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Utilizing Telemedicine in a Novel Approach to COVID-19 Management and Patient Experience in the Emergency Department

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Introduction

Since the first case of coronavirus disease 2019 (COVID-19) was reported to the Centers for Disease Control and Prevention (CDC) on January 21, 2020, the exponential growth in affected patients has caused an unprecedented strain on the U.S. health care system, particularly in New York City.1,2 The high volume faced by hospitals in conjunction with a severe shortage of personal protective equipment (PPE) poses serious safety risks for both patients and health care workers.3

Patients with suspected COVID-19 symptoms are isolated immediately upon arrival to emergency departments (EDs).4 Isolation among hospitalized infectious disease patients is a well-documented source of psychological distress, leading to loneliness and increased scores on depression and anxiety scales.5,6 For some patients, isolation can be even more difficult than the medical aspect of their illness.7 In addition to these psychological effects, isolation has a detrimental impact on care delivery. Attending physicians are only half as likely to conduct examinations on isolated patients, one of many factors contributing to lower Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from isolated patients for overall care, staff responsiveness, and respectful treatment by providers.8–10 These negative psychological and care delivery outcomes, which were previously documented in the 2003 severe acute respiratory syndrome (SARS) outbreak, are again leading to an increased prevalence of loneliness, anxiety, depression, and even suicide in isolated hospitalized patients during the current COVID-19 pandemic.11,12

Telemedicine, defined by the Centers for Medicare and Medicaid Services (CMS) as an exchange of medical information from one site to another through electronic communication to improve a patient’s health,13 has been called a “virtually perfect” tool to address these issues in the setting of a pandemic.14 In an effort to facilitate telemedicine services in this setting, the Department of Health and Human Services stated it will not penalize providers for noncompliance with regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), thereby allowing the use of popular video chat applications such as FaceTime and Zoom for patient interactions.15 CMS expanded Medicare telemedicine coverage to include all visits traditionally conducted in-person, and waived requirements for establishing in-person physician/patient relationships before telehealth visits.13 State regulators also showed flexibility in response to this crisis, with 44 states (including New York) waiving in-state licensure requirements for telemedicine physicians by mid-April 2020.16

Although the adoption of telemedicine has increased in recent years, most applications in the ED continue to focus on remote consultations.17,18 The rapidly shifting landscape of this pandemic has allowed for a novel, large-scale use of telemedicine to aid in the management of potential and confirmed COVID-19 patients in the EDs at NewYork-Presbyterian/Weill Cornell Medical Center (NYP/WCMC) and NewYork-Presbyterian/Lower Manhattan Hospital (NYP/LMH). NYP/WCMC is a quaternary care, urban academic medical center with 862 inpatient beds and an annual ED volume of 95,000 patients.19 The ED is a certified center for trauma (Level I), stroke, ST-segment elevation myocardial infarction, and burns, receiving referrals from local and regional hospitals. NYP/LMH is a 180-bed urban community hospital and certified stroke center in southern Manhattan, which sees ∼50,000 ED visits annually.20 Both locations had a strong ED telemedicine infrastructure predating the COVID-19 crisis, including teleconsults (for specialties such as otorhinolaryngology, neurology, psychiatry, and stroke/vascular), direct-to-consumer virtual urgent care,21,22 and the ED-based Express Care digital service initiated in 2016.23 A smaller scale teleisolation initiative using a single telemedicine cart was also conducted in response to Ebola virus disease. These prior initiatives have resulted in patient outcomes and satisfaction equivalent to in-person visits, and have been incorporated into our ED disaster preparedness planning.24–26 In these two centers, telemedicine carts were successfully deployed into COVID-19 isolation rooms to enable more frequent communication between clinical providers and patients, conserve PPE, and allow support staff subject to isolation restrictions to communicate with patients more effectively.

Materials and Methods: Telemedicine in COVID-19 Isolation Rooms

Overview of Teleisolation Cart System

Nineteen Avizia C250 telemedicine carts (14 at NYP/WCMC and 5 at NYP/LMH) were used for COVID-19 patient care and made available for use 24 h/day, 7 days/week (Fig. 1). Seven of these carts were repurposed from original uses obtaining medication history and teleconsults (ENT and psychiatry), and the remaining 12 carts were acquired for this COVID-19 initiative. The carts were equipped with tablets and Sony high-definition pan-tilt-zoom (PTZ) cameras that enable video communication. Each isolation room was also equipped with a landline phone as a backup to the carts.

Fig. 1.

Fig. 1. Teleisolation cart and provider workstation. Carts are placed adjacent to patient beds in isolation rooms for ease of touch-free access (A). Providers can initiate video calls from their workstations (B).

The carts enabled both clinical providers and other hospital staff to communicate with patients from their workstations by logging into a shared Avizia user account via their designated computer, starting a video call, and using a headset. Incoming calls automatically appeared and were answered on the patient’s screen, removing the need for patients to physically touch the system or have any knowledge as to how to connect. Once connected, providers could control the PTZ camera’s zoom and positioning by clicking the desired location on the screen or using arrows on the online Avizia interface (Fig. 2). At the conclusion of the patient interaction, providers would end the video call and log out of the system. The devices were used solely for video and audio connection, and no clinical notes or other official patient documentation was recorded through this interface.

