Technologies During the COVID-19 Pandemic: Teleconsultation in Care Management for Patients Undergoing Liver Transplant.

BACKGROUND: The aim of this study was to identify home care management strategies for patients undergoing liver transplant, through teleconsultation, during the COVID-19 pandemic for maintenance and improvements in treatment adherence. METHODS: This was a qualitative, exploratory, and descriptive research study. Participants included patients who underwent liver transplant between 2020 and 2021. Through a semistructured script, data were analyzed according to the recommendations of content analysis and then simple statistics were applied. RESULTS: Twenty-two people participated in the study. Two analysis categories were developed, which resulted in 7 strategies and 22 care actions. The care strategy with the highest adherence involved actions related to the prevention of COVID-19. CONCLUSIONS: Teleconsultation is an excellent tool to manage and supervise post-liver transplant care of patients. Considering that teleconsultation has presented strategies and care actions, which were developed by the patients, the patients have a direct effect on treatment adherence despite pandemic impositions.

Impact of a nurse-led teleconsultation strategy for cardiovascular disease management during COVID-19 pandemic in India: a pyramid model feasibility study.

OBJECTIVE: The COVID-19 pandemic necessitated the use of telemedicine to maintain continuity of care for patients with cardiovascular diseases (CVDs). This study aimed to demonstrate the feasibility of implementing a nurse-led teleconsultation strategy for CVD management during the COVID-19 pandemic in India and evaluated the impact of nurse-led teleconsultations on patient treatment satisfaction. DESIGN, SETTING AND PARTICIPANTS: We developed a two-stage teleconsultation strategy and tested the feasibility of implementing a nurse-led teleconsultation strategy to manage CVD in a northern state (Punjab) in India. A multidisciplinary team of experts developed the treatment protocol used for teleconsultations to manage CVD. Nurses were trained to provide teleconsultation, triaging of patients and referrals to the physicians. Patients with CVD who had an outpatient visit or hospitalisation between September 2019 and March 2020 at the Dayanand Medical College Hospital, Ludhiana, India, were contacted by phone and offered teleconsultations. Telemedicine strategy comprised: stage 1 nurse-led teleconsultations and stage 2 physician-led teleconsultations. Descriptive analysis was performed to report the proportion of patients triaged by the two-stage telemedicine strategy, and patient's clinical characteristics, and treatment satisfaction between the nurse-led versus physician-led teleconsultations. RESULTS: Overall, nurse-led stage 1 teleconsultations were provided to 12 042 patients with CVD. The mean (SD) age of the participants was 58.9 years (12.8), and men were 65.4%. A relatively small proportion of patients (6.3%) were referred for the stage-2 physician-led teleconsultations and of these only 8.4% required hospitalisations. During stage 1 nurse-led teleconsultations, patients were referred to the physicians due to uncontrolled diabetes (24.9%), uncontrolled hypertension (18.7%) and congestive heart failure (16.2%). The patient's treatment satisfaction was similar between the nurse-led versus physician-led teleconsultations (p=0.07). CONCLUSION: This study showed that a nurse-led telemedicine strategy is feasible to implement in a resource-constraint setting for triaging patients with CVD and reduces physician's burden.

Teledermatology to reduce face-to-face appointments in general practice during the COVID-19 pandemic: a quality improvement project.

Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing '4 Key Instructions' and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.

Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus.

BACKGROUND & AIMS: The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS: A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS: The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION: The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.

Utility of teleconsultation in accessing eye care in a developing country during COVID-19 pandemic.

