Adherence to Emergency Department Referral Criteria in a Direct-to-Consumer Telemedicine Center.

Background: The safety of direct-to-consumer telemedicine (TM) is closely related to red flag detection and correct referrals. The adherence to referral criteria from current guidelines is not well quantified. Objective: To analyze the emergency department (ED) referral rate and adherence to referral guidelines in TM encounters of acutely ill patients calling a center that adopts stewardship protocols. Methods: This is a retrospective observational unicentric study, between March 2020 and March 2022, with patients who spontaneously sought direct-to-consumer urgent virtual medical assistance. A video-based teleconsultation was provided immediately after connection. Physicians managed situations according to their clinical judgment. Current guidelines, containing specific guidance for referral if red flags were identified, were available for consultation. Physicians' semiannual performance feedback was carried out. We analyzed the patterns for referral to immediate face-to-face medical evaluation and the agreement degree with the institutional guidelines. Results: A total of 232,197 patients were available, and 14,051 (6.05%) patients were referred to ED. A total of 8,829 (68.4%) referrals were based in specific guidelines according to the International Classification of Diseases hypothesis, and 8,708 (98.6%) were justified according to guidelines. Diarrhea had the highest guidelines' adherence to referral (97.6%), followed by COVID-19 (90%), headache (84.2%), and conjunctivitis (78.8%). Policies did not support 5,222 (31.6%) referrals, though 5,100 (97.6%) of these were justified according to the doctor's clinical judgment. Conclusion: TM doctors' assessment of acutely ill patients has high rates of adherence to guidelines regarding referral. Stewardship protocol adoption provides high rates of red flag description, even in the referral of nonpolicy diseases.

Increasing Pediatric Hearing Aid Use: Considerations for Clinical Practice.

PURPOSE: Hearing aid use can be variable for young children, and inconsistent wear time can undermine spoken language development. This study explored the effectiveness of hearing aid data logging (DL) awareness and coaching sessions on increasing hours of hearing aid use. We also collected qualitative data on challenges participants experienced managing hearing aid use. METHOD: We used a single-subject design that included three conditions, during a 6-week period, in the same order for each participant. Condition A was baseline, Condition B was DL monitoring alone, and Condition C was remote coaching calls plus DL monitoring. RESULTS: Hours of hearing aid use increased for each child from baseline to the end of the study, ranging from 1.19 to 4.4 hr. Mothers reported that the coaching calls were beneficial and helped them identify and problem-solve issues. CONCLUSIONS: Parents were able to increase hours of hearing aid use with DL awareness and coaching support. Tele-audiology offers an opportunity to provide parents with more frequent support that can be individualized based on their situation, challenges, and family needs.

Propuesta técnica de equipamiento para un teleconsultorio / Technical equipment proposal for a teleconsultation

