Assessing patient safety in a pediatric telemedicine setting: a multi-methods study

Pediatric Primary Care Clinicians' Perspectives on Telemedicine Use, 2020 Versus 2021

Objective: We examined the change in pediatric primary care clinician attitudes and perceptions about telemedicine after one year of telemedicine use. Methods: We administered a survey to pediatric primary care clinicians across 50 primary care practices in Pennsylvania in 2020 and 2021. Surveys were linked using a combination of deterministic and probabilistic matching. We used McNemar's test to compare change in responses from 2020 to 2021. Results: Among pediatric primary care clinicians surveyed in 2020 and 2021 (n = 101), clinicians agreed that telemedicine could always or usually deliver high-quality care for mental health (80% in 2020 and 78% in 2021), care coordination (77% in 2020 and 70% in 2021), acute care (33% in 2020 and 34% in 2021), or preventive care (25% in 2020 and 18% in 2021) and this did not significantly change. Clinician perceptions of usability, while high, declined over time with fewer endorsing ease of use (93% in 2020 and 80% in 2021) and reliability (14% in 2020 and 0% in 2021) over time. Despite this, 62% of clinicians agreed that they were satisfied with their use of telemedicine at both time points. Respondents anticipated positive impact on equity and timeliness of care from telemedicine use but did not anticipate positive impact across child health, health care delivery, or clinician experience. Perceptions across these domains did not change over time. Conclusions: With one year of telemedicine experience, primary care clinicians maintained beliefs that telemedicine could deliver high-quality care for specific clinical needs but had worsening perceptions of usability over time.

Safety in Teletriage by Nurses and Physicians in the United States and Israel: Narrative Review and Qualitative Study

BACKGROUND

The safety of telemedicine in general and telephone triage (teletriage) safety in particular have been a focus of concern since the 1970s. Today, telehealth, now subsuming teletriage, has a basic structure and process intended to promote safety. However, inadequate telehealth systems may also compromise patient safety. The COVID-19 pandemic accelerated rapid but uneven telehealth growth, both technologically and professionally. Within 5-10 years, the field will likely be more technologically advanced; however, these advances may still outpace professional standards. The need for an evidence-based system is crucial and urgent.

OBJECTIVE

Our aim was to explore ways that developed teletriage systems produce safe outcomes by examining key system components and questioning long-held assumptions.

METHODS

We examined safety by performing a narrative review of the literature using key terms concerning patient safety in teletriage. In addition, we conducted system analysis of 2 typical formal systems, physician led and nurse led, in Israel and the United States, respectively, and evaluated those systems' respective approaches to safety. Additionally, we conducted in-depth interviews with representative physicians and 1 nurse using a qualitative approach.

RESULTS

The review of literature indicated that research on various aspects of telehealth and teletriage safety is still sparse and of variable quality, producing conflicting and inconsistent results. Researchers, possibly unfamiliar with this complicated field, use an array of poorly defined terms and appear to design studies based on unfounded assumptions. The interviews with health care professionals demonstrated several challenges encountered during teletriage, mainly making diagnosis from a distance, treating unfamiliar patients, a stressful atmosphere, working alone, and technological difficulties. However, they reported using several measures that help them make accurate diagnoses and reasonable decisions, thus keeping patient safety, such as using their expertise and intuition, using structured protocols, and considering nonmedical factors and patient preferences (shared decision-making).

CONCLUSIONS

Remote encounters about acute, worrisome symptoms are time sensitive, requiring decision-making under conditions of uncertainty and urgency. Patient safety and safe professional practice are extremely important in the field of teletriage, which has a high potential for error. This underregulated subspecialty lacks adequate development and substantive research on system safety. Research may commingle terminology and widely different, ill-defined groups of decision makers with wide variation in decision-making skills, clinical training, experience, and job qualifications, thereby confounding results. The rapid pace of telehealth's technological growth creates urgency in identifying safe systems to guide developers and clinicians about needed improvements.

