the COVID-19 pandemic has led to greater use of home telemonitoring devices. The aim of this study was to assess the usability of continuous home-monitoring care with an oxygen saturation device on post-COVID-19 patients.

Method

The system consists of a digital continuous pulse oximeter and a smartphone with an App, which were provided to patients. A survey composed of a standard Post-Study System Usability Questionnaire, and a satisfaction questionnaire was exploited to conduct a usability and feasibility analysis of the service.

Results

A total of 29 patients (17.2% female) with a mean age of 65 ± 11.5 years were enrolled: 20 patients were smartphone users (69%) with a mean age of 60.2 ± 9.5 years, and 9 patients (31%) did not own a smartphone (mean age 76.8 ± 5.9). The monitoring period was 1 month: a total of 444 recordings were conducted, 15 recordings per patient averagely. In total, 82% of the recordings performed did not require any intervention, while 18% led to the production of a report and subsequent intervention by a nurse who verified, together with the specialist, the need to intervene (i.e. the patient accessed the clinic for medical control and/or modification of oxygen therapy). A total of 17 patients compiled a usability questionnaire. The service was perceived as useful and well-structured, although it often required caregiver support.

Conclusions

Using continuous home-monitoring care with an oxygen saturation device seems feasible and useful for patients who could be followed at home avoiding going back to the hospital every time a trend oximetry is needed. Further improvements in connections, data flow processes, and simplifications, based on patients' feedback, are needed to scale up the service.

Definition of a Method for the Evaluation of Telemedicine Platforms in the Italian Context

Background: The COVID-19 outbreak led to the diffusion of several telemedicine solutions. The choice of the correct platform is crucial for ensuring the release of effective assistance. However, there is a lack of an objective method for the assessment of technical features. Objective: This study proposes a methodology for the evaluation of functional requirements of telemedicine platforms. This approach also permits the comparison of solutions in the Italian market by means of defined parameters, thus directing the choice of health care professionals. Methods: The study is divided into three phases. First, a mapping of the telemedicine platforms operating in Italy is performed. Then, the available platforms are selected based on the offered telemedicine activity. Finally, a method for evaluating the investigated platforms is defined. Results: Thirty-three (n = 33) technological systems were identified through an accurate investigation on the web and interviews with IT companies. Fifteen parameters were defined and organized into three categories: (1) usability of the telemedicine platform, (2) security, and (3) technological and organizational aspects. A score between 1 and 4 was assigned to each parameter, proportionally to the completeness of the platform. In particular, 62.96% of platforms reached an average score between 3.01 and 4 points; 33.33% of them had scores between 2.01 and 3, while the remaining 3.70% of solutions obtained a result between 1.01 and 2. Conclusions: The study provides an evaluation approach that is easily usable by health professionals to select the most suitable platform. The number of solutions and quality of information could be updated to obtain a complete tool.

Discharge from the emergency department and early hospital revaluation in patients with COVID-19 pneumonia: a prospective study

Objective The national health systems are currently facing the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We assessed the efficacy of outpatient management for patients with SARS-CoV-2 related pneumonia at risk of progression after discharge from the emergency department.Methods This was a single-center prospective study. We enrolled patients with confirmed SARS-CoV-2 pneumonia, without hypoxemic respiratory failure, and at least one of the following: age ≥ 65 years or the presence of relevant comorbidities or pneumonia extension > 25% on high resolution computed tomography. Patients with pneumonia extension > 50% were excluded. An ambulatory visit was performed after at least 48 hours, when patients were either discharged, admitted, or deferred for a further visit. As a control, we evaluated a comparable historical cohort of hospitalized patients.Results A total of 84 patients were enrolled (51 male patients; mean age, 62.8 years). Two-thirds of the patients had at least one comorbidity and 41.6% had a lung involvement > 25% on high resolution computed tomography; the mean duration of symptoms was 8.0 ± 3.0 days, and the mean PaO2/FiO2 ratio was 357.5 ± 38.6. At the end of the follow-up period, 69 patients had been discharged, and 15 were hospitalized (mean stay of 6 days). Older age and higher National Early Warning Score 2 were significant predictors of hospitalization at the first follow-up visit. One hospitalized patient died of septic shock. In the control group, the mean hospital stay was 8 days.Conclusion Adopting a “discharge and early revaluation” strategy appears to be safe, feasible, and may optimize hospital resources during the SARS-CoV-2 pandemic.