INTRODUCCIÓN: Las acciones de telemedicina demostraron ser de gran utilidad, principalmente, durante la pandemia por coronavirus en 2019. Diversas instituciones, con el fin de dar continuidad a la atención de la población, optaron por la utilización de plataformas y herramientas tecnológicas que permitían realizar actividades a distancia como seguimiento, asesoría y consulta y, con ello, se respetaban y fomentaban las medidas para disminuir la propagación del virus del COVID-19, como la implementación de la sana distancia. Si bien, los servicios presenciales han regresado prácticamente a la normalidad, muchas actividades de atención a distancia se siguen realizando a través de plataformas tecnológicas; sobre todo, aquellas que por su poca complejidad no generan barreras adicionales y otorgan resultados de gran beneficio en salud para la población y las instituciones. Con el objetivo de que los servicios de atención a distancia se lleven a cabo con calidad, han surgido modelos y lineamientos que favorecen una mejor comunicación e interacción a través de las tecnologías de la información y las comunicaciones, tanto para el cuidado de la salud como para temas generales. Además, se han propuesto una serie de recomendaciones operativas que mejoran la experiencia de las personas usuarias de los sistemas electrónicos. Estas recomendaciones son básicas y muchas veces obvias, pero si no son tomadas en cuenta pueden disminuir la calidad de la comunicación y, en el caso de la atención médica, la relación entre las personas beneficiarias y el personal de la salud que lo asiste a la distancia, puede verse disminuida. En este documento, se comentan aspectos para el manejo de la luz, posición de las cámaras y de los micrófonos, colores y texturas, todo con la finalidad de que el profesional de la salud obtenga una mejor información de la persona y la comunicación no se vea afectada por artefactos, sombras, ruidos y alguna situación imprevista mientras se lleva a cabo la atención a distancia. ALCANCE: Las recomendaciones descritas están encaminadas a ser utilizadas, primordialmente, durante cualquier videoconferencia o teleconsulta, además, pueden aplicar para diversas acciones de atención médica a distancia. Se requiere inversión para acondicionar los espacios donde se encontrará el equipo de trabajo que atiende de forma remota, y creatividad para utilizar la infraestructura existente en aquellos casos donde no es posible realizar un gasto adicional en el corto tiempo, en ocasiones es suficiente con incorporar adecuadamente elementos con los que ya cuenta la unidad y con una mejor redistribución de los espacios y ubicación de los equipos. RELACIÓN CON EL MODELO DE LA UNIDAD DE CONTACTO PARA LA ATENCIÓN A DISTANCIA EM SALUD (UCADS): Con el objetivo de fortalecer el primer nivel de atención, se establecen estrategias para una mejor comunicación y organización entre las redes de atención. Para ello, se desarrollan modelos a distancia basados en la calidad y el acercamiento con la población y no enfocados exclusivamente, en el diagnóstico o entrega de un tratamiento. Esto permite una relación más estrecha entre las personas beneficiarias y personal de salud, antes de sus consultas y posterior a ellas. El modelo de atención, basado exclusivamente en la teleconsulta, se modifica notoriamente. Se incorporan más actores como enfermeras, auxiliares, promotores de salud y su participación es mucho más amplia. Por lo tanto, cobra mayor importância conocer criterios para mejorar la calidad del servicio basados en tecnologías digitales, e independientemente del tipo de equipo con el que se logre establecer contacto, y de la modalidad de la atención (seguimiento, asesoría o consulta). En todos los casos, es fundamental cuidar aspectos como la privacidad de las personas beneficiarias, el manejo adecuado de la seguridad de la información, un canal de audio claro y sin ruido externo, una imagen lo más parecida y cercana a la realidad y una ubicación que permita total concentración para una mejor toma de decisiones. PROPUESTA TÉCNICA DE EQUIPAMIENTO PARA UN TELECONSULTORIO: Consultorio de telemedicina o teleconsultorio: "Espacio físico en el centro remisor con acceso a internet y flujo eléctrico donde se instalan los equipos para prestar el servicio de telemedicina." ESCENARIOS DE ACONDICIONAMIENTO DE ESPACIOS FÍSICO: Se considera que, en ambas propuestas, se cuente con un mínimo de mobiliario y materiales dentro del consultorio médico, con base en un análisis inicial.

Impact of coronavirus disease 19 outbreak on arrhythmic events and mortality among implantable cardioverter defibrillator patients followed up by remote monitoring: a single center study from the Veneto region of Italy.

BACKGROUND: The 2020 severe acute respiratory syndrome coronavirus 2 outbreak entailed reduced availability of traditional (in-office) cardiology consultations. Remote monitoring is an alternative way of caring that may potentially mitigate the negative effects of the epidemic to the care of cardiovascular diseases. We evaluated the outcome of implantable cardioverter defibrillator (ICD) carriers followed up remotely in 2020 (epidemic period) versus 2019 (control). METHODS: We included all patients with an ICD who remained remotely monitored from the beginning to the end of each year. The combined end point included: new-onset atrial fibrillation; sustained ventricular tachycardia >170 bpm without ICD intervention; appropriate ICD intervention (either shock or antitachycardia pacing); any-cause death. Multiple events in the same patients were counted separately if occurring ≥48 h apart. RESULTS: In 2020, 52 end points occurred in 37 of 366 (10%) ICD carriers [0.14/patient (95% confidence interval [CI] = 0.11-0.19)] versus 43 end points in 32 of 325 (10%) ICD carriers in 2019 [0.13/patient (95% CI = 0.10-0.18) P  = 0.75]. There was no difference between the distribution of any individual end point in 2020 versus 2019 although a nonsignificant mortality increase was observed (from 2.8% to 4.6%, P  = 0.19). The lowest weekly event rate occurred during the national lock down in spring 2020 but a similar trend occurred also in 2019 suggesting that the effect may not be linked to social distancing measures. CONCLUSIONS: We did not observe an increase in a combined end point including arrhythmic events and mortality in ICD carriers who were remotely monitored in 2020, compared to 2019, despite the negative impact of the coronavirus disease 2019 outbreak on the healthcare system.