Evaluation of healthcare professionals' experiences of taking telephone calls from parents of children with congenital heart disease. A risky business

The Congenital Heart Disease Standards for England indicate that parents and children should have access to a 24-h telephone advice service, however, little is known about existing services. This paper presents phase two of a mixed-methods service evaluation, which aimed to evaluate staff experiences of telephone communication with these parents. All nursing and support staff in a single specialist children's cardiac surgical centre were invited to participate in an online survey during July-November 2019. Data were descriptively and thematically analysed. Participants (N = 39) were predominantly nurses (n = 32, 82%) with 64.1% (n = 25) working in the speciality >10 years. Positive experiences included: signposting and preventing further deterioration; supporting families to get expert advice quickly; providing reassurance. Challenging experiences included: offering advice without being able to see the child, dealing with telephone calls alongside busy workload; and parents running out of medications and telephoning out of hours. In conclusion, taking telephone calls were perceived to be time consuming and are potentially high risk. A standardised approach to assessment, intervention and documentation was deemed necessary. Implementation of an updated parental early warning tool was recommended, along with staff and parental education.

Remote Communications between Patients and General Practitioners: Do Patients Choose the Most Effective Communication Routes?

The use of remote communication between patients and general practitioners has greatly increased worldwide, especially following the COVID-19 outbreak. Yet, it is important to evaluate the impact of this shift on healthcare quality. This study aimed at evaluating remote healthcare quality by comparing four remote patient-to-physician communication modes used in Israel. The research methodology entailed criteria-based analysis conducted by healthcare quality experts and a subjective patient-perception questionnaire regarding the healthcare quality attributed to each mode and the extent to which each mode was used. Our findings indicate that the extent to which each mode is used was found to be inversely related to its rated quality. As such, the common assumption whereby patients tend to choose the mode of communication that will most likely ensure high service quality is refuted. Our findings also indicate that remote services often hinder the physician's understanding of the patient's clinical issues, as patients encounter difficulties in correctly articulating and conveying them; such services also hinder the patient's understanding of the recommended course of treatment. These findings should be addressed by policymakers for improving remote communication services to ensure optimal healthcare service quality.

Telehealth Use in Pediatric Care during the COVID-19 Pandemic: A Qualitative Study on the Perspectives of Caregivers

This qualitative study surveyed caregivers regarding their perspectives on the benefits of, challenges with, and suggestions for improving telehealth during the COVID-19 pandemic. Caregivers who had the responsibility for caring for at least one child aged under 18 years of age in Genesee County, MI, participated. The caregivers were biological parents, stepparents, foster parents, adoptive parents, and guardians. A total of 105 caregivers completed a survey with open-ended questions via Qualtrics. Two independent coders developed themes based on the responses using grounded theory. Participants were primarily biological parents and non-Hispanic White and African Americans. According to the participants, the benefits of telehealth included prevention of exposure to the COVID-19 virus, quality communication with physicians, savings in travel time, and cost-effective methods to receive care. The challenges included a lack of in-person interaction, fear of compromised confidentiality, and the potential for misdiagnosis. Suggestions for improvement by caregivers included increasing access to telehealth for poorer families, offering a media educational campaign to promote telehealth use, and creating a universal platform to share patient information. Future studies may test the effectiveness of interventions such as those suggested by caregivers in this study to improve telehealth.

Clinician perspectives on rapid transition to telehealth during COVID-19 in Australia - a qualitative study

Objective The coronavirus disease 2019 (COVID-19) pandemic precipitated a major shift in the use of telehealth in Australia. The changes highlighted gaps in our knowledge regarding the efficacy of, and clinician attitudes to, the use of telehealth. The current study expands and deepens the available evidence as a result of being collected in unique circumstances that removed one of the major barriers (lack of Medicare rebates) and also one major enablers (willingness) of telehealth uptake. Methods Using a semi-structured interview, we invited clinicians (N  = 39) to share their perspectives, attitudes and experiences of using telehealth. Topics covered included perceptions of the strengths and challenges of telehealth, and how experience of using telehealth during the COVID-19 pandemic had influenced clinicians' views and intentions regarding their future practice. Participants included clinicians from five disciplines across public and private practice: paediatrics, neurology, immunology, rural general practice, and orthopaedics. Results We found three key dimensions for consideration when assessing the suitability of telehealth for ongoing practice: the attributes of the patient population, the attributes of the clinical context and environment, and the risks and benefits of a telehealth approach. These findings map to the existing literature and allow us to infer that the experiences of clinicians who previously would have chosen telehealth did not differ significantly from those of our 'pandemic-conscripted' clinicians. Conclusions Our findings map clearly to the existing literature and allow us to infer that the experiences of the clinicians who have chosen telehealth (and are already represented in the literature) did not differ significantly from those trying out telehealth under the unique circumstances of the removal of the Medicare Benefits Scheme barrier and external pressure that over-rides the 'willingness' enabling factor in uptake decisions.

