Abstract
The COVID-19 pandemic has presented pediatric emergency departments with unique challenges, resulting in a heightened demand for adapted clinical pathways. In response to this need, the Montreal Children's Hospital pediatric emergency department introduced the WAVE (Waiting Room Assessment to Virtual Emergency Department) pathway, a video-based telemedicine pathway for selected non-critical patients, aiming to reduce safety issues related to emergency department overcrowding, while providing timely care to all children presenting and registering at our emergency department. The objective of the WAVE pilot phase was to evaluate the feasibility and acceptability of telemedicine in our pediatric emergency department, which was previously unfamiliar with this mode of care delivery. During the six-week, three-evening per week deployment, we conducted 18 five-hour telemedicine shifts. In total, 27 patients participated in the WAVE pathway. Results from this pilot phase met four of five a priori feasibility and acceptability criteria. Overall, participating families were satisfied with this novel care pathway and reported no disruptive technological barriers.
Introduction
According to the American Academy of Pediatrics, telemedicine can enable high-quality pediatric care. 1 It facilitates the remote connection between health care providers and patients through the use telecommunication technologies. 2 In neonatal and pediatric medicine, the impact of telemedicine presents distinct benefits, such as improved access, communication and education. It also faces challenges related to provider reimbursement, medicolegal obligations, disparities in access and concerns regarding safety and privacy.2–7 Family and caregiver perspectives support the use of carefully designed telemedicine models in the pediatric tertiary care setting.8,9
Rapid and ongoing health system adaptations in response to the COVID-19 pandemic accelerated the adoption of telemedicine, given its potential for safe and timely patient care.10,11 Initial decreases in emergency department (ED) visits, partially driven by the fear of COVID-19 exposure, prompted concerns over delayed patient presentations and their associated risk of higher morbidity and mortality.12,13 Decreased ED volume also corroborates prior studies suggesting that non-acute presentations represent a significant proportion of visits, including the pediatric emergency department (PED) setting.14,15 Many of these visits may be safely amenable to virtual consultation.
ED crowding refers to a situation where service needs surpass the available resources, 16 thus threatening patient safety.17,18 Increases in ED visit volume (input) and operational factors during ED care (throughput) are major contributors to PED crowding.18–20 The COVID-19 pandemic further constrained PED resources. ED staff were spending more time donning and doffing personal protective equipment, conducting COVID-19 tests and disinfecting patient rooms. Social distancing requirements reduced waiting room capacity. Clinicians were faced with diagnostic challenges demanding adapted clinical pathways, as in the recognition and management of pediatric inflammatory multisystem syndrome.21,22 Case reports of delayed presentation to care associated with detrimental patient outcomes have highlighted a feared collateral consequence of the pandemic. 13 Pediatric emergency health care systems have undergone significant adaptations to face these challenges, particularly in anticipation of seasonal overcrowding patterns and multiple waves of COVID-19 infection.
This context motivated the creation of a Canadian PED taskforce to guide the design, implementation and evaluation of telemedicine in our field. Some Canadian PEDs initiated synchronous telemedicine programs among selected patient populations, in an effort to reduce the proportion of care conducted in-person and provide safe access to urgent pediatric care. 23 Live modifications to system operations present distinct challenges in the health care setting. 24 In this report, we describe the gradual implementation and evaluation of video-based telemedicine in our PED, which was previously unfamiliar with this mode of care delivery.
Our setting
The Montreal Children's Hospital (MCH) ED is one of two pediatric EDs in the city of Montréal, Canada. We serve a multi-cultural urban population of 3.5 million people and are the referral site for remote communities located in the Northern and Western parts of the province of Quebec. With over 80,000 annual visits, we are one of the busiest PEDs in North America. The MCH ED is staffed by 25 board-certified pediatric emergency medicine specialists and five adult emergency medicine physicians with advanced pediatric expertise.
Role of telemedicine in our emergency department
In May 2020, our hospital mandated all divisions to prepare for increased patient volumes following the anticipated de-escalation of a regional lock-down. Our division's experience with telemedicine was limited to synchronous, phone-based, provider-to-provider consultations to discuss pediatric acute care management and potential transfers. We had no prior experience in telemedicine between patients and providers. Given this context, we undertook a multi-phase telemedicine rollout. Our model aimed to reduce safety issues related to ED overcrowding, while providing timely care to all children presenting and registering at our ED.
This report focuses on the pilot phase, which evaluated the feasibility and acceptability of a novel care pathway in our setting. The Waiting Room Assessment to Virtual Emergency Department (WAVE) pathway occurred between November 3, 2020, and December 16, 2020.
