Telemedicine Implementation in COVID-19 ICU: Balancing Physical and Virtual Forms of Visibility

Impact of restricted family presence during the COVID-19 pandemic on critically ill patients, families, and critical care clinicians: a qualitative systematic review

BACKGROUND

We aimed to synthesize the qualitative evidence on the impacts of COVID-19-related restricted family presence policies from the perspective of patients, families, and healthcare professionals from neonatal (NICU), pediatric (PICU), or adult ICUs.

METHODS

We searched MEDLINE, EMBASE, Cochrane Databases of Reviews and Clinical Trials, CINAHL, Scopus, PsycINFO, and Web of Science. Two researchers independently reviewed titles/abstracts and full-text articles for inclusion. Thematic analysis was completed following appraising article quality and assessing confidence in the individual review findings using standardized tools.

RESULTS

We synthesized 54 findings from 184 studies, revealing the impacts of these policies in children and adults on: (1) Family integrated care and patient and family-centered care (e.g., disruption to breastfeeding/kangaroo care, dehumanizing of patients); (2) Patients, families, and healthcare professionals (e.g., negative mental health consequences, moral distress); (3) Support systems (e.g., loss of support from friends/families); and (4) Relationships (e.g., loss of essential bonding with infant, struggle to develop trust). Strategies to mitigate these impacts are reported.

CONCLUSION

This review highlights the multifaceted impacts of restricted visitation policies across distinct care settings and strategies to mitigate the harmful effects of these policies and guide the creation of compassionate family presence policies in future health crises.

REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290263 .

Telemedicine and Teamwork Among Health Care Professionals: State of the Science

Background: As telemedicine becomes further rooted in standard patient care delivery, it is critical to understand how it may affect teamwork among health care providers. Understanding the state of the science between telemedicine and teamwork is an important first step. Obejctive: The purpose of this state-of-the-science review was to synthesize the published research on teamwork within the context of telemedicine. Methods: Data abstraction and analysis were structured following the Virtual Team Performance and the "Big Five" of Teamwork theoretical frameworks. The concepts within these models were used to organize data extraction. This state of the science used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results: A total of 14 studies met the inclusion criteria after final review. The most common variables were communication, tasks, leadership, team orientation, and team cohesion. Despite variable commonalities across the included articles, there was a discrepancy between improved and reduced teamwork outcomes with telemedicine. Conclusions: Multiple teamwork variables are influential across health care teams using telemedicine technologies-those that include communication, task facilitation, leadership, team orientation, and cohesion appear to have the greatest impact. However, it is not an individual teamwork variable, type of technology, or care environment alone that influences positive or negative outcomes among health care teams using telemedicine. Instead, it is a combination of factors and mechanisms that facilitate or hinder teamwork outcomes. A comprehensive model that describes the interaction of these common variables in teamwork among blended virtual and in-person health care teams is needed.

Designing for flexibility in hybrid care services: lessons learned from a pilot in an internal medicine unit

Digital transformation in healthcare during the COVID-19 pandemic led to the development of new hybrid models integrating physical and virtual care. The ability to provide remote care by telemedicine technologies and the need to better manage and control hospitals' occupancy accelerated growth in hospital-at-home programs. The Sheba Medical Center restructured to create Sheba Beyond as the first virtual hospital in Israel. These transformations enabled them to deliver hybrid services in their internal medicine unit by managing inpatient hospital-care with remote home-care based on the patients' medical condition. The hybrid services evolved to integrate care pathways multiplied by the mode of delivery-physical (in person) or virtual (technology enabled)-and the location of care-at the hospital or the patient home. The study examines this home hospitalization program pilot for internal medicine at Sheba Medical Center (MC). The research is based on qualitative semi-structured interviews with Sheba Beyond management, medical staff from the hospital and the Health Maintenance Organization (HMO), Architects, Information Technology (IT), Telemedicine and Medtech organizations. We investigated the implications of the development of hybrid services for the future design of the physical built-environment and the virtual technological platform. Our findings highlight the importance of designing for flexibility in the development of hybrid care services, while leveraging synergies across the built environment and digital platforms to support future models of care. In addition to exploring the potential for scalability in accelerating the flexibility of the healthcare system, we also highlight current barriers in professional, management, logistic and economic healthcare models.