Telephone Referral to a Paediatric Emergency Department: Why Do Parents Not Show Up?

Medical call centres can evaluate and refer patients to an emergency department (ED), a physician or provide guidance for self-care. Our aim was (1) to determine parental adherence to an ED orientation after being referred by the nurses of a call centre, (2) to observe how adherence varies according to children's characteristics and (3) to assess parents' reasons for non-adherence. This was a prospective cohort study set in the Lausanne agglomeration, Switzerland. From 1 February to 5 March 2022, paediatric calls (<16 years old) with an ED orientation were selected. Life-threatening emergencies were excluded. Parental adherence was then verified in the ED. All parents were contacted by telephone to respond to a questionnaire regarding their call. Parental adherence to the ED orientation was 75%. Adherence decreased significantly with increasing distance between the place the call originated and the ED. The child's age, sex and health complaints within calls had no effect on adherence. The three major reasons for non-adherence to telephone referral were: improvement in the child's condition (50.7%), parents' decision to go elsewhere (18.3%) and an appointment with a paediatrician (15.5%). Our results offer new perspectives to optimise the telephone assessment of paediatric patients and decrease barriers to adherence.

Impact of the COVID-19 pandemic on the digitization of routine pediatric practice in Spain: A nationwide survey study

INTRODUCTION

The COVID-19 pandemic forced a change in the working dynamics of all healthcare professionals, leading to the sudden introduction of telemedicine. Although until that moment telemedicine applications had been described in the paediatric age, their use was anecdotal.

OBJECTIVE

To analyse the experience of Spanish paediatricians after the forced digitization of consultations due to the pandemic.

METHODS

A cross-sectional survey-type study was designed to obtain information from Spanish paediatricians about the changes that took place in the usual clinical practice.

RESULTS

306 health professionals participated in the study Most of them agreed on the use of the internet and social networks during the pandemic, referring to mail or WhatsApp® as usual channels of communication with their patients' families. There was a great agreement among paediatricians that the evaluation of newborns after hospital discharge and establishing methodologies that allow childhood vaccination and the identification of subsidiary patients for face-to-face evaluation were necessary although the limitations of the lockdown. The idea that telephone and digital consultations have optimized the consultation time and that they will probably continue after the end of the pandemic was generally accepted. No changes in adherence to breastfeeding or the start of complementary feeding were referred to, but an increase in the duration of breastfeeding and the appearance of frequent hoaxes in social networks concerning infant feeding were found.

CONCLUSIONS

It is necessary to analyse the impact of telemedicine in paediatric consultations during the pandemic to evaluate its effectiveness and quality to maintain it in routine paediatric practice.

Nurse Practitioner Delivered Virtual Care in a Pediatric Specialty Clinic

INTRODUCTION

Virtual care in pediatric specialty practice has become widely used to increase access to care, one in which nurse practitioners (NPs) can play a vital role. We sought to evaluate the outcomes of virtual care provided by pediatric cardiology and electrophysiology (EP) NPs for pediatric and congenital heart disease patients.

METHOD

Retrospective review of all virtual care visits performed by pediatric EP NPs between October 2019 and October 2021 at a single tertiary care center.

RESULTS

NPs delivered virtual care for 287 pediatric EP evaluations for 276 patients; 132 (45%) independently, with the remaining 155 collaborating with an electrophysiologist as a shared visit. The mean age was 15.2 ± 8.9 years.