Organizational engagement
Project leaders from our division (JS, JT) developed a virtual care ramp-up plan in coordination with the hospital's telehealth department (CQB, SW). This fruitful collaboration led to the development of the WAVE pathway. Aiming to optimize the safety of this process, we opted for an initial in-situ quality improvement (QI) project, where physicians and patients engaged virtually while remaining within the hospital premises. This project aligned with national and provincial guidelines regarding the provision of virtual care.25–27
Quality improvement evaluation framework
During this pilot phase, we evaluated the feasibility and acceptability of the WAVE pathway. We defined those a priori, based on expert consensus at our site:
≥ 80% recruitment rate among families approached to participate; ≥ 80% telemedicine visit completion without significant technological concerns; < 1% critical event rate within 72 h of the telemedicine visit; < 10% telemedicine to in-person conversion rate; ≥ 70% of participating patients/families rating their overall experience as being “somewhat” or “very” satisfied.
We recorded patient demographics, visit characteristics and satisfaction surveys at the time of the ED visit. Information on additional care episodes following discharge was captured at a planned 72 h phone follow-up. The Centre for Applied Ethics of the McGill University Health Centre approved the QI proposal and deemed it exempt from a Research Ethics Board review.
Definition of clinical appropriateness
We developed a list of eligibility criteria based on similar work at other Canadian pediatric EDs, expert opinion from physician and nursing leadership within our department, and provincial guidelines on telemedicine. 26 We restricted eligible visits to those involving patients aged older than 3 months. In addition, we only included patients at the lowest triage categories (4 and 5) of the Paediatric Canadian Triage and Acuity Scale (PaedCTAS). 28 Given the novelty of this mode of care delivery at our ED and the focus on safety, we further limited the WAVE pathway to patients without a complex medical background or immunodeficiency. In addition, specific conditions were deemed clinically inappropriate for this pathway due to the presumed need for a physical examination (e.g., eye trauma, ear pain, musculoskeletal injury with reduced range of motion) or potential need for acute medical intervention (e.g., respiratory distress, altered mental status, intoxication, head injury, moderate to severe dehydration). The complete list of retained inclusion and exclusion criteria is shown in Table 1.
Inclusion and exclusion criteria for WAVE pathway.
ED: emergency department.
MSK: musculoskeletal
OR: this is not an acronym
FT: Fast-track
IFHP: Interim federal health program (a federal program which provides limited, temporary coverage of health-care benefits to certain individual who are not eligible for provincial or territorial health insurance)
RAMQ: Régie de l'assurance maladie du Québec (provincial public health insurance)
Emergency department deployment
During this pilot phase, our clinical team consisted of one nurse and five alternating pediatric emergency physicians. Virtual shifts were scheduled on three evenings per week to align with typical peak patient volumes in our ED. In total, we completed 18 five-hour telemedicine shifts over a six-week period. Since patients and families remained in the ED during this pilot phase, two rooms equipped with a tablet, webcam and microphone were allocated for this purpose. The telemedicine physician was located in a separate ED office with a webcam and microphone-equipped computer using a health ministry-approved telemedicine platform (ZOOM and TEAMS). 27 Patients followed the usual process for ED registration and triage. The telemedicine nurse on shift approached potential candidates after reviewing their triage notes on the ED information system. If patients met eligibility criteria and verbally consented to being part of this QI project, the virtual visit occurred within the next 30 min. The physician made clinical decisions regarding any further treatment, investigations, or the need for an in-person assessment in our ED. Despite the in-situ nature of this pathway, telemedicine-dedicated physicians were never in physical contact with families as the entire encounters were conducted virtually (Figure 1).
Swimlane diagram of the WAVE pathway pilot phase.
Our experience
Over the six weeks of the WAVE pathway, there were 220 patients in the eligible triage categories during WAVE pathway hours. Of those, 32 patients met all other eligibility criteria and 27 (84%) agreed to participate in a telemedicine visit. This represented 12.3% of all patients with a triage category of 4 or 5 who presented during the operational hours of the WAVE pathway. These patients had a mean age of 5.8 years (range of 6 months to 11 years); 16 (59%) were females; all were covered by a public provincial (89%) or federal (11%) health insurance program. PaedCTAS triage category 5 predominated (77.7%). The most common primary reason for consultation was “cough or upper respiratory tract infection” (5/27), followed by “fever and dysuria” (4/27), “mental health concerns” (4/27), “rash” (3/27) and “constipation” (2/27).
The mean virtual consultation duration was 12.7 min. The mean length of stay in the ED was 74.8 min (from registration to discharge). During the study period, the average length of stay in the ED for all patients with a Canadian Triage and Acuity Scale triage level of 4 or 5 was 4 h.
The virtual visit was converted to an in-person assessment in six patients (22%). In three of these visits, the conversion was deemed clinically necessary: one patient required laboratory testing and imaging; one needed a genital examination; another needed an ear exam. The three other visit conversions occurred primarily out of convenience, as the patient was already in the ED. One participated in an in-person psychiatry assessment given the availability of the resource at the time of their visit; two in-person assessments following teleconsultation were provided upon parental request Thus, we determined that 3/27 patients (11%) truly required the same-day in-person assessment following their virtual visit.