OBJECTIVE: To evaluate the utility of teleconsultation in the provision of eye care services during the COVID-19 lockdown. Disparities in the consultation burden of sub-specialities and socio-demographic differences in teleconsultation utilization were also assessed. METHODS: Al-Shifa Trust Eye Hospital Rawalpindi began audio and video teleconsultation using broadband telecommunication services during the lockdown. Patients' and consultations' data gathered during the first three weeks after the commencement of this programme were compared with data from the four weeks prior to lockdown. The weekly consultation ratio and overall consultation burden of sub-specialities were measured. Chi-Square tests of association determined the relationship between different variables (socioeconomic status and consultation characteristics) and consultation modality (on-site vs online). RESULTS: In total, 17507 on-site consultations (4377/week) were conducted compared to 1431 teleconsultations (477/week), which maintained 10.89% of the weekly pre-lockdown eye care services. The post-lockdown teleconsultation programme saw a relatively higher percentage of service utility among female (47.09% vs 44.71%), younger-age (31.33±19.45 vs 41.25±23.32 years) and higher-socioeconomic-status (32.21% vs 0.30%) patients compared to pre-lockdown on-site consultations. The most common indication for teleconsultation was red-eye (16.70%). While cornea and glaucoma clinics maintained most of the pre-lockdown services (30.42% and 29% respectively), the highest dropout was seen in optometric and vitreoretinal services supporting only 5.54% and 8.28% of pre-lockdown services, respectively. CONCLUSION: Digital initiatives could partially maintain eye care services during the lockdown. Focused strategies to improve teleconsultation utilization are required during the pandemic and beyond.

The remote neuro-otology assessment - managing dizziness in the coronavirus disease 2019 era.

BACKGROUND: Coronavirus disease 2019 and other factors have driven interest in conducting remote consultations, but there has been little research on this topic in neuro-otology. With suitable preparation, neuro-otology patients with dizziness can have remote assessments that include elements of neuro-otological physical examination, with tailored management and onward pathways arranged. METHODS: This paper reports experience with remote consultation in over 700 neuro-otology patient consultations and suggests a systematic approach, illustrated by a clinical case report and data on 100 consultations. CONCLUSION: Remote consultations can play a role in neuro-otology clinics. Further research is needed to establish patient acceptability, diagnostic accuracy, safety and efficiency of remote models of care for this patient group.

Patient Use of Low-cost Digital Videoscopes and Smartphones for Remote Ear and Oropharyngeal Examinations.

Importance: During the novel coronavirus disease 2019 pandemic, telehealth has become a vital component of health care delivery. For otolaryngology evaluations, examination of the ear and oropharynx is important but difficult to achieve remotely. Objective: To assess the feasibility of patient use of low-cost digital videoscopes and smartphones for examination of the ear and oropharynx. Design, Setting, and Participants: A prospective quality improvement study was conducted in an academic adult otolaryngology clinic including 23 patients who presented for an in-person appointment and owned a smartphone device. The study was conducted from July 1 to 15, 2020. Interventions: Participants were asked to capture pictures and videos of their ear canals and oropharynx with digital videoscopes and their smartphones under real-time guidance over a telehealth platform. They were then surveyed about their experience. Main Outcomes and Measures: The primary outcomes were ratings by health care clinicians and a blinded otolaryngologist reviewer of image acceptability. Secondary outcomes included participant time to image acquisition and willingness to purchase digital videoscopes for telehealth use. Results: Of the 23 participants included, 14 were women (61%); mean age was 50 years (range, 21 to 80 years). Of the images obtained using the digital otoscope ear examination, 95% were considered acceptable by the health care clinicians and 91% were considered acceptable by the blinded reviewer; 16 participants (70%) reported that the otoscope was easy to use. The mean time to acquire images for both ears was 114 seconds (95% CI, 84-145 seconds). Twenty-one participants (91%) were willing to pay for a digital otoscope for telehealth use. For the oropharyngeal examination, a greater proportion of smartphone video examinations were considered acceptable by clinicians (63% acceptability) and the blinded reviewer (55%) compared with the digital endoscope (clinicians, 40%; blinded reviewer, 14%). The mean time required for the oropharyngeal examination smartphone video capture was shorter at 35 seconds compared with both the digital endoscope (difference, -27 seconds; 95% CI, -7 to -47 seconds) and smartphone photo capture (difference, -53 seconds; 95% CI, -20 to -87 seconds). Conclusions and Relevance: Digital otoscopes and smartphones apparently can facilitate remote head and neck physical examination in telehealth. Digital otoscopes were useful for ear examinations, and smartphone videos appeared to be the most useful for oropharyngeal examinations. Further studies are required to determine specific diagnostic capabilities in various telehealth practice settings.