DISCUSSION

NPs performed a significant subset of these visits independently and were a vital part of all visits in this study. The role of the NP in specialty pediatric virtual care should continue to be supported and advanced.

Triage through telemedicine in paediatric emergency care—Results of a concordance study

Background

In the German health care system, parents with an acutely ill child can visit an emergency room (ER) 24 hours a day, seven days a week. At the ER, the patient receives a medical consultation. Many parents use these facilities as they do not know how urgently their child requires medical attention. In recent years, paediatric departments in smaller hospitals have been closed, particularly in rural regions. As a result of this, the distances that patients must travel to paediatric care facilities in these regions are increasing, causing more children to visit an ER for adults. However, paediatric expertise is often required in order to assess how quickly the patient requires treatment and select an adequate treatment. This decision is made by a doctor in German ERs. We have examined whether remote paediatricians can perform a standardised urgency assessment (triage) using a video conferencing system.

Methods

Only acutely ill patients who were brought to a paediatric emergency room (paedER) by their parents or carers, without prior medical consultation, have been included in this study. First, an on-site paediatrician assessed the urgency of each case using a standardised triage. In order to do this, the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) was translated into German and adapted for use in a standardised IT-based data collection tool. After the initial on-site triage, a telemedicine paediatrician, based in a different hospital, repeated the triage using a video conferencing system. Both paediatricians used the same triage procedure. The primary outcome was the degree of concordance and interobserver agreement, measured using Cohen’s kappa, between the two paediatricians. We have also included patient and assessor demographics.

Results

A total of 266 patients were included in the study. Of these, 227 cases were eligible for the concordance analysis. In n = 154 cases (68%), there was concordance between the on-site paediatrician’s and telemedicine paediatrician’s urgency assessments. In n = 50 cases (22%), the telemedicine paediatrician rated the urgency of the patient’s condition higher (overtriage); in 23 cases (10%), the assessment indicated a lower urgency (undertriage). Nineteen medical doctors were included in the study, mostly trained paediatric specialists. Some of them acted as an on-site doctor and telemedicine doctor. Cohen’s weighted kappa was 0.64 (95% CI: 0.49–0.79), indicating a substantial agreement between the specialists.

Conclusions

Telemedical triage can assist in providing acute paediatric care in regions with a low density of paediatric care facilities. The next steps are further developing the triage tool and implementing telemedicine urgency assessment in a larger network of hospitals in order to improve the integration of telemedicine into hospitals’ organisational processes. The processes should include intensive training for the doctors involved in telemedical triage.

Trial registration

DRKS00013207.

Fast, cheap and feasible: Implementation of pediatric telemedicine in a public hospital during the Covid-19 pandemic

OBJECTIVE

In Brazil, telemedicine was allowed as an exception during the coronavirus disease (COVID-19) pandemic. Despite its recognized value and availability, telemedicine is not universally used, suggesting that some barriers prevent its adoption and acceptance within the community. This study aims to describe the implementation of a low-cost telemedicine service in a pediatric hospital in Brazil.

METHOD

Retrospective descriptive study reporting the first three months (April to June 2020) of the experience of implementing a low-cost telemedicine emergency care program in a public tertiary hospital. The service was available to patients up to 18 years of age enrolled in this hospital. A tool for assessing the severity of the patient was developed, the aim of standardizing the procedure, while maintaining quality and safety. Guardian's satisfaction was assessed with a questionnaire sent after teleconsultations.

RESULTS

255 teleconsultations were carried out with 140 different patients. Of the total consultations, 182 were from 99 patients that had performed the Real-Time Polymerase Chain Reaction (RT-PCR) test for the new coronavirus (SARS-Cov-2) or had direct contact with a person known to be positive for COVID-19. Only 26 (14%) were referred to an in-person consultation. No deaths, adverse events or delayed diagnosis were recorded. 86% of the patients who answered the satisfaction questionnaire were satisfied and 92% would use telemedicine again.

CONCLUSION

This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service, serving as a reference for future implementation in other public services in Brazil and developing countries.

