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

'It's not as good as the face-to-face contact': A sociomaterialist analysis of the use of virtual care among Canadian gay, bisexual and queer men during the COVID-19 pandemic

The COVID-19 pandemic led to the widespread adoption of virtual care-the use of communication technologies to receive health care at home. We explored the differential impacts of the rapid transition to virtual care during the COVID-19 pandemic on health-care access and delivery for gay, bisexual and queer men (GBQM), a population that disproportionately experiences sexual and mental health disparities in Canada. Adopting a sociomaterial theoretical perspective, we analysed 93 semi-structured interviews with GBQM (n = 93) in Montreal, Toronto and Vancouver, Canada, conducted between November 2020 and February 2021 (n = 42) and June-October 2021 (n = 51). We focused on explicating how the dynamic relations of humans and non-humans in everyday virtual care practices have opened or foreclosed different care capacities for GBQM. Our analysis revealed that the rapid expansion and implementation of virtual care during the COVID-19 pandemic enacted disruptions and challenges while providing benefits to health-care access among some GBQM. Further, virtual care required participants to change their sociomaterial practices to receive health care effectively, including learning new ways of communicating with providers. Our sociomaterial analysis provides a framework that helps identify what works and what needs to be improved when delivering virtual care to meet the health needs of GBQM and other diverse populations.

Virtual family-centered rounds: a quality improvement initiative to adapt inpatient care during COVID-19 using a human-centred participatory design approach

BACKGROUND

Family-centered rounds (FCR) are fundamental to pediatric inpatient care. During the COVID-19 pandemic, we aimed to design and implement a virtual family-centered rounds (vFCR) process that allowed continuation of inpatient rounds while following physical distancing guidelines and preserving personal protective equipment (PPE).

METHODS

A multidisciplinary team developed the vFCR process using a participatory design approach. From April through July 2020, quality improvement methods were used to iteratively evaluate and improve the process. Outcome measures included satisfaction, perceived effectiveness, and perceived usefulness of vFCR. Data were collected via questionnaire distributed to patients, families, staff and medical staff, and analyzed using descriptive statistics and content analysis. Virtual auditors monitored time per patient round and transition time between patients as balancing measures.

RESULTS

Seventy-four percent (51/69) of health care providers surveyed and 79% (26/33) of patients and families were satisfied or very satisfied with vFCR. Eighty eight percent (61/69) of health care providers and 88% (29/33) of patients and families felt vFCR were useful. Audits revealed an average vFCR duration of 8.4 min (SD = 3.9) for a single patient round and transition time between patients averaged 2.9 min (SD = 2.6).

CONCLUSION

Virtual family-centered rounds are an acceptable alternative to in-person FCR in a pandemic scenario, yielding high levels of stakeholder satisfaction and support. We believe vFCR are a useful method to support inpatient rounds, physical distancing, and preservation of PPE that may also be valuable beyond the pandemic. A rigorous process evaluation of vFCR is underway.

Gaps in our knowledge of managing inpatient dysglycaemia and diabetes in non-critically ill adults: A call for further research

AIMS

To describe the gaps in knowledge for the care of people in the hospital who have dysglycaemia or diabetes.

METHODS

A review of the current literature and the authors' knowledge of the subject.

RESULTS

Recent data has suggested that the prevalence of hospitalised people with diabetes is approximately three times the prevalence in the general population and is growing annually. A wealth of observational data over the last 4 decades has shown that people with hyperglycaemia, severe hypoglycaemia or diabetes, all experience more harm whilst in the hospital than those who do not have the condition. This often equates to a longer length of stay and thus higher costs. To date, the proportion of federal funding aimed at addressing the harms that people with dysglycaemia experience in hospitals has been very small compared to outpatient studies. National organisations, such as the Joint British Diabetes Societies for Inpatient Care, the American Diabetes Association and the Endocrine Society have produced guidelines or consensus statements on the management of various aspects of inpatient care. However, whilst a lot of these have been based on evidence, much remains based on expert opinion and thus low-quality evidence.

CONCLUSIONS

This review highlights that inpatient diabetes is an underfunded and under-researched area.

"You're Socially Distant and Trying Not to Be Emotionally Distant." Physicians' Perspectives of Communication and Therapeutic Relationships in the ICU During the COVID-19 Pandemic: A Qualitative Study

To: 1) characterize how COVID-19-related policies influence patient-clinician communication and relationships in the ICU, with attention to race and ethnicity as factors and 2) identify interventions that may facilitate patient-clinician communication.

DESIGN

We conducted a qualitative study between September 2020 and February 2021 that explored facilitators and barriers to patient-clinician communication and the formation of therapeutic relationships. We used thematic analysis to develop findings describing patient-communication and therapeutic relationships within the ICU early in the COVID-19 pandemic.

SETTING

We purposively selected hospital dyads from regions in the United States that experienced early and/or large surges of patients hospitalized with COVID-19.

SUBJECTS

We recruited a national sample of ICU physicians from Veteran Affairs (VA) Health Care Systems and their associated academic affiliate hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-four intensivists from seven VA hospitals and six academic-affiliate hospitals participated. Intensivists noted the disproportionate impact of the pandemic on among people holding minoritized racial and ethnic identities, describing how language barriers and restrictive visitation policies exacerbated institutional mistrust and compromised physicians' ability to develop therapeutic relationships. We also identified several perceived influences on patient-clinician communication and the establishment of therapeutic relationships. Barriers included physicians' fear of becoming infected with COVID-19 and use of personal protective equipment, which created obstacles to effective physical and verbal interactions. Facilitators included the presence of on-site interpreters, use of web-based technology to interact with family members outside the ICU, and designation of a care team member or specialist service to provide routine updates to families.