Teleconsultation in General Surgery during COVID-19 pandemic, satisfaction survey and feasibility for future.

BACKGROUND: The COVID-19 pandemic has made us to respond to the needs of the community. Telemedicine has gained worldwide acceptance. We describe our experience with teleconsultation in surgical patients during the first wave of the COVID-19 pandemic and evaluate patient satisfaction and the feasibility of maintaining it as a future strategy in selected patients. METHODS: An observational, retrospective, single-site cohort study was carried out by reviewing electronic medical records and conducting a telephone survey. RESULTS: During this time, 1706 teleconsultations have been carried out: 59.5% of patients were rescheduled, 26.1% have been solved and of these 57.3% (255 patients) have been discharged; 12.19% were not contacted. The 73.6% considered that teleconsultation was able to fully or partially resolve the reason for their medical appointment; 61.6% were willing to continue with teleconsultation; 15.2% of the patients needed some kind of help or required a second call to speak with a family member, and 37.2% would prefer a face-to-face visit because of difficulties with the teleconsultation. The overall satisfaction was 8.7 out of 10. CONCLUSIONS: Telemedicine has demonstrated to be a useful tool even for surgical patients during COVID-19 pandemic. A high proportion of patients can be managed by telephone call. Patients reported a high degree of satisfaction. Teleconsultation is a feasible strategy not also during the current COVID-19 pandemic but also for future.

Remote triage incorporating symptom-based risk stratification for suspected head and neck cancer referrals: A prospective population-based study.

BACKGROUND: Remote triage for suspected head and neck cancer (HNC) referrals was adopted by many institutions during the initial peak of the coronavirus disease 2019 pandemic. Its safety in this population has not been established. METHODS: A 16-week, prospective, multicenter national service evaluation was started on March 23, 2020. Suspected HNC referrals undergoing remote triage in UK secondary care centers were identified and followed up for a minimum of 6 months to record the cancer status. Triage was supported by risk stratification using a validated calculator. RESULTS: Data for 4568 cases were submitted by 41 centers serving a population of approximately 26 million. These represented 14.1% of the predicted maximum referrals for this population outside of pandemic times, and this gave the study a margin of error of 1.34% at 95% confidence. Completed 6-month follow-up data were available for 99.8% with an overall cancer rate of 5.6% (254 of 4557). The rates of triage were as follows: urgent imaging investigation, 25.4% (n = 1156); urgent face-to-face review, 27.8%; (n = 1268); assessment deferral, 30.3% (n = 1382); and discharge, 16.4% (n = 749). The corresponding missed cancers rates were 0.5% (5 of 1048), 0.3% (3 of 1149), 0.9% (12 of 1382), and 0.9% (7 of 747; P = .15). The negative predictive value for a nonurgent triage outcome and no cancer diagnosis was 99.1%. Overall harm was reported in 0.24% (11 of 4557) and was highest for deferred assessments (0.58%; 8 of 1382). CONCLUSIONS: Remote triage, incorporating risk stratification, may facilitate targeted investigations for higher risk patients and prevent unnecessary hospital attendance for lower risk patients. The risk of harm is low and may be reduced further with appropriate safety netting of deferred appointments. LAY SUMMARY: This large national study observed the widespread adoption of telephone assessment (supported by a risk calculator) of patients referred to hospital specialists with suspected head and neck cancer during the initial peak of the coronavirus disease 2019 pandemic. The authors identified 4568 patients from 41 UK centers (serving a population of more than 26 million people) who were followed up for a minimum of 6 months. Late cancers were identified, whether reviewed or investigated urgently (0.4%) or nonurgently (0.9%), but the overall rate of harm was low (0.2%), with the highest rate being seen with deferred appointments (0.6%).