Application and implementation of telehealth services designed for the elderly population during the COVID-19 pandemic: A systematic review

BACKGROUND

Telehealth has many benefits, in routine care and especially during times of epidemics in which restrictions to direct patient/healthcare-provider interaction exist.

OBJECTIVE

To explore the availability, application, and implementation of telehealth services during the Covid-19 era, designed for the aged population (age 65 and more).

METHODS

This systematic review/analysis was conducted by searching the most popular databases including PubMed, Embase, and Web of Science. We included studies that clearly defined any use of telemedicine services in any aspect of healthcare during the COVID-19 pandemic, aimed at the elderly population, published in peer-reviewed journals. We independently assessed search results, extracted the relevant studies, and assessed their quality.

RESULTS

3225 articles were identified after removing duplicates. After reading the full texts of 40 articles, 11 articles were finally included. Among the telehealth services, there were services aimed for triage and control during the outbreak of the COVID-19 pandemic, remote monitoring and treatment, follow-ups online meetings for patients residing in health centers, and application of online services.

CONCLUSIONS

Although the elderly population may benefit the most from telehealth services, especially during pandemics and social distancing restrictions, not enough services were developed and implemented to satisfy the needs of this population.

A Review of Telemedicine Practice Guidelines for COVID-19 and Global Emergencies

An incorrect version of this manuscript was published online and so has been withdrawn.

Diagnoses and Health Care Utilization for After-Hours Telemedicine Versus Primary Care Visits

OBJECTIVE

The use of a nation-wide, pediatricians online (PO) after-hours telemedicine service has been offered in Israel for more than a decade. We sought to compare PO visits with those to the primary care pediatrician (PCP).

METHODS

This is a retrospective cross-sectional study using Israel's largest health care provider database. We included children aged 0 to 18 years using either PO or PCP between 2015 and 2018. We compared the baseline characteristics, matching by socioeconomic status, chronic illness, and diagnosis, and compared their admission rates, laboratory testing, and medication prescription.

RESULTS

During this study period there were 262,541 PO visits and a random 10% sample of PCP visits which yielded 1,813,103 visits. Users of PO were more likely to have a higher socioeconomic status (43% vs 28.9%), fever (13.3% vs 4.4%) and less likely to have acute respiratory conditions (8.8% vs 16.7%). Users of PO had higher rates of emergency department admissions (2.9% vs 0.4%), hospital admissions (0.9% vs 0.2%), and lower rates of laboratory testing (3.7% vs 7.4%) and medication prescription (42.0% vs 52.0%) within 24 hours. All differences were statistically significant (P < .005).

CONCLUSIONS

Our pediatric telemedicine service operating after-hours has been found to be feasible, and widely used, for a myriad of clinical conditions. Significant differences exist between PO and PCP visit characteristics and outcomes. However, it remained unclear whether these differences reflect the difference in the patient population or whether they are the result of the different clinical services. Further research is warranted to clarify this matter.

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.

Telemedicine Surge for Pediatric Patients in Response to the COVID-19 Pandemic in New York City

Background: Our objective is to describe our pediatric virtual urgent care (VUC) experience at a large urban academic medical center, in response to the COVID-19 pandemic in New York City (NYC). Materials and Methods: We conducted a retrospective cohort study of our pediatric VUC program of patients less than age 18 years, from March 1 to May 31, 2020. We include data on expansion of staffing, patient demographics, virtual care, and outcomes. Results: We rapidly onboarded, educated, and trained pediatric telemedicine providers. We evaluated 406 pediatric patients with median age 4.4 years and 53.9% male. Median call time was 5:12 pm, median time to provider was 5.7 min, and median duration of call was 11.1 min. The most common reasons for a visit were COVID-19-related symptoms (36%), dermatologic (15%), and trauma (10%). Virtual care for patients consisted of conservative management (72%), medication prescription (18%), and referral to an urgent care or pediatric emergency department (PED) (10%). Of 16 patients referred and presented to our emergency department, 2 required intensive care for multisystem inflammatory syndrome in children. Oral antibiotics were prescribed for 7.1% of all patients. Only 0.005% of patients had an unplanned 72-h PED visit resulting in hospitalization after a VUC visit. Conclusion: Pediatric emergency VUC allowed for high-quality efficient medical care for patients during the peak of the COVID-19 pandemic in NYC. Although most patients were managed conservatively in their home, telemedicine also enabled rapid identification of patients who required in-person emergency care.