The impact of hospital command centre on patient flow and data quality: findings from the UK National Health Service

In the last 6 years, hospitals in developed countries have been trialling the use of command centres for improving organizational efficiency and patient care. However, the impact of these command centres has not been systematically studied in the past. It is a retrospective population-based study. Participants were patients who visited the Bradford Royal Infirmary hospital, Accident and Emergency (A&E) Department, between 1 January 2018 and 31 August 2021. Outcomes were patient flow (measured as A&E waiting time, length of stay, and clinician seen time) and data quality (measured by the proportion of missing treatment and assessment dates and valid transition between A&E care stages). Interrupted time-series segmented regression and process mining were used for analysis. A&E transition time from patient arrival to assessment by a clinician marginally improved during the intervention period; there was a decrease of 0.9 min [95% confidence interval (CI): 0.35-1.4], 3 min (95% CI: 2.4-3.5), 9.7 min (95% CI: 8.4-11.0), and 3.1 min (95% CI: 2.7-3.5) during 'patient flow program', 'command centre display roll-in', 'command centre activation', and 'hospital wide training program', respectively. However, the transition time from patient treatment until the conclusion of consultation showed an increase of 11.5 min (95% CI: 9.2-13.9), 12.3 min (95% CI: 8.7-15.9), 53.4 min (95% CI: 48.1-58.7), and 50.2 min (95% CI: 47.5-52.9) for the respective four post-intervention periods. Furthermore, the length of stay was not significantly impacted; the change was -8.8 h (95% CI: -17.6 to 0.08), -8.9 h (95% CI: -18.6 to 0.65), -1.67 h (95% CI: -10.3 to 6.9), and -0.54 h (95% CI: -13.9 to 12.8) during the four respective post-intervention periods. It was a similar pattern for the waiting and clinician seen times. Data quality as measured by the proportion of missing dates of records was generally poor (treatment date = 42.7% and clinician seen date = 23.4%) and did not significantly improve during the intervention periods. The findings of the study suggest that a command centre package that includes process change and software technology does not appear to have a consistent positive impact on patient safety and data quality based on the indicators and data we used. Therefore, hospitals considering introducing a command centre should not assume there will be benefits in patient flow and data quality.

The impact of COVID-19 on visitors' wayfinding within healthcare centers

The novel COVID-19 pandemic has caused substantial calamities in developing countries such as Iran, which initially suffered from inadequate infrastructure essential for the pandemic control. Due to the ongoing development of this malady, healthcare centers are recognized as one of the most significant hotspots within public settings so they are directly pertinent to the physical and mental health of visitors. The main objective for conducting the present study is to investigate the impact of the COVID-19 pandemic on the visitors' wayfinding procedure within Qa'em hospital, located in Rasht, northern Iran. The adopted methodology in the present study is based on a comparison between the collected data regarding the wayfinding behavior of visitors before and after the outbreak of the COVID-19 pandemic using mixed methods, namely Space Syntax, gate counting, people following, and semi-structured interviews. The obtained empirical results displayed that visitors were significantly confused and hesitant throughout their wayfinding process after the outbreak of the pandemic. Indeed, spatial accessibility and legibility were not found to be adequate for facilitating the wayfinding of the visitors. Moreover, the requirements for the reconfiguration of furniture layout in the waiting areas, according to the underlying notions of social distancing, became conspicuous as the pragmatic implications for the post-pandemic healthcare centers.

Implementation of Tele-Intensive Care Unit Services During the COVID-19 Pandemic: A Systematic Literature Review and Updated Experience from Shandong Province

Background: While the use of telemedicine had been expanding before the initial outbreak of COVID-19, the pandemic has dramatically accelerated its implementation and expanded its usage in many hospitals. Tele-intensive care unit (ICU) is a specialized type of telemedicine that adapts available technologies to the unique needs of critically ill patients. We published an editorial in 2020 describing our initial experiences of Tele-ICU application in Shandong Province. Here, we update our insights gained over the past 2 years, and we provide a systematic review of the literature to compare our perspectives with those from other institutions. Methods: We performed a systematic literature review of publications describing the use of telemedicine in an ICU setting during COVID-19. The PubMed database was searched for studies published after January 1, 2020, which offered detailed descriptions of tele-ICU usage. Extracted data included details regarding tele-ICU technologies, descriptions of the institution, usage cases, assessments of tele-ICU effectiveness, and site-reported opinions (e.g., advantages, disadvantages). Results: We screened 162 studies resulting from the PubMed literature search, along with one expert recommendation. Of the 112 full-text articles retrieved, 11 were selected for inclusion in this qualitative summary. All were retrospective descriptions of tele-ICU experiences at a single site. Some pairs of included articles reported results from the same institution, with seven unique sites being described. Three sites employed centralized models of tele-ICU, while four allowed staff to participate from distant locations. Five sites collected user-reported feedback regarding tele-ICU. While the advantages and disadvantages described rarely overlapped directly between sites, many reported positive opinions of tele-ICU use overall. Conclusions: The potential applications of tele-ICU technologies vary widely, making them highly adaptable to the needs of individual institutions. Tele-ICU has proven invaluable to some hospitals during COVID-19 due to its effectiveness at aiding patient care while mitigating risk to health care workers.