Management of diabetes mellitus through teleconsultation during COVID-19 and similar scenarios - Guidelines from Indian Council of Medical Research (ICMR) expert group.

INTRODUCTION: Emergence of COVID-19 pandemic has led to increased use of telemedicine in health care delivery. Telemedicine facilitates long-term clinical care for monitoring and prevention of complications of diabetes mellitus. GUIDELINES: Precise indications for teleconsultation, clinical care services which can be provided, and good clinical practices to be followed during teleconsultation are explained. Guidance on risk assessment and health education for diabetes risk factors, counselling for blood glucose monitoring, treatment compliance, and prevention of complications are described. CONCLUSION: The guidelines will help physicians in adopting teleconsultation for management of diabetes mellitus, facilitate access to diabetes care and improve health outcomes.

The Colorectal Telephone Clinic: a new normal post-COVID-19?

INTRODUCTION: In light of the COVID-19 recommendations from the Association of Coloproctology of Great Britain and Ireland, we aimed to study patient and clinician satisfaction with a newly established telephone (TP) colorectal clinic service in lieu of traditional face-to-face (FTF) appointments. Comparative outcomes included patient versus clinician satisfaction; patient versus clinician desire to continue TP clinics postpandemic; and views of Specialty Trainee 3+ (ST3+)/Specialty Associate Specialist (SAS) doctors versus consultants on TP compared with FTF appointments. METHODS: We conducted a prospective service evaluation of patient and clinician satisfaction with colorectal surgery TP clinics between 1 June 2020 and 30 June 2020 in a British District General Hospital. RESULTS: Patients had higher satisfaction than clinicians with TP clinics: 91.5% versus 66.6% reported above-average experience [odds ratio (OR) = 5.35, 95% confidence interval (CI) 1.53 to 18.75, p = 0.01]. Clinicians had lower demand to continue TP clinics post-COVID-19 versus patients, with a trend towards significance (60% versus 82.9%, OR = 0.31, 95% CI 0.10 to 0.97, p = 0.08). ST3+/SAS doctors were more likely than consultants to find TP clinics inferior to FTF consultation for patient assessment (48.3% versus 23.7%, OR = 3.00, 95% CI 1.17 to 7.71, p = 0.03). CONCLUSIONS: While clinicians may be concerned that patient assessment suffers, patient satisfaction with TP clinics is high. There should be a place for TP clinics post-COVID-19 but there must be a robust process for patient selection as well as adequate training for current and future generations of clinicians.

Doctor-patient communication during the Corona crisis - web-based interactions and structured feedback from standardized patients at the University of Basel and the LMU Munich.

