RESUMEN
Background: Home parenteral nutrition (HPN) is the primary treatment for patients with pediatric intestinal failure. It is a complex, life-sustaining therapy requiring a central venous catheter (CVC), and carries high morbidity. Central line-associated bloodstream infection (CLABSI) is a common and potentially fatal complication of HPN. Patients on HPN require a skilled multi-disciplinary team- including physicians, nurses, dietitians and pharmacists-to prevent HPN related complications, provide safe and individualized nutrition support that is evaluated on a regular basis in the ambulatory setting. In-person visits in the clinic setting allow for HPN patients to be evaluated by all disciplines, and full assessment of weight and general condition, fluid status and laboratory values. Importantly, clinic evaluations also allow for close examination of central venous catheter (CVC), discussion with caregivers to identify potential infection risks, and opportunities for education to prevent infections and other complications. Program standard of care is bimonthly clinic and laboratory evaluation, more frequently if clinically indicated. The COVID-19 crisis required transition of many of these evaluations from in-person to telemedicine, which has created new challenges in caring for high-risk pediatric HPN patients and prevention of CLABSI. Multi-disciplinary telemedicine visits including nursing, dietitians and physicians were substituted for in-person evaluations at first exclusively at onset of pandemic, then to every other visit as COVID rates improved and vaccinations became more available. Method(s): HPN clinic encounters from 2019-present were reviewed in a large pediatric HPN program and compared to CLABSI rates. Attention was paid to in-person versus telemedicine evaluations in the setting of COVID-19 pandemic. CLABSI rate was defined as # of ambulatory infections/1000 catheter days, as defined by National Healthcare Safety Network (NHSN) guidelines. Result(s): Despite decreased frequency of in-person clinic evaluation, ambulatory CLABSI rates did not increase during this time. In fact, median CLABSI rate from 2020 to present decreased from 0.81/1000 catheter days to 0.5/1000 catheter days. In 2020, there was a mild trend toward increased CLABSI rate in patients who had higher percentage of telemedicine versus in-person encounters;however, this was not statistically significant. This trend was not observed in 2021. Conclusion(s): Pediatric patients receiving HPN are high-risk and require evaluation by a multidisciplinary team at regular intervals to maintain safety. COVID-19 pandemic interrupted ability to see these complex patients for in-person evaluation with regular frequency;therefore multidisciplinary telemedicine visits were substituted. While in-person evaluation remains the gold standard for management of patients on HPN, intermittent use of multi-disciplinary telemedicine encounters can be utilized to safely care for pediatric HPN patients, without resultant (Figure Presented).
RESUMEN
Background: The global COVID-19 pandemic forced the abrupt transition of in-person clinic visits to a virtual care platform in the Home Parenteral Nutrition (HPN) Program. Remote patient monitoring technology (TytocareTM) allows for accurate and validated vital sign and nutritional assessment by the caregiver which is shared asynchronously or in real-time with medical providers. This novel FDA-approved device provides high quality data, facilitates precise clinical diagnosis and requires caregiver training and participation. Without remote patient monitoring, accurate nutritional assessments during virtual visits are challenging. The implementation process of this novel device after a 6-month pilot period was investigated. Methods: Tytocare™ (TytoHome™kits, weight scales, pulse oximeters and blood pressure machines) devices (Figure 1) were provided through a Federal Communication Commission grant funding the employment of telemedicine services during the COVID-19 pandemic. 139 devices were deployed to all patients in the HPN program through mail or clinic visit/hospital distribution. 