Postsurgical Remote Patient Monitoring Outcomes and Perceptions: A Mixed-Methods Assessment

Objective

To determine how postsurgical remote patient monitoring (RPM) influences readmissions and emergency visits within 30 days of discharge after operation and to understand patient and surgeon perspectives on postsurgical RPM.

Patients and Methods

This study was conducted at a US tertiary academic medical center between April 1, 2021, and December 31, 2021. This mixed-methods evaluation included a randomized controlled trial evaluation of RPM after operation and a qualitative assessment of patients' and surgeons' perceptions of RPM's acceptability, feasibility, and effectiveness.

Results

A total of 292 patients participated in the RPM trial, and 147 were assigned to the RPM intervention. Despite a good balance between the groups, results indicated no difference in primary or secondary outcomes between the intervention and control groups. The qualitative component included 11 patients and 9 surgeons. The overarching theme for patients was that the program brought them peace of mind. Other main themes included technological issues and perceived benefits of the RPM platform. The major themes for surgeons included identifying the best patients to receive postsurgical RPM, actionable data collection and use, and improvements in data collection needed.

Conclusion

Although quantitative results indicate no difference between the groups, postsurgical RPM appears well-accepted from the patient's perspective. However, technological issues could eliminate the benefits. Hospitals seeking to implement similar programs should carefully evaluate which populations to use the program in and seek to collect actionable data.

Lessons learnt for enhancing hospital resilience to pandemics: A qualitative analysis from Italy

The COVID-19 pandemic has outlined the need to strengthen the resilience of healthcare systems. It has cost millions of human lives and has had indirect health impacts too. Hospital buildings have undergone extensive modifications and adaptations to ensure infection control and prevention measures, and, as it is happened following past epidemics, the COVID-19 experience might change the design of hospital buildings in the future. This paper aims to capitalise on the knowledge developed by the stakeholders directly involved with the hospital response during the pandemic to generate new evidence that will enhance resilience of hospital buildings to pandemics. The research adopted qualitative research methods, namely literature review and interviews with Italian experts including doctors and facility managers to collect data which were analysed through a thematic analysis. The findings include the identification of new needs for hospital buildings and the related actions to be taken or already performed at hospital building and service level which are viable for long term implementation and are aimed at improving hospital resilience to pandemics. The results specify how to improve resilience by means of structural modifications (e.g. placing filter zones among different wards, ensuring the presence of airborne infection isolation rooms at least in the emergency departments), technological changes (e.g. oversizing capacity such as medical gases, information technology improvement for delivering healthcare services remotely), and operational measures (e.g. assessing the risk of infection before admission, dividing acute-care from low-care assets). The needs discussed in this paper substantiate the urge to renovate the Italian healthcare infrastructures and they can be considered useful elements of knowledge for enhancing hospital resilience to pandemics in the extended and in the post-COVID-19 era.

The Impact of Digital Health Transformation Driven by COVID-19 on Nursing Practice: Systematic Literature Review

Background

The COVID-19 pandemic has accelerated the uptake of digital health innovations due to the availability of various technologies and the urgent health care need for treatment and prevention. Although numerous studies have investigated digital health adoption and the associated challenges and strategies during the pandemic, there is a lack of evidence on the impact on the nursing workforce.

Objective

This study aims to identify the impact of digital health transformation driven by COVID-19 on nurses.

Methods

The online software Covidence was used to follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Relevant scientific health and computing databases were searched for papers published from January 2020 to November 2021. Using the 8D sociotechnical approach for digital health in health care systems, the papers were analyzed to identify gaps in applying digital health in nursing practice.

Results

In total, 21 papers were selected for content analysis. The analysis identified a paucity of research that quantifies the impact of the digital health transformation on nurses during the pandemic. Most of the initiatives were teleconsultation, followed by tele–intensive care unit (tele-ICU), and only 1 (5%) study explored electronic medical record (EMR) systems. Among the sociotechnical elements, the human-related factor was the most explored and the system measurement was the least studied item.