Background: Due to the pandemic-related restrictions in classroom teaching at the medical faculties of the LMU Munich and the University of Basel, teaching methods with standardized patients (SPs), were shifted to a digital, web-based format at short notice as of April 2020. We report on our experiences with the WebEncounter program, which was used for the first time in German-speaking countries. The program enables one-to-one encounters between SPs and students. Students receive an invitational email with brief instructions and background information on the case. SPs use case-specific criteria that are compliant with the learning objectives for digital evaluation during the encounter. A feedback session takes place immediately following the encounter. The SPs address the didactically relevant sections and can illustrate them with the corresponding video sequences. Finally, the students receive the links to the video recordings of the encounter and the feedback unit by email. Project description: The aim of this pilot study was to analyze the practicability of the program and its acceptance by students and SPs. In addition, we examined whether the operationalization of the learning objectives in the form of assessment items has an impact on the content and thematic development of courses in the area of doctor-patient communication. Methods: To implement the program, patient cases previously tested in communication seminars in Munich and Basel were rewritten and case-specific evaluation criteria were developed. SPs were trained to use the program, to present their patient figure online and to give feedback. The experience of those involved (faculty, SPs and SP trainers, students) in implementing the program was documented at various levels. The frequency and causes of technical problems were described. Student results on the patient cases and on the feedback items were collected quantitatively and, where possible, supplemented by free-text statements. Results: Data from 218/220 students in Basel and 120/127 students in Munich were collected and evaluated. Students were very satisfied with the patient cases, the encounter with the SPs and their feedback: 3.81±0.42. SPs experienced the training as an increase in their competence and the structured feedback as particularly positive. The training effort per SP was between 2.5 and 4 hours. The results show predominantly normally-distributed, case-specific sum scores of the evaluation criteria. The analysis of the individual assessment items refers to learning objectives that students find difficult to achieve (e.g. explicitly structuring the conversation). Problems in the technical implementation (<10 percent of the encounters) were due mainly to the use of insufficient hardware or internet connection problems. The need to define case-specific evaluation criteria triggered a discussion in the group of study directors about learning objectives and their operationalization. Summary: Web-based encounters can be built into the ongoing communication curriculum with reasonable effort. Training the SPs and heeding the technical requirements are of central importance. Practicing the virtual consultation was evaluated very positively by the students - in particular, the immediate feedback in the protected dialogue was appreciated by all involved.

Clinical placements in General Practice: concepts and considerations of implementing remote virtual placements in the COVID world.

Medical students are considered as 'essential workers' within the National Health Service (NHS) and the delivery of clinical experience is essential to their learning and progression into the workforce. The COVID-19 pandemic impacted the delivery of clinical placements in primary care; GPs are currently delivering the majority of consultations using telephone or video methods and difficulties in attaining placement experience are being encountered by medical students. Virtual remote consultations are an appropriate adjunct to conventional face-to-face patient encounters and could facilitate students to attain core learning outcomes. This article describes some of the approaches that enable remote (home) virtual patient encounters in Primary Care for medical students. These are categorised as methods that a) enable remote access into GP clinical systems, b) enable remote access into individual patient consultations and c) enable an observational-only experience. Key considerations are highlighted to enable safe and effective implementation of remote virtual consultations, along with the advantages and disadvantages of each method. These include patient consent, confidentiality, data sharing and protection, professionalism, student agreements and data gathering templates. It is hoped that sharing of these methods of virtual consulting will support the ongoing delivery of Primary Care education across medical schools.

Favorable Outcomes From an In-person and Online Feasibility Mindful Moment Pilot Study.

Long hours, inadequate staff, and increasingly complicated patients make nurses more vulnerable to increased levels of stress and burnout. Nurses skilled in exercising self-care practices are better equipped to manage complex clinical situations. The purpose of this pilot study was to evaluate the feasibility of short mindfulness sessions (Mindful Moment) practiced prior to a shift, available in person and online, on nurse burnout and perceived levels of stress. The 8-week Mindful Moment study consisted of 20-minute sessions delivered either in person or online that included yoga, self-reflection, and meditation. Nurse burnout was assessed using the Maslach Burnout Inventory at weeks 0, 4, and 8. Perceived stress was assessed using a visual analog scale before and after each Mindful Moment session. Descriptive statistics, pre/postintervention differences, and percent change calculations were used to evaluate study outcomes. Forty-seven nurses agreed to participate, with 20 nurses completing the study (43%). Participants were all female, aged 36.8 ± 9.8 years, with 12 ± 8.6 years of nursing experience. With respect to nurse burnout, there was a -31% change in emotional exhaustion (P = .079), a -31% change in depersonalization (P = .057), and a +10% change in personal accomplishment (P = .331). There were consistent reductions in nurses' perceived stress pre/post-Mindful Moment session, with percent changes ranging from -35% to 40%. Findings from this study suggest that practicing a brief Mindful Moment prior to the start of a shift is feasible and self-care interventions provide lower levels of burnout and perceived stress among this sample of nurses.

The value of physical examination in the era of telemedicine.