21 Tytocare™devices were returned or not accounted for due caregivers not yet reporting to have received the device (n=10), caregiver opt-out (n=4), discharge from the HPN program (n=3), repatriation (n=2), prolonged inpatient admission (n=1) and death (n=1). From November 2020 through May 2021, 97 unique Tytocare™visits were completed. Patients/caregivers were trained on how to use the TytoCare™app with their device. Patients either saw a provider online in a real-time virtual visit or submitted a TytoCare™exam asynchronously in preparation of their scheduled virtual clinic visit. Assessments included weight, pulse oximetry, heart rate, respiratory rate, blood pressure and temperature. Precise photographs of key components of the examination of a patient with intestinal failure on HPN were sent, including central venous catheter (CVC) dressings, CVC insertion sites, skin rashes and enteral tube sites. A 10-question patient experience survey was emailed to the 118 caregivers with active devices after 6 months of device deployment. Results: 85% (n=118) of patients in our HPN program reported use of the Tytocare™device during or prior to telehealth visits. Patient age ranged from 5 months to 34 years old. Of the nine responses received, results were overall favorable. The average was 7.22 for patient satisfaction (ten-level Likert scale;1 = extremely unsatisfied, 10 = extremely satisfied). 0 disagreed with the statement regarding the Tytocare™device being helpful for patient care management (five-level Likert scale;1 = strongly agree, 5 = strongly disagree) and the average for recommending the device to others was 7.56 (ten-level Likert scale;1 = extremely unlikely, 10 = extremely likely). Conclusion: With the assistance of the Innovation and Digital Health Accelerator team, the HPN program successfully and promptly implemented a remote patient monitoring program to complement our telehealth platform. The ability to utilize Tytocare™during the global COVID-19 pandemic was well-received by caregivers of patients requiring home parenteral nutrition. Of the survey responders, caregiver satisfaction and experience were favorable. However, the data presented may not be a true representation of overall impressions given the limited response rate. Future studies will investigate the feasibility, accuracy and impact of remote patient monitoring in complex pediatric populations and will focus on improving patient experience survey response rates.
RESUMEN
Purpose or Objective: Remote healthcare applications have been developing over many years, however clinical implementation has been cautious. As society has embraced technology during the Covid-19 pandemic, the question is: have attitudes towards remote healthcare technology also changed? One particular aspect of healthcare that could be addressed remotely is the collection of patient reported outcome measures (PROMs) using a digital voice assistant (DVA) such as the Amazon Echo (Alexa). This could improve both the frequency and quality of data collected. Materials and Methods: A questionnaire was developed to evaluate patient and carer opinions on using a DVA to report radiotherapy-related side effects. This was distributed to the adult patients in the radiotherapy department in February 2019 and to the Teenager, Young Adult and Paediatric radiotherapy department in mid 2019. It was redistributed in September 2020, allowing a pre/post Covid-19 comparison. To maximise engagement with the questionnaire, it was decided to ask a small number of simple questions. These four questions sought to ascertain whether the respondent was a patient or carer, respondent age (decade grouping), how knowledgeable they were about the Amazon Echo, and how willing they would be to participate in a hypothetical study in which they would use an Amazon Echo to record the side effects they experienced as a result of their cancer treatment. A comments box was included to allow participants to convey additional information. Results: 85 completed questionnaires were collected in 2019 and 43 in 2020. The median age of the initial survey cohort was 60-69 years old whilst for the second cohort was 50-59 years old. The slight difference in median age of the cohorts is likely a reflection on modifications to clinical practice due to Covid-19. 16% of the initial cohort and 19% of the second cohort were carers. 67% of the initial cohort responded that they had some or good knowledge of Amazon Echo, this increased to 84% in the second cohort (fig. 1). Willingness to participate was highest in the group of patients with good knowledge. 44% of the initial cohort were willing to take part in a study using an Amazon Echo to record side effects, increasing to 58% in the subsequent cohort (fig. 2). However, the percentage of respondents who were not willing to take part also increased from 32% to 37% with a reduction in the number of respondents who didn’t know (25% to 5%). Willingness to participate varied with age. Comments were diverse and included concerns about using technology and data security but also positive comments on the potential to reduce hospital visits. (Figure Presented) Conclusion: Overall, the survey results indicate an increased knowledge of DVA. There was also an increased willingness to engage with a DVA for remote collection of radiotherapy outcome data following the first wave of the Covid-19 pandemic.