Development and evaluation of a virtual reality training for emergency treatment of shortness of breath based on frameworks for serious games.

Background: Virtual reality (VR) can offer an innovative approach to providing training in emergency situations, especially in times of COVID-19. There is no risk of infection, and the procedure is scalable and resource-efficient. Nevertheless, the challenges and problems that can arise in the development of VR training are often unclear or underestimated. As an example, we present the evaluation of the feasibility of development of a VR training session for the treatment of dyspnoea. This is based on frameworks for serious games, and provides lessons learned. We evaluate the VR training session with respect to usability, satisfaction, as well as perceived effectiveness and workload of participants. Methods: The VR training was developed using the established framework (Steps 1-4) for serious games of Verschueren et al. and Nicholson's RECIPE elements for meaningful gamification. Primary validation (Step 4) was performed at the University of Bern, Switzerland, in a pilot study without control group, with a convenience sample of medical students (n=16) and established measurement tools. Results: The theoretical frameworks permitted guided development of the VR training session. Validation gave a median System Usability Scale of 80 (IQR 77.5-85); for the User Satisfaction Evaluation Questionnaire, the median score was 27 (IQR 26-28). After the VR training, there was a significant gain in the participants' confidence in treating a dyspnoeic patient (median pre-training 2 (IQR 2-3) vs. post-training 3 (IQR 3-3), p=0.016).Lessons learned include the need for involving medical experts, medical educators and technical experts at an equivalent level during the entire development process. Peer-teaching guidance for VR training was feasible. Conclusion: The proposed frameworks can be valuable tools to guide the development and validation of scientifically founded VR training. The new VR training session is easy and satisfying to use and is effective - and is almost without motion sickness.

Telehealth use by walk-in patients who subsequently visited an academic emergency department: a repeated cross-sectional study during the COVID-19 summer 2021.

AIM OF THE STUDY: During the COVID-19 pandemic, telehealth use increased worldwide in a variety of medical specialities and reached new population groups. A baseline survey of telehealth use prior to admission to the emergency department (ED) conducted before COVID-19 concluded that predominantly well-educated men used telehealth. It is unclear how COVID-19 changed the use of telehealth in Swiss emergency patients. We therefore aimed to investigate (i) the frequency of telehealth use during the pandemic, and (ii) how the pandemic has influenced telehealth use and users. MATERIALS AND METHODS: A repeated cross-sectional study was conducted among ED walk-in patients at a tertiary university hospital in Switzerland. The study took place one and a half years after the first confirmed COVID-19 case, during 30 shifts from 8 to 29 July 2021 and compared with the baseline survey conducted in 2019. Eligible patients were questioned about their use of, and attitudes to telehealth. RESULTS: A total of 1020 patients were screened for the COVID survey and 443 complete questionnaires were evaluated. A trend towards a general increase (+6.4%) in telehealth use was demonstrated (50.3%, n = 223 COVID survey vs 43.9%, n = 183 baseline survey; p = 0.058), with a shift to more female patients using telehealth in the COVID survey (female 54.9%, n = 124 vs 45.1%, n = 102; p = 0.052). During the pandemic, first use of telehealth was reported by 12.2% (n = 54) of patients, with a significant increase among patients with low educational status, and the latter patients often indicated that they did not plan to use telehealth after the pandemic. The perceived usefulness of telehealth and adherence to recommendations increased in the COVID survey compared with the baseline survey (adherence 90.3%, n = 149, vs 78.0%, n = 131; p = 0.002). CONCLUSION: We found a trend towards increased use of telehealth among Swiss ED patients. First-time users of telehealth were predominantly less educated and inclusion of these user groups may not be sustainable, as was indicated by the patients. COVID-19 led to greater adherence to telehealth recommendations and higher perceived usefulness. This could be due to the limited access to healthcare providers due to pandemic precautions. When offering telehealth, the needs of all patient groups must be considered, in order to ensure that telehealth provides the greatest benefit with lower barriers to use.