COVID-19 Era Effect on Pandemic and Post-pandemic Pediatric Telemedicine Use: A Survey of the European Academy of Pediatrics Research in Ambulatory Settings Network

Background: During the COVID-19 pandemic, telemedicine use has increased within community pediatrics. This trend runs counter to reluctance to adaptation of the new mode of healthcare that existed prior to the pandemic. Little is known about what we can expect after the pandemic: if physicians will opt for telemedicine modalities and if tele-pediatrics will continue to be a significant mode of community pediatric care. Objective: The goal of this study was to survey primary pediatric care providers as to their experiences and clinical decision making with telemedicine modalities prior to and during the COVID-19 pandemic, as well as their projected use after the pandemic ends. Material and methods: Using the EAPRASnet database we surveyed pediatricians throughout Europe, using a web-based questionnaire. The survey was performed during the COVID-19 pandemic (June-July 2020), assessed telemedicine use for several modalities, prior to and during the pandemic as well as predicted use after the pandemic will have resolved. Participants were also surveyed regarding clinical decision making in two hypothetical clinical scenarios managed by telemedicine. Results: A total of 710 physicians participated, 76% were pediatricians. The percentage of respondents who reported daily use for at least 50% of all encounters via telemedicine modalities increased during the pandemic: phone calls (4% prior to the pandemic to 52% during the pandemic), emails (2-9%), text messages (1-6%), social media (3-11%), cell-phone pictures/video (1-9%), and video conferencing (1-7%) (p < 0.005). The predicted post-pandemic use of these modalities partially declined to 19, 4, 3, 6, 9, and 4%, respectively (p < 0.005), yet demonstrating a prospectively sustained use of pictures/videos after the pandemic. Reported high likelihood of remotely treating suspected pneumonia and acute otitis media with antibiotics decreased from 8 to 16% during the pandemic to an assumed 2 and 4% after the pandemic, respectively (p < 0.005). Conclusions: This study demonstrates an increased utilization of telemedicine by pediatric providers during the COVID-19 pandemic, as well as a partially sustained effect that will promote telemedicine use as part of a hybrid care provision after the pandemic will have resolved.

Telemedicine in paediatric otorhinolaryngology: Lessons learnt from remote encounters during the Covid19 pandemic and implications for future practice

INTRODUCTION

Covid19 has necessitated new methods of conducting outpatient consultations. At our institute, patient-facing paediatric ENT appointments were replaced with telemedical consultations.

METHOD

We performed a prospective analysis of the outcomes following telephone consultations with parents and describe our experience of remote consulting during a pandemic, and the possibilities for future applications of telemedicine in paediatric ENT.

RESULTS

215 patients were appropriately referred to the paediatric ENT clinic, 65% of these patients were deemed suitable for remote telephone consultation. Following a telephone call, 50% did not need further ENT clinic management, most commonly due to being listed for surgery (20%) or discharged (18%). The treating consultant assessed 81% of phone consultations as being effective. When given the choice, patients reported that 29% would choose a telephone consultation whilst 43% preferred a face to face consultation.

CONCLUSION

Our experience has shown that there are areas of paediatric ENT that can be streamlined effectively by substituting face to face consultations with telephone consultations. However, prospective evaluation of these remote contacts suggest that telephone consultations are not a panacea and cannot be indiscriminately applied to all. Instead, the strategies to take forwards into a post Covid19 practice are vetting of referrals, individualised treatment plans, and giving patients a choice.

The future of telemedicine visits after COVID-19: perceptions of primary care pediatricians

Background

Facing the global health crisis of COVID-19, health systems are increasingly supporting the use of telemedicine in ambulatory care settings. It is not clear whether the increased use of telemedicine will persist after the pandemic has resolved. The aims of this study were to assess the use of telemedicine by Israeli pediatricians before and during the first lockdown phase of the pandemic, and to elucidate how they foresee telemedicine as a medium of medical practice in the post-pandemic era.