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era.

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

Remote monitoring of marginalised populations affected by COVID-19: a retrospective review.

OBJECTIVES: The COVID-19 outbreak in Singapore has largely centred around migrant worker dormitories, comprising over 90% of all cases in the country. Dormitories are home to a culturally and linguistically distinct, low-income population, without on-site healthcare after-hours. The primary objective of this study was to assess the engagement and utilisation of a simple, low-cost, accessible, mobile health solution for remote self-reporting of vital parameters in dormitory residents with COVID-19. DESIGN: Retrospective review of medical care. SETTING: Two large migrant worker dormitories with a combined population of 31 546. PARTICIPANTS: All COVID-19-affected residents housed in dormitories during the study period. INTERVENTION: All residents were taught to use a chat assistant to self-report their temperature, heart rate and oxygen saturations. Results flowed into a dashboard, which alerted clinicians of abnormal results. OUTCOMES: The primary outcome measure was engagement rate. This was derived from the total number of residents who registered on the platform over the total number of COVID-19-affected residents in the dormitories during the study period. Secondary outcome measures included outcomes of the alerts and subsequent escalations of care. RESULTS: 800 of the 931 COVID-19-affected residents (85.9%) engaged with the platform to log a total of 12 511 discrete episodes of vital signs. Among 372 abnormal readings, 96 teleconsultations were initiated, of which 7 (1.8%) were escalated to emergency services and 18 (4.9%) were triaged to earlier physical medical review on-site. CONCLUSIONS: A chat-assistant-based self-reporting platform is an effective and safe community-based intervention to monitor marginalised populations with distinct cultural and linguistic backgrounds, living communally and affected by COVID-19. Lessons learnt from this approach may be applied to develop safe and cost-effective telemedicine solutions across similar settings.

Impact of Remote Consultations on Antibiotic Prescribing in Primary Health Care: Systematic Review.

BACKGROUND: There has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed. OBJECTIVE: This study aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing. METHODS: Searches were conducted in MEDLINE, Embase, HMIC, PsycINFO, and CINAHL for literature published since the databases' inception to February 2020. Peer-reviewed studies conducted in primary health care settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing to be included in this systematic review. Studies were excluded if there were no comparison groups (face-to-face consultations). RESULTS: In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations. CONCLUSIONS: There is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further, well-conducted studies are needed to inform safe and appropriate implementation of remote consulting to ensure that there is no unintended impact on antimicrobial resistance.

Use of WhatsApp for Polyclinic Consultation of Suspected Patients With COVID-19: Retrospective Case Control Study.