Conclusions

The review identified a significant gap in research on how implementing digital health solutions has impacted nurses during the COVID-19 pandemic. This gap needs to be addressed by further research to provide strategies for empowering the nursing workforce to be actively involved in digital health design, development, implementation, use, and evaluation.

Nursing Workflow Change in a COVID-19 Inpatient Unit Following the Deployment of Inpatient Telehealth: Observational Study Using a Real-Time Locating System

BACKGROUND

The COVID-19 pandemic prompted widespread implementation of telehealth, including in the inpatient setting, with the goals to reduce potential pathogen exposure events and personal protective equipment (PPE) utilization. Nursing workflow adaptations in these novel environments are of particular interest given the association between nursing time at the bedside and patient safety. Understanding the frequency and duration of nurse-patient encounters following the introduction of a novel telehealth platform in the context of COVID-19 may therefore provide insight into downstream impacts on patient safety, pathogen exposure, and PPE utilization.

OBJECTIVE

The aim of this study was to evaluate changes in nursing workflow relative to prepandemic levels using a real-time locating system (RTLS) following the deployment of inpatient telehealth on a COVID-19 unit.

METHODS

In March 2020, telehealth was installed in patient rooms in a COVID-19 unit and on movable carts in 3 comparison units. The existing RTLS captured nurse movement during 1 pre- and 5 postpandemic stages (January-December 2020). Change in direct nurse-patient encounters, time spent in patient rooms per encounter, and total time spent with patients per shift relative to baseline were calculated. Generalized linear models assessed difference-in-differences in outcomes between COVID-19 and comparison units. Telehealth adoption was captured and reported at the unit level.

RESULTS

Change in frequency of encounters and time spent per encounter from baseline differed between the COVID-19 and comparison units at all stages of the pandemic (all P<.001). Frequency of encounters decreased (difference-in-differences range -6.6 to -14.1 encounters) and duration of encounters increased (difference-in-differences range 1.8 to 6.2 minutes) from baseline to a greater extent in the COVID-19 units relative to the comparison units. At most stages of the pandemic, the change in total time nurses spent in patient rooms per patient per shift from baseline did not differ between the COVID-19 and comparison units (all P>.17). The primary COVID-19 unit quickly adopted telehealth technology during the observation period, initiating 15,088 encounters that averaged 6.6 minutes (SD 13.6) each.

CONCLUSIONS

RTLS movement data suggest that total nursing time at the bedside remained unchanged following the deployment of inpatient telehealth in a COVID-19 unit. Compared to other units with shared mobile telehealth units, the frequency of nurse-patient in-person encounters decreased and the duration lengthened on a COVID-19 unit with in-room telehealth availability, indicating "batched" redistribution of work to maintain total time at bedside relative to prepandemic periods. The simultaneous adoption of telehealth suggests that virtual care was a complement to, rather than a replacement for, in-person care. However, study limitations preclude our ability to draw a causal link between nursing workflow change and telehealth adoption. Thus, further evaluation is needed to determine potential downstream implications on disease transmission, PPE utilization, and patient safety.

Telemedicine Intensive Care Unit (Tele-ICU) Implementation During COVID-19: A Scoping Review

Telemedicine intensive care unit (Tele-ICU) programs entail command centers staffed with intensivists and critical care nurses who electronically aid with and deliver real-time information to frontline clinicians. The benefits of Tele-ICU are numerous, but the barriers to it often prove insurmountable, accounting for slow adoption in rural and underserved areas where it is needed the most. Remote monitoring can quickly detect patient deterioration, while consultation provided by a remote intensivist expands the capabilities of smaller facilities. The emergence of the coronavirus disease 2019 (COVID-19) pandemic has brought about a sense of urgency, paving the way for the successful adaptation of tele-intensive care concepts. The goal of this scoping review is to map out the available published data regarding healthcare professionals’ experiences with implementing Tele-ICU modalities during the COVID-19 pandemic. A primary literature search was performed on PubMed/MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from October 2020 to October 2021. Of the 1,083 records screened, 19 were identified as meeting our inclusion criteria and selected for the final scoping review. Five major areas of Tele-ICU use were identified: teleconsultation, telerounding, telemonitoring, family visitation via teleconference, and changing of hospital infrastructure. A heterogeneous mix of improvised Tele-ICU platforms emerged with a common theme of interdisciplinary and family collaboration in the care of critically ill patients. Existing Tele-ICU systems were expanded, and novel programs were launched. A groundbreaking national network in the U.S. (NETCCN) will standardize the deployment of Tele-ICU and expand its reach. Future research should focus on determining accurate costs and the most reliable forms of remote communication, physician compact agreement licensure, the practical composition of Tele-ICU teams, and standardized access to the electronic health record.

