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Kandasamy S, Rameshkumar R, Sangaralingam T, Krishnamoorthy N, Shankar NCG, Vijayakumar V, Sridharan B. High-flow nasal oxygen in infants and children for early respiratory management of pneumonia-induced acute hypoxemic respiratory failure: the CENTURI randomized clinical trial. INTENSIVE CARE MEDICINE. PAEDIATRIC AND NEONATAL 2024; 2:15. [PMID: 38567201 PMCID: PMC10982089 DOI: 10.1007/s44253-024-00031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/01/2024] [Indexed: 04/04/2024]
Abstract
Objective To compare the effectiveness of early high-flow nasal cannula (HFNC) and low-flow oxygen support (LFOS) in children under 5 years with acute hypoxemic respiratory failure (AHRF) due to severe community-acquired pneumonia in low-middle-income countries. Methods An open-label randomized clinical trial enrolled children aged 2-59 months with AHRF due to severe community-acquired pneumonia and randomized into HFNC and LFOS. In the LFOS group, the patient received cold wall oxygen humidified by bubbling through sterile water administered through simple nasal prongs at a fixed flow rate of 2 L/min. In the HFNC group, the patient received humidified, heated (37 °C), high-flow oxygen at a flow rate assigned based on weight range, with a titratable oxygen fraction. The primary outcome was treatment failure in 72 h (escalating the respiratory support method using any modality other than primary intervention). Results Data was analyzed intention-to-treat (HFNC = 124; LFOS = 120). Median (IQR) age was 12 (6-20) and 11 (6-27) months, respectively. Treatment failure occurred in a significantly lower proportion in the HFNC group (7.3%, n = 9/124) as compared to the LFOS group (20%, n = 24/120) (relative risk = 0.36, 95% CI 0.18 to 0.75; p = 0.004; adjusted hazard ratio 0.34, 95% CI 0.16 to 0.73; p = 0.006). The intubation rate was significantly lower in the HFNC group (7.3%, n = 9/124 vs. 16.7%, n = 20/120; relative risk = 0.44, 95% CI 0.21 to 0.92, p = 0.023). There were no significant differences noted in other secondary outcomes. No mortality occurred. Conclusion High-flow nasal cannula oxygen therapy used as early respiratory support in children under 5 years with acute hypoxemic respiratory failure due to severe community-acquired pneumonia was associated with significantly lower treatment failure compared with standard low-flow oxygen support. Trial registration CTRI/2016/04/006788. Registered 01 April 2016, https://ctri.nic.in/Clinicaltrials/advsearch.php. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-024-00031-8.
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Affiliation(s)
- Sasidaran Kandasamy
- Advanced Pediatric Critical Care Centre, Pediatric Acute Care Education & Research (PACER) Unit, Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006 India
- Present Address: Pediatric Critical Care, Mediclinic City Hospital, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates
| | | | | | - N. C. Gowri Shankar
- Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Vimalraj Vijayakumar
- Advanced Pediatric Critical Care Centre, Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Balaji Sridharan
- Pediatric Acute Care Education and Research (PACER) Unit, Department of Pediatrics, Mehta Multi-Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
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2
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Edwards G, O'Shea JE. Is telemedicine suitable for remotely supporting non-tertiary units in providing emergency care to unwell newborns? Arch Dis Child 2023; 109:5-10. [PMID: 37438088 DOI: 10.1136/archdischild-2022-325057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/08/2023] [Indexed: 07/14/2023]
Abstract
Although the majority of term infants will breathe spontaneously at birth, the requirement for advanced resuscitation can be unpredictable, as can the precipitous delivery of an extremely preterm infant in a non-tertiary neonatal unit. Infants born in hospitals without a tertiary neonatal intensive care unit have a higher mortality which is a disparity that has been difficult to resolve.Telemedicine, the use of videoconferencing software to connect those at the scene of a resuscitation to a remote clinician, can allow for real-time two-way communication between a local unit and a tertiary neonatal specialist. It has been present for some time in neonatology to provide secure video messaging with families and its use in neonatal acute care and resuscitation has been growing in recent years.We sought to perform a review of the current evidence available on the use of telemedicine in neonatal resuscitation. Studies demonstrate improved quality of resuscitation, improved adherence to resuscitation guidelines and positive experiences reported by local and tertiary teams. Suitable technology needs to be available to establish a rapid and secure video connection, as does adequate availability of experienced neonatologists to provide remote guidance. Telemedicine is an exciting and emerging tool which is being developed as a standard of care in units which have piloted it.