Identifying Policy Gaps in a COVID-19 Online Tool Using the Five-Factor Framework

Introduction: Worldwide health systems are being faced with unprecedented COVID-19-related challenges, ranging from the problems of a novel condition and a shortage of personal protective equipment to frequently changing medical guidelines. Many institutions were forced to innovate and many hospitals, as well as telehealth providers, set up online forward triage tools (OFTTs). Using an OFTT before visiting the emergency department or a doctor's practice became common practice. A policy can be defined as what an institution or government chooses to do or not to do. An OFTT, in this case, has become both a policy and a practice. Methods: The study was part of a broader multiphase sequential explanatory design. First, an online survey was carried out using a questionnaire to n = 176 patients who consented during OFTT usage. Descriptive analysis was carried out to identify who used the tool, for what purpose, and if the participant followed the recommendations. The quantitative results shaped the interview guide's development. Second, in-depth interviews were held with a purposeful sample of n = 19, selected from the OFTT users who had consented to a further qualitative study. The qualitative findings were meant to explain the quantitative results. Third, in-depth interviews were held with healthcare providers and authorities (n = 5) that were privy to the tool. Framework analysis was adopted using the five-factor framework as a lens with which to analyze the qualitative data only. Results: The five-factor framework proved useful in identifying gaps that affected the utility of the COVID-19 OFTT. The identified gaps could fit and be represented by five factors: primary, secondary, tertiary, and extraneous factors, along with a lack of systems thinking. Conclusion: A theory or framework provides a road map to systematically identify those factors affecting policy implementation. Knowing how and why policy practice gaps come about in a COVID-19 OFFT context facilitates better future OFTTs. The framework in this study, although developed in a universal health coverage (UHC) context in South Africa, proved useful in a telehealth context in Switzerland, in Europe. The importance of systems thinking in developing digital tools cannot be overemphasized.

Public health communication: Attitudes, experiences, and lessons learned from users of a COVID-19 digital triage tool for children

Background The pandemic has made public health communication even more daunting because acceptance and implementation of official guidelines and recommendations hinge on this. The situation becomes even more precarious when children are involved. Our child-specific COVID-19 online forward triage tool (OFTT) revealed some of the public health communication challenges. We aimed to explore attitudes, experiences, and challenges faced by OFTT users and their families, in regard to public health recommendations. Methods We selected key informants (n = 20) from a population of parents, teachers, guardians, as well as doctors who had used the child-specific COVID-19 OFTT and had consented to a further study. Videos rather than face-face interviews were held. Convenience and quota sampling were performed to include a variety of key informants. Interviews were recorded, transcribed verbatim, and analyzed for themes. Results Several themes emerged, namely;(1) definition and expectations of high-risk persons, (2) quarantine instructions and challenges, (3) blurred division of responsibility between authorities and parents, (4) a novel condition and the evolution of knowledge, (5) definition and implications of socioeconomic status, (6) new normal and societal divisions, and (7) the interconnectedness of these factors-systems thinking. Conclusion As the virus is evolving and circumstances are changing rapidly, the communication of public health to the different interest groups becomes, both an art and science, even more so when using a new technological communication channel: an OFTT. A myriad of interconnected factors seems to influence attitudes toward public health recommendations, which calls for systems thinking in public health communication.

The Utility of a Pediatric COVID-19 Online Forward Triage Tool in Switzerland

Background To offset the burden on the health system, hospitals set up telehealth interventions, such as online forward triage tools (OFTT). The website www.coronabambini.ch was developed to specifically address the needs of children and their families in Switzerland and to facilitate the decision to test, isolate, attend school, or access the health care system. Methods Video interviews were held with key informants (n = 20) from a population of parents, teachers, guardians, as well as doctors who had used the child-specific COVID-19 OFTT and had consented to a further study. Convenience and quota sampling were done to include a variety of key informants. Interviews were recorded, transcribed verbatim, and analyzed for themes. Results Three main themes emerged: i) the usefulness of the OFTT to the users, ii) expectation management and importance of stakeholder involvement in OFTT development, and iii) OFTT limitations. Conclusion Our study highlights opportunities, limitations, and lessons to consider when developing a pediatric COVID-19 OFTT. The involvement of stakeholders, parents, teachers, and health care providers in the design, set up, implementation, and evaluation of telehealth interventions is critical as this can help with expectation management and enhance OFTT utility.

