Written by: Y. Razvi, H. Wong
The COVID-19 pandemic continues to restrict, change and affect our lives in many different ways. In addition to promoting a decentralized model of care to families and providers all across Ontario, we can now see many real world examples of the success and limitations related to this form of care.
Early in the pandemic, there was a significant decrease in emergency department (ED) visits across the globe. The Children’s Hospital of Eastern Ontario (CHEO) similarly noted a 60% decrease in their ED visits, in a likely attempt by families to limit exposure to COVID-19. In response to this, the division of emergency medicine created the first virtual pediatric ED (V-PED) in Canada. The platform saw 1036 patients within its first two months, which constituted 76% of all CHEO ED ‘visits’ . Of these patients, only 17% later presented for an in-person assessment. 170 patients completed a post-visit survey, where 87% of respondents rated their care as excellent. All respondents stated that V-PED addressed their concerns and that they would use it again in the future. Had it not been for V-PED, 70% stated that they would have presented to the ED in person, potentially placing themselves and their children at-risk of contracting COVID-19. Furthermore, 13% of their Ontario users lived >50 km away, while another 14% lived in Quebec. This highlights the potential burden that ED visits may have on families through indirect costs of transportation. Overall, V-PED demonstrated the power of distributed pediatric care in the acute care setting, something that differs significantly from the conventional ED visit.
Beyond acute care, other tertiary children’s hospitals in Ontario developed virtual means of longitudinal follow-up. One such example was seen in the Hospital for Sick Children in Toronto, where their chronic pain clinic rapidly mobilized to deliver 77 appointments virtually during the early weeks of the pandemic . Patients were assessed via videoconferencing and were engaged in the modified physical exam, where the caregiver was instructed to perform maneuvers after watching a demonstration. Following the discussion and physical examination, the care team regrouped privately in Microsoft Office Teams to discuss a plan for the patient. This care plan was then relayed to the patient directly and included in an after-visit summary that was distributed via email. No gaps in service delivery were identified and visits were equally as efficient in time, where new appointments were still allotted 90 minutes and follow-ups 45 minutes . Staff identified the team culture of collaboration and flexibility, as well as institutional support, as being key to their success.
There is evidence to suggest that the uptake of telemedicine during the pandemic was widespread and not simply limited to pediatrics. The proportion of ambulatory care made up by virtual visits was shown to have increased from 1.6% in the second quarter of 2019 to 70.6% in the second quarter of 2020 . Similarly, the number of Ontarians who had at least one virtual visit increased from 1.3% to 29.2% in the same time period . The use of telemedicine was also shown to have expanded from traditional rural communities to more urbanized centers. This was shown by the proportion of virtual visits coming from rural communities decreasing from 28.6% to 5.9% between 2012 to 2020 . While much of our present discussion has centred on the benefits to the pediatric population, elderly patients were in fact the highest users of virtual care. The use of virtual care was highest for patients with mental health concerns, followed by heart failure, COPD, angina, diabetes, hypertension, and asthma . These results highlight the widespread adoption of virtual care as a result of the pandemic and its benefits beyond pediatrics.
While the benefits of distributed care are notable, it is not without its limitations. Both cases from CHEO and the Hospital for Sick Children noted limitations in the extent of the virtual physical exam. Given the longitudinal nature of the chronic pain clinic, certain exam maneuvers were deferred for an in-person visit at a later date. However, the acuity of the CHEO ED necessitated that some patients present for immediate assessment. Furthermore, the use of telemedicine was identified as a potential barrier to care for patients who have poor technological literacy and lack the necessary infrastructure to support virtual visits, such as appropriate devices and high-speed internet . General technological difficulties also remain a concern both on the part of the clinician and patient . Finally, virtual care creates a physical barrier between the clinician, their patient, and their colleagues, which may limit the feelings of comfort and trust that are vital for the therapeutic relationship .
Real world examples of the widespread adoption and success of virtual care are growing every day. These examples show the importance of telemedicine as an integrated part of our society. As we design and improve our healthcare system for the future, any model we consider should include a component of virtual care.
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