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Affiliation(s)
- Gemma Edwards
- Neonatal Unit, Princess Royal Maternity Hospital, Glasgow, UK
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3
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Larribau R, Healey B, Chappuis VN, Boussard D, Guiche F, Herren T, Gartner BA, Suppan L. Contribution of Live Video to Physicians' Remote Assessment of Suspected COVID-19 Patients in an Emergency Medical Communication Centre: A Retrospective Study and Web-Based Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3307. [PMID: 36834002 PMCID: PMC9959421 DOI: 10.3390/ijerph20043307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
The COVID-19 pandemic had a major impact on emergency medical communication centres (EMCC). A live video facility was made available to second-line physicians in an EMCC with a first-line paramedic to receive emergency calls. The objective of this study was to measure the contribution of live video to remote medical triage. The single-centre retrospective study included all telephone assessments of patients with suspected COVID-19 symptoms from 01.04.2020 to 30.04.2021 in Geneva, Switzerland. The organisation of the EMCC and the characteristics of patients who called the two emergency lines (official emergency number and COVID-19 number) with suspected COVID-19 symptoms were described. A prospective web-based survey of physicians was conducted during the same period to measure the indications, limitations and impact of live video on their decisions. A total of 8957 patients were included, and 2157 (48.0%) of the 4493 patients assessed on the official emergency number had dyspnoea, 4045 (90.6%) of 4464 patients assessed on the COVID-19 number had flu-like symptoms and 1798 (20.1%) patients were reassessed remotely by a physician, including 405 (22.5%) with live video, successfully in 315 (77.8%) attempts. The web-based survey (107 forms) showed that physicians used live video to assess mainly the breathing (81.3%) and general condition (78.5%) of patients. They felt that their decision was modified in 75.7% (n = 81) of cases and caught 7 (7.7%) patients in a life-threatening emergency. Medical triage decisions for suspected COVID-19 patients are strongly influenced by the use of live video.
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Affiliation(s)
- Robert Larribau
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH 1211 Geneva, Switzerland
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4
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Lu AD, Veet CA, Aljundi O, Whitaker E, Smith WB, Smith JE. A Systematic Review of Physical Examination Components Adapted for Telemedicine. Telemed J E Health 2022; 28:1764-1785. [PMID: 35363573 DOI: 10.1089/tmj.2021.0602] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: The COVID-19 pandemic ushered in a rapid, transformative adoption of telemedicine to maintain patient access to care. As clinicians made the shift from in-person to virtual practice, they faced a paucity of established and reliable clinical examination standards for virtual care settings. In this systematic review, we summarize the accuracy and reliability of virtual assessments compared with traditional in-person examination tools. Methods: We searched PubMed, Embase, Web of Science, and CINAHL from inception through September 2019 and included additional studies from handsearching of reference lists. We included studies that compared synchronous video (except allowing for audio-only modality for cardiopulmonary exams) with in-person clinical assessments of patients in various settings. We excluded behavioral health and dermatological assessments. Two investigators abstracted data using a predefined protocol. Results: A total of 64 studies were included and categorized into 5 clinical domains: neurological (N = 41), HEENT (head, eyes, ears, nose, and throat; N = 5), cardiopulmonary (N = 5), musculoskeletal (N = 8), and assessment of critically ill patients (N = 5). The cognitive assessment within the neurological exam was by far the most studied (N = 19) with the Mini-Mental Status Exam found to be highly reliable in multiple settings. Most studies showed relatively good reliability of the virtual assessment, although sample sizes were often small (<50 participants). Conclusions: Overall, virtual assessments performed similarly to in-person exam components for diagnostic accuracy but had a wide range of interrater reliability. The high heterogeneity in population, setting, and outcomes reported across studies render it difficult to draw broad conclusions on the most effective exam components to adopt into clinical practice. Further work is needed to identify virtual exam components that improve diagnostic accuracy.