Use of Video Technology in End-of-Life Care for Hospitalized Patients During the COVID-19 Pandemic

BACKGROUND

Infection control protocols, including visitor restrictions, implemented during the COVID-19 pandemic threatened the ability to provide compassionate, family-centered care to patients dying in the hospital. In response, clinicians used videoconferencing technology to facilitate conversations between patients and their families.

OBJECTIVES

To understand clinicians' perspectives on using videoconferencing technology to adapt to pandemic policies when caring for dying patients.

METHODS

A qualitative descriptive study was conducted with 45 clinicians who provided end-of-life care to patients in 3 acute care units at an academically affiliated urban hospital in Canada during the first wave of the pandemic (March 2020-July 2020). A 3-step approach to conventional content analysis was used to code interview transcripts and construct overarching themes.

RESULTS

Clinicians used videoconferencing technology to try to bridge gaps in end-of-life care by facilitating connections with family. Many benefits ensued, but there were also some drawbacks. Despite the opportunity for connection offered by virtual visits, participants noted concerns about equitable access to videoconferencing technology and authenticity of technology-assisted interactions. Participants also offered recommendations for future use of videoconferencing technology both during and beyond the pandemic.

CONCLUSIONS

Clinician experiences can be used to inform policies and practices for using videoconferencing technology to provide high-quality end-of-life care in the future, including during public health crises.

Patient Perspectives of Inpatient Telemedicine During COVID-19: A Qualitative Assessment (Preprint)

Background

Telemedicine has been adopted in the inpatient setting to facilitate clinical interactions between on-site clinicians and isolated hospitalized patients. Such remote interactions have the potential to reduce pathogen exposure and use of personal protective equipment but may also pose new safety concerns given prior evidence that isolated patients can receive suboptimal care. Formal evaluations of the use and practical acceptance of inpatient telemedicine among hospitalized patients are lacking.

Objective

We aimed to evaluate the experience of patients hospitalized for COVID-19 with inpatient telemedicine introduced as an infection control measure during the pandemic.

Methods

We conducted a qualitative evaluation in a COVID-19 designated non–intensive care hospital unit at a large academic health center (Stanford Health Care) from October 2020 through January 2021. Semistructured qualitative interviews focused on patient experience, impact on quality of care, communication, and mental health. Purposive sampling was used to recruit participants representing diversity across varying demographics until thematic saturation was reached. Interview transcripts were qualitatively analyzed using an inductive-deductive approach.

Results

Interviews with 20 hospitalized patients suggested that nonemergency clinical care and bridging to in-person care comprised the majority of inpatient telemedicine use. Nurses were reported to enter the room and call on the tablet far more frequently than physicians, who typically entered the room at least daily. Patients reported broad acceptance of the technology, citing improved convenience and reduced anxiety, but preferred in-person care where possible. Quality of care was believed to be similar to in-person care with the exception of a few patients who wanted more frequent in-person examinations. Ongoing challenges included low audio volume, shifting tablet location, and inconsistent verbal introductions from the clinical team.

Conclusions

Patient experiences with inpatient telemedicine were largely favorable. Although most patients expressed a preference for in-person care, telemedicine was acceptable given the circumstances associated with the COVID-19 pandemic. Improvements in technical and care team use may enhance acceptability. Further evaluation is needed to understand the impact of inpatient telemedicine and the optimal balance between in-person and virtual care in the hospital setting.

Inpatient Telemedicine and New Models of Care during COVID-19: Hospital Design Strategies to Enhance Patient and Staff Safety

The challenges of the COVID-19 pandemic have led to the development of new hospital design strategies and models of care. To enhance staff safety while preserving patient safety and quality of care, hospitals have created a new model of remote inpatient care using telemedicine technologies. The design of the COVID-19 units divided the space into contaminated and clean zones and integrated a control room with audio-visual technologies to remotely supervise, communicate, and support the care being provided in the contaminated zone. The research is based on semi-structured interviews and observations of care processes that implemented a new model of inpatient telemedicine at Sheba Medical Center in Israel in different COVID-19 units, including an intensive care unit (ICU) and internal medicine unit (IMU). The study examines the impact of the diverse design layouts of the different units associated with the implementation of digital technologies for remote care on patient and staff safety. The results demonstrate the challenges and opportunities of integrating inpatient telemedicine for critical and intermediate care to enhance patient and staff safety. We contribute insights into the design of hospital units to support new models of remote care and suggest implications for Evidence-based Design (EBD), which will guide much needed future research.