The Utility of an Online Forward Triage Tool During the SARS-CoV-2 Pandemic: Health Care Provider and Health Authority Perspectives

Introduction The SARS CoV-2 pandemic poses major challenges not only to patients but also to health care professionals and policy-makers, with rapidly changing, sometimes complex, recommendations, and guidelines to the population. Online forward triage tools (OFTT) got a major boost from the pandemic as they helped with the implementation and monitoring of recommendations. Methods A multiphase mixed method sequential explanatory study design was employed. Quantitative data were collected first and informed the qualitative interview guides. Video interviews were held with key informants (health care providers and health authorities) between 2 September and 10 December 2020. Audio-recordings were transcribed verbatim, coded thematically and compared with patient perspectives (framework). Objectives To explore the perspectives of health care providers and authorities in Canton Bern on the utility of a COVID-19 OFTT, as well as elicit recommendations for telehealth in future. Results The following themes emerged;(i) accessibility (ii) health system burden reduction (iii) utility in preventing onward transmission (iv) utility in allaying fear and anxiety (v) medical decision-making utility (vi) utility as information source (vii) utility in planning and systems thinking. The health care providers and health authorities further provided insights on potential barriers and facilitators of telehealth in future. Conclusion Similar to patients, health care providers acknowledge the potential and utility of the COVID-19 OFTT particularly as an information source and in reducing the health system burden. Data privacy, doctor-patient relationship, resistance to change, regulatory, and mandate issues, and lack of systems thinking were revealed as barriers to COVID-19 OFTT utility.

Effects and utility of an online forward triage tool during the SARS-CoV-2 pandemic: a mixed method study and patient perspectives, Switzerland.

OBJECTIVE: To assess the effects (quantitatively) and the utility (qualitatively) of a COVID-19 online forward triage tool (OFTT) in a pandemic context. DESIGN: A mixed method sequential explanatory study was employed. Quantitative data of all OFTT users, between 2 March 2020 and 12 May 2020, were collected. Second, qualitative data were collected through key informant interviews (n=19) to explain the quantitative findings, explore tool utility, user experience and elicit recommendations. SETTING: The working group e-emergency medicine at the emergency department developed an OFTT, which was made available online. PARTICIPANTS: Participants included all users above the age of 18 that used the OFTT between 2 March 2020 and 12 May 2020. INTERVENTION: An OFTT that displayed the current test recommendations of the Federal Office of Public Health on whether someone needed testing for COVID-19 or not. No diagnosis was provided. RESULTS: In the study period, 6272 users consulted our OFTT; 40.2% (1626/4049) would have contacted a healthcare provider had the tool not existed. 560 participants consented to a follow-up survey and provided a valid email address. 31.4% (176/560) participants returned a complete follow-up questionnaire. 84.7% (149/176) followed the recommendations given. 41.5% (73/176) reported that their fear was allayed after using the tool. Qualitatively, seven overarching themes emerged namely (1) accessibility of tool, (2) user-friendliness of tool, (3) utility of tool as an information source, (4) utility of tool in allaying fear and anxiety, (5) utility of tool in medical decision-making (6) utility of tool in reducing the potential for onward transmissions and (7) utility of tool in reducing health system burden. CONCLUSION: Our findings demonstrated that a COVID-19 OFTT does not only reduce the health system burden but can also serve as an information source, reduce anxiety and fear, reduce potential for cross infections and facilitate medical decision-making.

A Utility Framework for COVID-19 Online Forward Triage Tools: A Swiss Telehealth Case Study.