Methods

A web-based survey was distributed among Israeli pediatricians in May 2020, soon after the end of first lockdown was announced. The survey assessed the frequency of telemedicine use as well as its influence on clinical decision making before and during the first COVID-19 lockdown, using two hypothetical clinical scenarios. The same scenarios were also used to assess how the pediatricians foresaw telemedicine in the post-pandemic period. In addition, administrative data from Maccabi on telemedicine use before, during and after the first lockdown were retrieved and analyzed.

Results

One hundred and sixty-nine pediatricians responded to the survey (response rate = 40%). The percentage of respondents who reported daily use of text messages, pictures and videoconferencing increased from 24, 15 and 1% before COVID-19 to 40, 40 and 12% during the lockdown, respectively (p < 0.05). After the pandemic, projected use of text messages and pictures/videoclips was expected to decrease to 27 and 26% of respondents, respectively (p < 0.05), but pictures/videoclips were expected to increase from 15% of respondents before to 26% of respondents after (p < 0.05). The reported high likelihood of treating suspected pneumonia or prescribing antibiotics for suspected otitis media via telemedicine was expected to decrease from 20% of respondents during the COVID-19 lockdown to 6%% of respondents after (p < 0.05), and from 14% of respondents during the lockdown to 3% of respondents after, respectively. (p < 0.05).

Maccabi administrative data indicated that during the lockdown, there was an increase in phone visits and a decrease in in-person visits compared to the pre-lockdown levels of use. One month after the end of the first lock-down there was a partial return to baseline levels of in-person visits and a sustained increase in phone visits. Phone visits accounted for 0% of pediatrician visits before the first lockdown, 17% of them during the lockdown, and 19% of them 1 month after the lockdown relaxation.

Conclusions

The study indicates that use of telemedicine technologies by primary care pediatricians increased substantially during the first COVID-19 lockdown. The study also found that pediatricians expected that use levels will recede after the pandemic. As the pandemic continues and evolves, it will be important to continue to monitor the level of telemedicine use as well as expectations regarding post-pandemic use levels.

Patient Safety in Ambulatory Pediatrics

Purpose of Review

The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics.

Recent Findings

The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety.

Summary

There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.

The paediatric weight management office visit via telemedicine: pre- to post-COVID-19 pandemic

Telemedicine is a powerful tool that erases many logistical barriers to care and may increase access. Due to the need for social distancing, the COVID-19 pandemic has temporarily reduced in-person visits for clinical care. Providers, clinical staff and patients are pressed to acutely learn new skills and adapt clinical care through the use of telemedicine whilst administrators, policy makers and regulatory organizations make changes to existing policies to meet this national emergency. Our tertiary care, interdisciplinary paediatric weight management clinic began the use of telemedicine 5 years ago to bring access to an underserved, rural population at their primary care office, which has allowed our clinic to pivot seamlessly to in-home telemedicine visits during the pandemic. Telemedicine rules and regulations are rapidly changing to meet the COVID-19 national emergency, but many supports for new telemedicine providers are already in place. In this article, we provide an overview of telemedicine components, policies and regulations. We review the operationalization of our clinic's telemedicine visit prior to the pandemic. We discuss how telemedicine services are impacted by COVID-19 and key resources are provided. Finally, we reimagine telemedicine services post-pandemic to expand effective, coordinated health care, particularly for patients with chronic needs such as obesity.

Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program During the COVID-19 Pandemic

BACKGROUND

In the novel coronavirus disease 2019 (COVID-19) pandemic, social distancing has been necessary to help prevent disease transmission. As a result, medical practices have limited access to in-person visits. This poses a challenge to maintain appropriate patient care while preventing a substantial backlog of patients once stay-at-home restrictions are lifted. In practices that are naïve to telehealth as an alternative option, providers and staff are experiencing challenges with telemedicine implementation. We aim to provide a comprehensive guide on how to rapidly integrate telemedicine into practice during a pandemic.