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Affiliation(s)
- Amy D Lu
- Division of General Internal Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA.,Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Clark A Veet
- Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Omar Aljundi
- Palo Alto Medical Foundation Medical Group, San Carlos, California, USA
| | - Evans Whitaker
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - William B Smith
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Janeen E Smith
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Florin TA, Lorenz D, Ramgopal S, Burns R, Rainwater D, Benedetti J, Ruddy RM, Gerber JS, Kuppermann N. Feasibility and reliability of telemedicine examinations for respiratory distress in children: A pilot study. J Telemed Telecare 2022:1357633X221125833. [PMID: 36168273 DOI: 10.1177/1357633x221125833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Respiratory disorders are a leading cause of acute care visits by children. Data establishing the reliability of telemedicine in evaluating children with respiratory concerns are limited. The overall objective of this pilot study was to evaluate the use of telemedicine to evaluate children with respiratory concerns. We performed a pilot prospective cohort study of children 12 to 71 months old presenting to the emergency department (ED) with lower respiratory tract signs and symptoms. Three examinations were performed simultaneously-one by the ED clinician with the patient, one by a remote ED clinician using telemedicine, and one by the child's parent. We evaluated measures of agreement between (a) the local and remote clinicians, (b) the local clinician and the parent, and (c) the parent and the remote clinician. Twenty-eight patients were enrolled (84 paired examinations). Except for heart rate, all examination findings evaluated (general appearance, capillary refill time, grunting, nasal flaring, shortness of breath, retractions, impression of respiratory distress, respiratory rate, and temperature) had acceptable or excellent agreement between raters. In this pilot study, we found that telemedicine respiratory examinations of young children are feasible and reliable, using readily available platforms and equipment.
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Affiliation(s)
- Todd A Florin
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago; Department of Pediatrics, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, 5170University of Louisville, Louisville, KY, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago; Department of Pediatrics, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rebecca Burns
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago; Department of Pediatrics, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel Rainwater
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago; Department of Pediatrics, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jillian Benedetti
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago; Department of Pediatrics, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard M Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Emergency Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey S Gerber
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine; Division of Infectious Diseases, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine and UC Davis Health, Sacramento, CA, USA
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6
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Severini RDSG, Oliveira PCD, Couto TB, Simon Junior H, Andrade APMD, Nanbu DY, Farhat SCL, Schvartsman C. Fast, cheap and feasible: Implementation of pediatric telemedicine in a public hospital during the Covid-19 pandemic. J Pediatr (Rio J) 2022; 98:183-189. [PMID: 34181889 PMCID: PMC8196314 DOI: 10.1016/j.jped.2021.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Rafael da Silva Giannasi Severini
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Pedro Carpini de Oliveira
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Thomaz Bittencourt Couto
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Hany Simon Junior
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Anarella Penha Meirelles de Andrade
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Danilo Yamamoto Nanbu
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sylvia C L Farhat
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Cláudio Schvartsman
- Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil; Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
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7
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Ponnapalli A, Khare Y, Dominic C, Ganesh S, Bhalla G, Gokani SA. Remote risk-stratification of dyspnoea in acute respiratory disorders: a systematic review of the literature. J R Coll Physicians Edinb 2021; 51:221-229. [PMID: 34528608 DOI: 10.4997/jrcpe.2021.304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Telephone and video-based triage of dyspnoea has become commonplace and clinicians are faced with a new challenge in risk stratification of patients with dyspnoea due to suspected COVID-19. This review aimed to identify existing remote assessment modalities for acute dyspnoea which can be applied during pandemics. METHODS We conducted a systematic search of Medline, Embase, the Cochrane Library and medRxiv for studies of remote assessment of dyspnoea [PROSPERO ID: CRD42020202292]. A total of 3014 abstracts were screened independently by two reviewers and 32 studies were progressed to full text screening. RESULTS Five studies met the inclusion criteria. Commonly assessed clinical features included respiratory rate, work of breathing, counting time and mental status. All studies found remote triage modalities to be appropriate for detecting severe respiratory distress or the need for emergency level care. CONCLUSION Evidence-based tools to remotely assess dyspnoea will reduce resource strain during current and future pandemics.