The SARS-CoV-2 pandemic caused a surge in online tools commonly known as symptom checkers. The purpose of these symptom checkers was mostly to reduce the health system burden by providing worried people with testing criteria, where to test and how to self-care. Technical, usability and organizational challenges with regard to online forward triage tools have also been reported. Very few of these online forward triage tools have been evaluated. Evidence for decision frameworks may be of particular value in a pandemic setting where time frames are restricted, uncertainties are ubiquitous and the evidence base is changing rapidly. The objective was to develop a framework to evaluate the utility of COVID-19 online forward triage tools. The development of the online forward triage tool utility framework was conducted in three phases. The process was guided by the socio-ecological framework for adherence that states that patient (individual), societal and broader structural factors affect adherence to the tool. In a further step, pragmatic incorporation of themes on the utility of online forward triage tools that emerged from our study as well as from the literature was performed. Seven criteria emerged; tool accessibility, reliability as an information source, medical decision-making aid, allaying fear and anxiety, health system burden reduction, onward forward transmission reduction and systems thinking (usefulness in capacity building, planning and resource allocation, e.g., tests and personal protective equipment). This framework is intended to be a starting point and a generic tool that can be adapted to other online forward triage tools beyond COVID-19. A COVID-19 online forward triage tool meeting all seven criteria can be regarded as fit for purpose. How useful an OFTT is depends on its context and purpose.

Feasibility, acceptability and needs in telemedicine for palliative care.

BACKGROUND: Telemedicine in palliative care was initially developed in countries where geography or resources limit access to care services. Recently, largely owing to the COVID-19 pandemic, this technology is being increasingly used in highly urbanised countries such as Switzerland. However, there is still scepticism regarding whether these tools can be used effectively in palliative care, a relationship-based speciality that is generally highly dependent on compassion, communication and direct human interaction. The objective of this review was to analyse the needs, elements of feasibility, and reasons for acceptance or possible barriers before the implementation of a telemedicine intervention in Switzerland. METHODS: The method used was a scoping review, following the PRISMA-ScR reporting guidelines. We searched the PubMed, Ovid SP, Medline, Cochrane and Scopus databases for relevant reports. Charting and analyses of the data were done by a single researcher. A total of 520 records were screened and assessed for eligibility. Finally, 27 studies and 4 registry entries were included. Main reasons for exclusion were wrong population and intervention. RESULTS: The prevailing study type was the single-arm intervention study. Most studies originated from countries with geographic barriers to access. Feasibility was good in 69% of all studies. Good acceptability (84.1-100%) was confirmed in the majority of the studies. The needs of the patients or the healthcare professionals were directly addressed in only five (16%) studies. Three needs were consistently reported: communication, coordination and technical reliability. CONCLUSION: Despite a broad range of studies on telemedicine in palliative care, patients' needs are rarely addressed. Therefore, especially in countries such as Switzerland, a needs assessment is recommended before the implementation of a new telemedicine intervention, to guarantee high feasibility and acceptability.

What does a pandemic proof health system look like?

Switzerland is currently in a lockdown and other lockdowns are looming world-wide. Many countries in the West are now experiencing a third COVID-19 wave. While some scientists are aiming for Zero Covid, calls to learn to live with the virus are becoming prominent as anti-lockdown protests spread across Europe. A health system is defined as all organizations, institutions and resources that produce actions whose primary purpose is to improve health. A health care system on the other hand, is defined as institutions, people and resources involved in delivering health care to individuals. Many countries that have health systems previously thought to be world class, have also been tested, pushed to the edge and in some ways found wanting. The pandemic took all countries by some surprise and the discussion on appropriate national and global strategies is very diverse. Lessons from similar earlier outbreaks seem to suggest, that living and learning to live with the virus could be the way forward. Others argue that the virus is new, not like any other we have fought before, calling for novel ways of containing the virus. Irrespective of standpoint, being a high-, middle- or low-income country, pandemic fatigue is setting in, while new variants are being discovered. It is urgent and unprecedented. The pandemic is here and more pandemics are expected to follow. What does, 'living with the virus,' mean in practical terms? The purpose of this viewpoint is to stimulate debate on how we can move towards pandemic proof health care systems.

The development and validation of a resource consumption score of an emergency department consultation.