BACKGROUND: Telephones, internet-connected devices (phablets, personal computers), chat platforms, and mobile apps (eg, Skype, Facebook Messenger, WhatsApp) can be exploited for telemedicine applications. WhatsApp and similar apps are also widely used to facilitate clinical communication between physicians. Moreover, WhatsApp is used by emergency department (ED) physicians and consulting physicians to exchange medical information during ED consultations. This platform is regarded as a useful app in the consultation of dermatological and orthopedic cases. Preventing overcrowding in the ED is key to reducing the risk of disease transmission, and teleconsulting practice is thought to be effective in the diagnosis, treatment, and reduction of transmission risk of disease, most notably during the COVID-19 pandemic. Video consultation is highly recommended in some countries on the grounds that it is likely to reduce the risk of transmission. WhatsApp-like apps are among the video consultation platforms that are assumed to reduce the risk of contamination by minimizing patient-physician contact. OBJECTIVE: The aim of this study was to investigate the effects of WhatsApp video consultation on patient admission and discharge times in comparison to bedside consultation in the evaluation of potential patients with COVID-19 visiting a COVID-19 outpatient clinic during the pandemic. METHODS: Patients who presented to the ED COVID-19 outpatient clinic between March 11 and May 31, 2020, and for whom an infectious disease specialist was consulted (via WhatsApp or at bedside) were included in the study in accordance with the inclusion and exclusion criteria. Eventually, 54 patients whose consultations were performed via WhatsApp and 90 patients whose consultations were performed at bedside were included in our study. RESULTS: The median length of stay in the ED of discharged patients amounted to 103 minutes (IQR 85-147.75) in the WhatsApp group and 196 minutes (IQR 141-215) in the bedside group. In this regard, the length of stay in the ED was found to be significantly shorter in the WhatsApp group than in the bedside group (P<.001). Among the consulted and discharged patients, 1 patient in each group tested positive for SARS-CoV-2 by polymerase chain reaction test and thus was readmitted and hospitalized (P=.62). The median length of stay of the inpatients in the ED was found to be 116.5 minutes (IQR 85.5-145.5) in the WhatsApp group and 132 minutes (IQR 102-168) in the bedside group. The statistical analysis of this time difference revealed that the length of stay in the ED was significantly shorter for patients in the WhatsApp group than in the bedside group (P=.04). CONCLUSIONS: Consultation via WhatsApp reduces both contact time with patients with COVID-19 and the number of medical staff contacting the patients, which contributes greatly to reducing the risk of COVID-19 transmission. WhatsApp consultation may prove useful in clinical decision making as well as in shortening process times. Moreover, it does not result in a decreased accuracy rate. The shortened discharge and hospitalization timespans also decreased the length of stay in the ED, which can have an impact on minimizing ED crowding. TRIAL REGISTRATION: ClinicalTrials.gov NCT04645563; https://clinicaltrials.gov/ct2/show/NCT04645563.

Teleconsultation Between Patients and Health Care Professionals in the Catalan Primary Care Service: Message Annotation Analysis in a Retrospective Cross-Sectional Study.

BACKGROUND: Over the last decade, telemedicine services have been introduced in the public health care systems of several industrialized countries. In Catalonia, the use of eConsulta, an asynchronous teleconsultation service between primary care professionals and citizens in the public health care system, has already reached 1 million cases. Before the COVID-19 pandemic, the use of eConsulta was growing at a monthly rate of 7%, and the growth has been exponential from March 15, 2020 to the present day. Despite its widespread usage, there is little qualitative evidence describing how this tool is used. OBJECTIVE: The aim of this study was to annotate a random sample of teleconsultations from eConsulta, and to evaluate the level of agreement between health care professionals with respect to the annotation. METHODS: Twenty general practitioners retrospectively annotated a random sample of 5382 cases managed by eConsulta according to three aspects: the type of interaction according to 6 author-proposed categories, whether the practitioners believed a face-to-face visit was avoided, and whether they believed the patient would have requested a face-to-face visit had eConsulta not been available. A total of 1217 cases were classified three times by three different professionals to assess the degree of consensus among them. RESULTS: The general practitioners considered that 79.60% (4284/5382) of the teleconsultations resulted in avoiding a face-to-face visit, and considered that 64.96% (3496/5382) of the time, the patient would have made a face-to-face visit in the absence of a service like eConsulta. The most frequent uses were for management of test results (26.77%, 1433/5354), management of repeat prescriptions (24.30%, 1301/5354), and medical enquiries (14.23%, 762/5354). The degree of agreement among professionals as to the annotations was mixed, with the highest consensus demonstrated for the question "Has the online consultation avoided a face-to-face visit?" (3/3 professionals agreed 67.95% of the time, 827/1217), and the lowest consensus for the type of use of the teleconsultation (3/3 professionals agreed 57.60% of the time, 701/1217). CONCLUSIONS: This study shows the ability of eConsulta to reduce the number of face-to-face visits for 55% (79% × 65%) to 79% of cases. In comparison to previous research, these results are slightly more pessimistic, although the rates are still high and in line with administrative data proxies, showing that 84% of patients using teleconsultations do not make an in-person appointment in the following 3 months. With respect to the type of consultation performed, our results are similar to the existing literature, thus providing robust support for eConsulta's usage. The mixed degree of consensus among professionals implies that results derived from artificial intelligence tools such as message classification algorithms should be interpreted in light of these shortcomings.