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Affiliation(s)
| | - Yuti Khare
- St George's University of London, London. UK
| | | | | | | | - Shyam Ajay Gokani
- Research Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK,
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8
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Mosnaim G, Safioti G, Brown R, DePietro M, Szefler SJ, Lang DM, Portnoy JM, Bukstein DA, Bacharier LB, Merchant RK. Digital Health Technology in Asthma: A Comprehensive Scoping Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2377-2398. [PMID: 33652136 DOI: 10.1016/j.jaip.2021.02.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND A variety of digital intervention approaches have been investigated for asthma therapy during the past decade, with different levels of interactivity and personalization and a range of impacts on different outcome measurements. OBJECTIVE To assess the effectiveness of digital interventions in asthma with regard to acceptability and outcomes and evaluate the potential of digital initiatives for monitoring or treating patients with asthma. METHODS We evaluated digital interventions using a scoping review methodology through a literature search and review. Of 871 articles identified, 121 were evaluated to explore intervention characteristics, the perception and acceptability of digital interventions to patients and physicians, and effects on asthma outcomes. Interventions were categorized by their level of interactivity with the patient. RESULTS Interventions featuring non-individualized content sent to patients appeared capable of promoting improved adherence to inhaled corticosteroids, but with no identified improvement in asthma burden; and data-gathering interventions appeared to have little effect on adherence or asthma burden. Evidence of improvement in both adherence and patients' impairment due to asthma were seen only with interactive interventions involving two-way responsive patient communication. Digital interventions were generally positively perceived by patients and physicians. Implementation was considered feasible, with certain preferences for design and features important to drive use. CONCLUSIONS Digital health interventions show substantial promise for asthma disease monitoring and personalization of treatment. To be successful, future interventions will need to include both inhaler device and software elements, combining accurate measurement of clinical parameters with careful consideration of ease of use, personalization, and patient engagement aspects.
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Affiliation(s)
- Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, North Shore University Health System, Evanston, Ill
| | | | - Randall Brown
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa
| | - Michael DePietro
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa.
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jay M Portnoy
- Pediatric Allergy and Immunology, Children's Mercy Hospital, Kansas City School of Medicine, Kansas City, Mo
| | - Don A Bukstein
- Allergy, Asthma and Sinus Center, Milwaukee, Greenfield, Wis
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tenn
| | - Rajan K Merchant
- Woodland Clinic Medical Group, Allergy Department, Dignity Health, Woodland, Calif
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9
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Turer RW, Jones I, Rosenbloom ST, Slovis C, Ward MJ. Electronic personal protective equipment: A strategy to protect emergency department providers in the age of COVID-19. J Am Med Inform Assoc 2020; 27:967-971. [PMID: 32240303 PMCID: PMC7184500 DOI: 10.1093/jamia/ocaa048] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 11/12/2022] Open
Abstract
Emergent policy changes related to telemedicine and the Emergency Medical Treatment and Labor Act during the novel coronavirus disease 2019 (COVID-19) pandemic have created opportunities for technology-based clinical evaluation, which serves to conserve personal protective equipment (PPE) and protect emergency providers. We define electronic PPE as an approach using telemedicine tools to perform electronic medical screening exams while satisfying the Emergency Medical Treatment and Labor Act. We discuss the safety, legal, and technical factors necessary for implementing such a pathway. This approach has the potential to conserve PPE and protect providers while maintaining safe standards for medical screening exams in the emergency department for low-risk patients in whom COVID-19 is suspected.