Telemedicine use has expanded rapidly to cope with increasing demand on services by delivering remote clinical review and monitoring of long-term conditions. Triaging individual patients to determine their suitability for telephone, video or face-to-face consultations is necessary. This is crucial in the context of COVID-19 to ensure doctor-patient safety. Telemedicine was shown to be safe and feasible in managing certain chronic diseases and providing patient education. When reviewing newly referred or long-term patients, different specialty clinics have different requirements for physical examination. Clinicians prefer face-to-face consultations at the initial visit to establish a doctor-patient relationship; telephone or video consultations are reasonable options for long-term patients where physical examination may not be needed. Video consultations, often aided by sophisticated devices and apps or medical assistants, are useful to facilitate remote physical examination. Most patients prefer telemedicine as it saves time and travel cost and provides better access to appointments.

[Checklist for patients with type 2 diabetes mellitus for remote consultation]. / Checklist para pacientes con diabetes mellitus tipo 2 en consulta telemática.

The current circumstances cause by the COVID-19 force primary care doctors to find out new ways to guarantee the health care of our type 2 diabetes patients. There is evidence that supports the remote consultation efficacy in the glycemic control in patients with type 2 diabetes. Facing the rapid adaptation of clinical practice to the remote consultation use, from de Diabetes Group of the Spanish Society of Family and Community Medicine (SemFyC), we have prepared a document embodied in a telematic action / monitoring algorithm in the care of patients with type 2 diabetes.

Advantages and disadvantages of telemedicine during the COVID-19 pandemic era among physicians in Taif, Saudi Arabia.

OBJECTIVES: To evaluate the advantages and disadvantages of telemedicine among physicians during the COVID-19 pandemic. To assess the awareness about telemedicine among physicians and determine their opinions about telemedicine in the post-pandemic era. METHODS: A cross-sectional study was conducted at government hospitals (King Faisal Medical Complex [KFMC]-King Abdulaziz Specialist Hospital [KASH]) in Taif, Kingdom of Saudi Arabia (KSA), from May-August 2020. Taif is a small city in the western region of KSA with a population of 689,000 and 2 main hospitals (KFMC & KASH) which also serve rural areas close to Taif city. A total of 36 physicians practiced telemedicine, only 25 physicians accepted to participate in this study. RESULTS: Thirty-six percent of the responders believed that telemedicine could improve the effectiveness of therapeutic intervention and 44% believed that the quality of care was enhanced using telemedicine. Difficulty in reaching the correct diagnosis due to the lack of physical examination was one of the disadvantages that faced the participants. CONCLUSION: Telemedicine should be part of medical services but should not completely replace physicians' personal interaction. Telemedicine could be continued for stable remotely residing patients even after the COVID-19 pandemic.

Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic.

PURPOSE: Lockdown during the COVID-19 pandemic compelled urologists to change access to healthcare, especially for oncology patients. Teleconsultation is a safe way to receive medical advice without a risk of infection, and was implemented urgently in our academic centres. Our purpose was to evaluate patient and physician satisfaction with teleconsultation set up during the COVID-19 pandemic. METHODS: From March 16th 2020, all face-to-face consultations were cancelled in France, except for emergencies. Teleconsultation was started immediately by five senior urologists in two academic hospitals. All patients received an email survey including the validated Teleconsultation Satisfaction Questionnaire (TSQ) and demographic questions. Data were collected prospectively. Physicians also responded to the TSQ. Patient satisfaction was measured objectively with the validated 14-item TSQ. Each item was scored on a 5-point Likert scale. Factors associated with positive satisfaction with teleconsultation were assessed by multivariable logistic regression. RESULTS: Overall, 105 patients replied to the survey (91.3%). Median age was 66 years (IQR: 55‒71) and 95 were men (90.5%). Median overall TSQ score was 67 (IQR: 60‒69); teleconsultation was judged to be a good experience by 88 patients (83.8%) and four physicians (80%). Patients who met their surgeon for the first time were more likely to have a good experience (OR = 1.2 [95% CI 1.1‒1.5], p = 0.03). CONCLUSION: Introduced rapidly during the COVID-19 lockdown, urology teleconsultation attained a high level of satisfaction among both patients and physicians. A major change in telemedicine use is foreseen in the post COVID-19 era.