BACKGROUND: Emergency Department (ED) visits and health care costs are increasing globally, but little is known about contributing factors of ED resource consumption. This study aims to analyse and to predict the total ED resource consumption out of the patient and consultation characteristics in order to execute performance analysis and evaluate quality improvements. METHODS: Characteristics of ED visits of a large Swiss university hospital were summarized according to acute patient condition factors (e.g. chief complaint, resuscitation bay use, vital parameter deviations), chronic patient conditions (e.g. age, comorbidities, drug intake), and contextual factors (e.g. night-time admission). Univariable and multivariable linear regression analyses were conducted with the total ED resource consumption as the dependent variable. RESULTS: In total, 164,729 visits were included in the analysis. Physician resources accounted for the largest proportion (54.8%), followed by radiology (19.2%), and laboratory work-up (16.2%). In the multivariable final model, chief complaint had the highest impact on the total ED resource consumption, followed by resuscitation bay use and admission by ambulance. The impact of age group was small. The multivariable final model was validated (R2 of 0.54) and a scoring system was derived out of the predictors. CONCLUSIONS: More than half of the variation in total ED resource consumption can be predicted by our suggested model in the internal validation, but further studies are needed for external validation. The score developed can be used to calculate benchmarks of an ED and provides leaders in emergency care with a tool that allows them to evaluate resource decisions and to estimate effects of organizational changes.

Online forward triage during the COVID-19 outbreak.

Health systems face major challenges during the COVID-19 pandemic with new information and challenges emerging daily and frequently changing guidelines. Online forward triage tools (OFTTs) provide useful information, direct patients and free physician resources.We implemented an OFTT targeted at the current pandemic, adapted the content and goals and assessed its effects. The OFTT was implemented on 2 March 2020 and modified regularly based on the revised testing criteria issued by the Swiss Federal Office of Public Health. After testing criteria liberalised, a chatbot tool was set up on 9 April 2020 to assess urgency of testing, referral to available testing sites and need for emergency care.In the first 40 days of the OFTT, there were more than 17 300 visitors and 69.8% indicated they would have contacted the healthcare system if the online test had not been available. During the initial week of operation, using the conservative testing strategy, 9.1% of visitors received recommendations to be tested, which increased to 36.0% of visitors after a change in testing criteria on 9 March 2020. Overall, since the implementation of the tool, 26.27% of all users of the site have been directed to obtain testing. The Chatbot tool has had approximately 50 consults/day.Setting up an OFTT should be considered as part of local strategies to cope with the COVID-19 pandemic. It may ease the burden on the healthcare system, reassure patients and inform authorities. To account for the dynamic development of the pandemic, frequent adaptation of the tool is of great importance. Further research on clinical outcomes of OFTT is urgently needed.

Barriers to seeking emergency care during the COVID-19 pandemic may lead to higher morbidity and mortality - a retrospective study from a Swiss university hospital.

AIMS OF THE STUDY: While COVID-19 significantly overburdens emergency rooms (ERs) and hospitals in affected areas, ERs elsewhere report a marked decrease in patient numbers. This study aimed to investigate the assumption that patients with urgent problems currently avoid the ER. METHODS: Electronic health records from the ER of a large Swiss university hospital were extracted for three periods: first, the awareness phase (ap) from the publication of the national government’s initiative “How to protect ourselves” on 1 March 2020 to the lockdown of the country on 16 March; second, the mitigation phase (mp) from 16–30 March; finally, patients presenting in March 2019 were used as a control group. We compared parameters including a critical illness as the discharge diagnosis (e.g., myocardial infarction, stroke, sepsis and ER death) using logistic and linear regression, as well as 15-day bootstrapped means and 95% confidence intervals for the control group. RESULTS: In the three periods, a total of 7143 patients were treated. We found a 24.9% (42.5%) significant decline in the number of patients presenting during the ap (mp). Patients presenting during the mp were more likely to be critically ill. There was an increase of 233% and 367% (ap and mp, respectively) of ER deaths (none related to COVID-19) compared with the control period. Apart from polytrauma (increase of 5% in the mp), all other critical illnesses as discharge diagnosis showed a lower incidence in descriptive analysis. Significantly more patients died in the ER in both the ap and mp. CONCLUSIONS: Barriers to seeking emergency care during COVID-19 pandemic may lead to higher morbidity and mortality. Healthcare authorities and hospitals must ensure low barriers to treatment and business as usual for all patients.