CONCLUSIONS

The COVID-19 pandemic has threatened patient-clinician communication and the development of therapeutic relationships in the ICU, particularly among people holding minoritized racial and ethnic identities and their families. We identified several facilitators to improve patient-clinician communication as perceived by intensivists that may help improve trust and foster therapeutic alliances.

Evaluating clinician‐led quality improvement initiatives: A system‐wide embedded research partnership at Stanford Medicine

Introduction

Many healthcare delivery systems have developed clinician‐led quality improvement (QI) initiatives but fewer have also developed in‐house evaluation units. Engagement between the two entities creates unique opportunities. Stanford Medicine funded a collaboration between their Improvement Capability Development Program (ICDP), which coordinates and incentivizes clinician‐led QI efforts, and the Evaluation Sciences Unit (ESU), a multidisciplinary group of embedded researchers with expertise in implementation and evaluation sciences.

Aim

To describe the ICDP‐ESU partnership and report key learnings from the first 2 y of operation September 2019 to August 2021.

Methods

Department‐level physician and operational QI leaders were offered an ESU consultation to workshop design, methods, and overall scope of their annual QI projects. A steering committee of high‐level stakeholders from operational, clinical, and research perspectives subsequently selected three projects for in‐depth partnered evaluation with the ESU based on evaluability, importance to the health system, and broader relevance. Selected project teams met regularly with the ESU to develop mixed methods evaluations informed by relevant implementation science frameworks, while aligning the evaluation approach with the clinical teams' QI goals.

Results

Sixty and 62 ICDP projects were initiated during the 2 cycles, respectively, across 18 departments, of which ESU consulted with 15 (83%). Within each annual cycle, evaluators made actionable, summative findings rapidly available to partners to inform ongoing improvement. Other reported benefits of the partnership included rapid adaptation to COVID‐19 needs, expanded clinician evaluation skills, external knowledge dissemination through scholarship, and health system‐wide knowledge exchange. Ongoing considerations for improving the collaboration included the need for multi‐year support to enable nimble response to dynamic health system needs and timely data access.

Conclusion

Presence of embedded evaluation partners in the enterprise‐wide QI program supported identification of analogous endeavors (eg, telemedicine adoption) and cross‐cutting lessons across QI efforts, clinician capacity building, and knowledge dissemination through scholarship.

Telerehabilitation: A Practical Remote Alternative for Coaching and Monitoring Physical Kinetic Therapy in Patients with Mild and Moderate Disabling Parkinson's Disease during the COVID-19 Pandemic

Background

The COVID-19 pandemic imposed social/physical distancing, lockdown measures, and forced reorientation of the rehabilitation programs for people with Parkinson's disease (PD). Epidemiologic safety measures boosted remote exercise-based treatment.

Objectives

Remote delivery of rehabilitation care services is not typically used in our department. Therefore, this study aimed to assess and implement a telehealth physical rehabilitation program tailored for outpatients with idiopathic PD and slight or medium functional limitations.

Methods

A prospective study was performed on a group of outpatients with idiopathic PD, selected from the database of the neurorehabilitation clinic of the Emergency Teaching Hospital "Bagdasar-Arseni." We studied 17 patients (5 women and 12 men), aged between 54-70 years (average 65.9 ± 4.87), with a disease history of 7.3 ± 3.6 (years), with mild or moderate disabling clinical forms, quantified by an average Hoehn and Yahr score of 2.3 ± 0.35 (limits 1.5-3). All patients underwent pharmacologic treatment with unchanged doses throughout the study. No patients had disabling osteoarticular problems (all could walk independently) and had no significant psycho-cognitive dysfunction. Patients were supervised and coached online in tandem by the therapist and physician. In addition, a family member assisted and supervised the patient's performance and coordinated the technical electronic procedures. Walking biodynamics was assessed by timing "6-meters walking" and "Get up and walk 3 meters" (TUG) tests. Each person attended ten sessions of motor telerehabilitation procedures (2 per week) lasting 50 minutes each during social distancing (October-December 2021).

Results

None of the patients was at increased risk of falling. They all improved their locomotor performance, reflected in a significant decrease in TUG duration (the initial average time improved from 13.50 seconds to 10.57). The telerehabilitation program also significantly improved the average walking speed (initially, 44.5 cm/sec and finally, it raised to 56.8 cm/sec). Discussion. The TUG and "6-meters walking" tests are helpful tools for a global biodynamic remote assessment of PD patients. Limitations of the study: a small group of selected patients, restrictive working conditions (due to epidemiological social/physical restrictions and no direct physiotherapist-patient contact), and need for supervision by an attendant to assist the subject and perform the audio-video transmission. Further studies are necessary to identify the optimal web-based model of care and boost the implementation of this modern neurorehabilitation concept.

Conclusions

Telemedicine turned the virtual space into a new reality and may compensate for the restrictions imposed on face-to-face meetings in pandemic conditions. Moreover, with modern telecommunication techniques, a regular and individualized physical kinetic rehabilitation program can be performed even in pandemic conditions. Remote delivery of kinetic motor programs was appropriate for selected groups of PD patients.

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.