We reached 26/27 patients at the planned post 72 h phone follow-up. Excluding patients who had the same-day conversion to in-person care at our ED, 2/26 (8%) attended an in-person clinical assessment following their discharge from the WAVE Pathway. One patient had a persistent cough and was seen by their primary physician two days after the telemedicine visit. There was no change to the diagnosis and management plan. The other patient, who was initially diagnosed with a urinary tract infection (UTI), returned to the ED within 72 h with flank pain and fever and required laboratory investigations and a next-day follow-up at our Medical Day Hospital. The final diagnosis (UTI) and management were unchanged. Given the reassuring clinical evaluation of these two patients, we identified no critical event within 72 h of the telemedicine visit.
Our patient satisfaction surveys were completed by 26/27 participants. Most responders (81%) found the WAVE pathway to be very useful and 76% felt their concerns were completely addressed. All participants felt the WAVE pathway was safe (“very safe”: 86.4%; “somewhat safe”: 13.6%). All patients and families were satisfied with the technology used during the telemedicine consultation. Given these results, the WAVE pilot phase met four of the five a priori criteria for feasibility and acceptability. It barely exceeded the acceptable rate of medically necessary virtual to in-person care conversion (11% vs. 10%). Overall, this care pathway helped reduce the number of families in our ED waiting room, shortened their length of stay and eliminated in-person contact between physicians and patients who were assessed virtually.
The path forward
The in-situ design and conservative eligibility criteria during the pilot phase of the WAVE pathway were selected to maximize the safety of participants, as this was our ED's first experience with telemedicine connecting patients with physicians. We did not identify any serious adverse outcomes attributable to this care pathway, but our small sample size limits the ability to draw definitive conclusions. Nonetheless, our in-situ approach and conservative eligibility criteria facilitated institutional approval while minimizing potential risks to patients. Opportunities for co-design with patients, families, physicians, nurses and other care providers will inform the next iterations of the WAVE pathway. The lessons learned from this QI study enabled our team to improve the next phase of the project, where families will return home if the triage assessment deems the visit to be virtualizable.
Barriers and limitations
During the 2020–2021 winter, PEDs across Canada and worldwide experienced unexpectedly low patient volumes. This context and our conservative eligibility criteria, focused on reducing safety risks, significantly limited the pool of potential participants to the WAVE pathway. Moreover, the in-situ nature of the pilot phase may have incentivized “convenience-based” in-person assessments following teleconsultation, thus inflating the reported conversion rate and unnecessarily increasing the utilization of precious resources. We expect improvements in these regards during the next phase of the WAVE pathway, when patients will participate in telemedicine visits from the comfort of their homes.
We recognize that marginalized communities with limited access to primary care may present to the ED with non-urgent complaints. Many of these conditions are ideally suited for successful evaluation by telemedicine, but can cause further barriers to care for digitally excluded communities. 29 Future iterations of the WAVE pathway must be carefully designed to reduce rather than enhance existing disparities in access to health care. 30
Future directions
We have developed a mapping process for the next phases of the project. In phase 1, eligible patients will return home for a telemedicine visit after completing their in-person registration and triage in the ED (Figure 2). Physicians will conduct video-based consultations from the ED office space designed in the pilot phase. Patients will be seen within 18 h from ED registration in this phase. A more comfortable wait at home, a scheduled appointment with a pediatric ED specialist and reduced waiting room crowding are among the added benefits of this intervention. However, as indicated by the three families (11%) who requested an in-person assessment despite a reassuring virtual visit, alternative pathways may be needed. Models where low urgency patients are evaluated by telemedicine and discharged from the ED could be considered for families who have already traveled to the hospital, particularly in times of global emergencies.31,32
Swimlane diagram of the WAVE pathway phase 1.
We chose specific ED metrics to determine when to activate the next phase, with a projected implementation time of two weeks to secure funding, hiring and adequate training. The next phase will be activated in the event of a sustained increase in patient volumes (> 200 patients per day for five consecutive days), excessive utilization of waiting room capacity (> 80% for five consecutive days) or additional concerns suggesting a looming risk of PED overcrowding.
We anticipate that the ongoing expansion of telemedicine will outlast the COVID-19 pandemic, and PEDs must adapt to the changing nature of health care delivery. Our stepwise approach, focused on patient safety, enabled the implementation of a video-based telemedicine program and adaptation to future needs. In settings with limited prior telemedicine experience, a phased approach such as ours may facilitate the implementation and evaluation of virtual care delivery.
Footnotes
Acknowledgements
Participating patients and families
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