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Affiliation(s)
- Robert W Turer
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Emergency Medicine, Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee, USA
| | - Ian Jones
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Corey Slovis
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Metro Nashville Fire Department, Nashville, Tennessee, USA.,Department of Public Safety, Nashville International Airport, Nashville, Tennessee, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Emergency Medicine, Tennessee Valley Healthcare System VA Medical Center, Nashville, Tennessee, USA
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10
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Penninga L, Lorentzen AK, Davis C. A Telemedicine Case Series for Acute Medical Emergencies in Greenland: A Model for Austere Environments. Telemed J E Health 2019; 26:1066-1070. [PMID: 31804895 DOI: 10.1089/tmj.2019.0123] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Greenland is a vast country, with immense geographical distances and often extreme weather conditions. Specialized health care is limited to larger cities, and qualified medical care is not always immediately available in rural areas. Telemedicine infrastructure is available throughout the country. Purpose: The purpose of this study was to identify the role of telemedicine in the diagnosis and treatment of acute medical emergencies in remote settlements. Materials and Methods: All medical emergencies were screened from 2015 to 2016 in remote settlements of the Avannaa Health Region in Northwest Greenland, and cases in which telemedicine was utilized were identified. Results: Three illustrative cases were identified. Diagnoses were severe asthma, bilateral pneumonia, and heart failure. All three patients were accurately diagnosed through a telemedical consultation, and early treatment was initiated. In two out of three patients, acute medical evacuation by air ambulance was avoided, and the third patient was stabilized by the time an air ambulance arrived. Conclusions: Telemedicine allows for the accurate diagnosis of acute medical emergencies in remote settlements of Greenland and facilitates timely initiation of treatment. This may reduce morbidity and mortality of acute medical illness. In addition, telemedicine may aid in the clinical decision-making on whether or not to arrange for medical evacuation. Avoiding unnecessary medical evacuations reduces cost and risk to air ambulance crews. In addition, telemedicine allows for close monitoring of the patient until the air ambulance arrives. Telemedicine also ensures diagnostic and treatment options when medical evacuation is impossible due to extreme weather conditions. From a global perspective, telemedicine may increase the availability and quality of health care in remote areas and reduce health inequalities between remote and urban areas.
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Affiliation(s)
- Luit Penninga
- Avannaa Healthcare Region, Ilulissat Regional Hospital, Ilulissat, Greenland
| | | | - Christopher Davis
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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11
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A Qualitative Analysis of General Emergency Medicine Providers' Perceptions on Pediatric Emergency Telemedicine. Pediatr Emerg Care 2019; 35:856-861. [PMID: 28225376 DOI: 10.1097/pec.0000000000001067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Most children in the United States are evaluated in general emergency departments (ED), which are staffed by practitioners who care for both adults and children and may have limited pediatric resources. The application of telemedicine in pediatrics is growing and has been shown to be effective in outpatient as well as critical care settings. Telemedicine has the potential to address disparities in access to pediatric emergency care. The objective of this study was to explore experiences of general ED providers with telemedicine and their perception about a potential video telemedicine program with pediatric ED providers. METHODS Using qualitative methods, a purposeful sample of general ED providers (attending physicians and physician assistants) in 3 Connecticut hospitals participated in audio-recorded semistructured interviews. In line with grounded theory, 3 researchers independently coded transcripts, collectively refined codes, and created themes. Data collection and analysis continued in an iterative manner, past the point of theoretical saturation. RESULTS Eighteen general ED providers were interviewed. Three themes were identified: (a) familiarity with use in adult stroke patients but limited practical experience with telemedicine; (b) potential uses for pediatric telemedicine (guiding pediatric differential diagnosis and management, visual diagnosis, alleviating provider fears, low-frequency high-stakes events, determining disposition, assessing level of illness, and access to subspecialty consultation); and (c) limitations of telemedicine (infrequent need and implementation barriers). CONCLUSIONS General ED providers identified 7 specific potential uses of pediatric emergency video telemedicine. However, they also identified several limitations of telemedicine in caring for pediatric emergency patients. Further studies after implementation of telemedicine program and comparing provider perceptions with actual practice may be helpful. Furthermore, studies on telemedicine's effect on patient-related outcomes and studies on cost-effectiveness might be necessary before the widespread implementation of a telemedicine program.
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Abstract
The use of telemedicine (TM) to deliver health care has been growing throughout the United States and internationally through asynchronous and synchronous technology. It has proven to be an effective way of delivering health care at a distance. There are multiple ways that a practice can offer these services, from direct-to-consumer to consultations in ambulatory or inpatient services. TM can be used to deliver care in homes, schools, and virtually anywhere that a patient and provider can access technology. For rural communities, emergency departments and inpatient specialty consults that were not available previously are now routine. TM also has been proven to be effective in decreasing costs to patients and increasing access in pediatrics while providing high degrees of satisfaction among patients and providers. [Pediatr Ann. 2019;48(12):e479-e484.].