METHODS

We built a toolkit that details the following 8 essential components to successful implementation of a telemedicine platform: provider and staff training, patient education, an existing electronic medical record system, patient and provider investment in hardware, billing and coding integration, information technology support, audiovisual platforms, and patient and caregiver participation.

RESULTS

Rapid integration of telemedicine in our practice was required to be compliant with our institution's COVID-19 task force. Within 3 days of this declaration, our large specialty-care clinic converted to a telemedicine platform and we completed 638 visits within the first month of implementation.

CONCLUSIONS

Effective and efficient integration of a telemedicine program requires extensive staff and patient education, accessory platforms to facilitate video and audio communication, and adoption of new billing codes that are outlined in this toolkit.

Guidelines for TMS/tES clinical services and research through the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has broadly disrupted biomedical treatment and research including non-invasive brain stimulation (NIBS). Moreover, the rapid onset of societal disruption and evolving regulatory restrictions may not have allowed for systematic planning of how clinical and research work may continue throughout the pandemic or be restarted as restrictions are abated. The urgency to provide and develop NIBS as an intervention for diverse neurological and mental health indications, and as a catalyst of fundamental brain research, is not dampened by the parallel efforts to address the most life-threatening aspects of COVID-19; rather in many cases the need for NIBS is heightened including the potential to mitigate mental health consequences related to COVID-19.

OBJECTIVE

To facilitate the re-establishment of access to NIBS clinical services and research operations during the current COVID-19 pandemic and possible future outbreaks, we develop and discuss a framework for balancing the importance of NIBS operations with safety considerations, while addressing the needs of all stakeholders. We focus on Transcranial Magnetic Stimulation (TMS) and low intensity transcranial Electrical Stimulation (tES) - including transcranial Direct Current Stimulation (tDCS) and transcranial Alternating Current Stimulation (tACS).

METHODS

The present consensus paper provides guidelines and good practices for managing and reopening NIBS clinics and laboratories through the immediate and ongoing stages of COVID-19. The document reflects the analysis of experts with domain-relevant expertise spanning NIBS technology, clinical services, and basic and clinical research - with an international perspective. We outline regulatory aspects, human resources, NIBS optimization, as well as accommodations for specific demographics.

RESULTS

A model based on three phases (early COVID-19 impact, current practices, and future preparation) with an 11-step checklist (spanning removing or streamlining in-person protocols, incorporating telemedicine, and addressing COVID-19-associated adverse events) is proposed. Recommendations on implementing social distancing and sterilization of NIBS related equipment, specific considerations of COVID-19 positive populations including mental health comorbidities, as well as considerations regarding regulatory and human resource in the era of COVID-19 are outlined. We discuss COVID-19 considerations specifically for clinical (sub-)populations including pediatric, stroke, addiction, and the elderly. Numerous case-examples across the world are described.

CONCLUSION

There is an evident, and in cases urgent, need to maintain NIBS operations through the COVID-19 pandemic, including anticipating future pandemic waves and addressing effects of COVID-19 on brain and mind. The proposed robust and structured strategy aims to address the current and anticipated future challenges while maintaining scientific rigor and managing risk.

Telemedicine for pediatric physiatry: How social distancing can bring physicians and families closer together

The coronavirus (COVID-19) pandemic triggered wide scale implementation of telemedicine in the United States. The government response, Coronavirus Aid, Relief, and Economic Security (CARES) Act, permitted loosening of existing restrictions on telemedicine enabling its rapid incorporation into the delivery of medical care for children and adults. Prior to COVID-19, few pediatric physiatrists had opportunities to access high fidelity telemedicine platforms to provide health care for patients with special needs, mobility impairments, developmental delays, neuromuscular disorders or other complex medical conditions. This literature review will explore how telemedicine can optimize health care delivery options for pediatric physiatrists in various inpatient and outpatient settings such as consultations, acute inpatient units, outpatient clinics and long-term care facilities. Detailed analysis of the current research in telemedicine applications as well as a critical review of the limitations and barriers for its use offers a plethora of opportunities for enhancement of continuity and coordination of care. Telemedicine may decrease healthcare disparities and increase access of care for children with special needs. Additional research is needed to assess the efficacy of telemedicine when addressing complex medical conditions in children.