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Tomines A. Pediatric Telehealth: Approaches by Specialty and Implications for General Pediatric Care. Adv Pediatr 2019; 66:55-85. [PMID: 31230700 DOI: 10.1016/j.yapd.2019.04.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alan Tomines
- Department of Pediatrics, UCLA Geffen School of Medicine, Los Angeles, CA, USA; Enterprise Information Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Harbor-UCLA Medical Center, Torrance, CA, USA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
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Abstract
PURPOSE OF REVIEW Access to care for children requiring pediatric general or specialty surgery or trauma care who live in rural areas remains a challenge in the United States. RECENT FINDINGS The expertise of specialists in tertiary centers can be extended to rural and underserved areas using telemedicine. There are challenges to making these resources available that need to be methodically approached to facilitate appropriate relationships between hospitals and providers. Programs, such as the National Pediatric Readiness Project and the HRSA Emergency Medical Services for Children Program enhance the capability of the emergency care system to function optimally, keep children at the home hospital if resources are available, facilitate transfer of patients and relationship building, and develop necessary transfer protocols and guidelines between hospitals. SUMMARY Telehealth services have the potential to enhance the reach of tertiary care for children in rural and underserved areas where surgical and trauma specialty care is not readily available, particularly when used to augment the objectives of national programs.
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Umoren RA, Gray MM, Schooley N, Billimoria Z, Smith KM, Sawyer TL. Effect of Video-based Telemedicine on Transport Management of Simulated Newborns. Air Med J 2018; 37:317-320. [PMID: 30322635 DOI: 10.1016/j.amj.2018.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/18/2018] [Accepted: 05/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Video-based telemedicine is a reliable tool to assess the severity of respiratory distress in children, increasing the appropriateness of triage and disposition for acutely ill children. Telemedicine simulations may identify patterns in regional transport management and influence attitudes toward telemedicine. METHODS The objective was to determine the effect of videos on simulated neonatal transport care compared with telephone management. Participants received information about a newborn requiring respiratory support by an audio recording and made management decisions based on only that information. Four videos of varying respiratory distress on respiratory support were then shown. After each video, participants again rated patient stability and recommended management. RESULTS Sixteen neonatologists completed the cases. Compared with the telephone call, there were significant differences in ratings of patient stability and confidence in their assessment after watching the videos. When given the same information, participants were less likely to recommend intubation after viewing an infant in mild respiratory distress than after the telephone call (P < .05). Most participants felt that viewing the videos was helpful in formulating their assessment and plan. CONCLUSION Video-based telemedicine simulations influenced the perceived stability of neonates during transport. Viewing the patient increased provider confidence in their assessment and recommendations.
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Affiliation(s)
- Rachel A Umoren
- Neonatal Education and Simulation-Based Training Program, University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - Megan M Gray
- Neonatal Education and Simulation-Based Training Program, University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | | | - Zeenia Billimoria
- Neonatal Education and Simulation-Based Training Program, University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | | | - Taylor L Sawyer
- Neonatal Education and Simulation-Based Training Program, University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
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The Current State of the Pediatric Emergency Medicine Workforce and Innovations to Improve Pediatric Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Butler L, Whitfill T, Wong AH, Gawel M, Crispino L, Auerbach M. The Impact of Telemedicine on Teamwork and Workload in Pediatric Resuscitation: A Simulation-Based, Randomized Controlled Study. Telemed J E Health 2018; 25:205-212. [PMID: 29957150 DOI: 10.1089/tmj.2018.0017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described. OBJECTIVES To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation. METHODS Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively. RESULTS Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020). CONCLUSIONS In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.
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Affiliation(s)
- Lucas Butler
- 1 Department of Emergency Medicine, University of Washington, Seattle, Washington.,2 Department of Pediatrics, Section of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Travis Whitfill
- 2 Department of Pediatrics, Section of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Ambrose H Wong
- 3 Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marcie Gawel
- 4 Department of Community Outreach, Yale-New Haven Hospital, New Haven, Connecticut
| | - Lauren Crispino
- 2 Department of Pediatrics, Section of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Marc Auerbach
- 2 Department of Pediatrics, Section of Emergency Medicine, Yale University, New Haven, Connecticut.,3 Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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Urgent Care as Intermediary Care: How Inbound and Outbound Transport Can Enhance Care of Community-Based Pediatric Emergencies. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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