Fig. 2.

Fig. 2. NewYork-Presbyterian Avizia online interface. The online interface as shown in the NewYork-Presbyterian COVID-19 Teleisolation Training Guide (A), and in practice for a virtual pediatric visit (B). Photos published with permission.

Implementation and Training Process

By building on our preexisting relationship with Avizia and a telemedicine cart system already integrated into our care delivery apparatus, ED leadership was able to respond quickly to the evolving crisis based on the existing infrastructure and needs of each site. At NYP/WCMC, adapting carts for teleisolation required physically placing carts in COVID-19 isolation rooms, ensuring the rooms were equipped with wired internet connections as a backup to wireless internet, configuring designated provider workstations with cameras and headsets, demonstrating use of the system, and providing education for clinical users. In the NYP/LMH ED, there are only two negative pressure rooms, both of which were required for intubations and resuscitations. In part due to this scarcity, the teleisolation carts at NYP/LMH remained mobile and were available to be used in all ED rooms. This flexible strategy allowed us to continue using the carts for neurology, stroke, and psychiatry teleconsults in addition to COVID-19 teleisolation, maximizing the number of patients benefiting from the resource.

Alongside deployment of the carts, shared user profiles for teleisolation were created on the NewYork-Presbyterian Avizia portal, and a brief 5-min training on navigating the system was administered by providers experienced in using the platform to applicable ED staff. Each provider trained was asked to instruct two other people to use the system. This peer-to-peer training, which has been shown to be an effective educational tool in other ED settings, was used to provide rapid dissemination of knowledge amidst surging COVID-19 case volume.27,28 Carts were also available for use by internal medicine and other non-ED clinical teams caring for isolated ED patients, but only for providers physically present in the hospital.

In addition to the nine new carts and the provider headsets, the only monetary cost incurred in deploying this program was the time of the staff involved in implementation and education of the initial set of providers. Efficient implementation and training were essential as our departments quickly mobilized to tackle the rapid rise in COVID-19 ED arrivals.

Maintenance Requirements

In theory, this system required minimal ongoing maintenance once carts were placed in isolation rooms. In practice, carts were often unplugged and moved in and out of rooms during cleaning and emergencies, as well as to avoid disrupting patient sleep with a bright screen at night. As a result, they sometimes required remote rebooting by technology support staff and in-person adjustments to the microphone, camera, or speaker settings via the cart’s tablet. Carts were decontaminated by Environmental Services (EVS) along with the rest of the room between each patient in accordance with the hospital policy.

This study was reviewed and determined to be exempt by the Weill Cornell Medicine Institutional Review Board.

Results

The teleisolation program was implemented on March 10, 2020. It was used for 205 COVID-19 cases in March, 27 in April, and 29 in May, for a total of 261 cases over that 3-month period. The number of cases per day peaked at 24 on March 21, 2020 (Fig. 3).

Fig. 3.

Fig. 3. Daily total teleisolation cases, March 10, 2020–May 31, 2020. Cases include COVID-19 patient interactions using teleisolation carts at both NewYork Presbyterian/Weill Cornell Medical Center and NewYork Presbyterian/Lower Manhattan Hospital.

NYP/WCMC carts had 66% of the case volume over this period (173/261 cases), while NYP/LMH had the remaining 34% (88/261 cases) (Table 1). The three carts provided for the pediatric ED were the most heavily utilized, comprising 52% of all teleisolation visits (136/261 cases). Data on the number of unique COVID-19 patients included in these 261 provider/patient interactions were not available.

Table 1. Teleisolation Cases by Location March 10, 2020–May 31, 2020
TELEISOLATION CART NO. OF CASES
NYP/LMH 88
 Teleconsult (ED-1)/Isolation Floater 20
 Teleconsult (ED-2) 3
 LMH ED Isolation—A13 18
 LMH ED Isolation—A14 7
 LMH Peds Isolation—P1 40
NYP/WCMC 173
 Area C Room 15 4
 Area C Room 10 10
 Area C Room 14 11
 Area C Room 9 4
 Area B Room 1 7
 Area B Room 2 4
 Area B Room 8 2
 Adult B Room 9 4
 Adult C Room 13 5
 Adult C Room 8 7
 Adult D Room 5 13
 Area D Room 1 6
 Peds ED Room 5 49
 Peds ED Room 4 47
Total 261

In June 2020, four of the carts were repurposed for telepatient navigation to arrange post-ED care, a previously in-person process moved out of the ED due to concern about virus transmission to staff. Navigation by video for patients being discharged has resulted in a higher proportion of patients presenting for scheduled follow-up visits than when this process was solely conducted by phone earlier in the pandemic.

Over the course of these visits, the teleisolation carts provided benefits for a variety of stakeholders. Based on qualitative feedback, clinical providers found that the carts were most useful after an initial in-person patient evaluation, during which time they had the opportunity to introduce the communication modality to the patient and handle minor cart adjustments as needed. Clinicians reported that after a brief familiarization period, using this system streamlined their workflow by eliminating the time-consuming PPE process and increased their frequency of communication with isolated patients. For example, providers previously waited for an entire set of laboratory and imaging results to arrive before donning PPE and entering an isolation room; with the carts, clinicians could provide patients with updates as results arrived in an expedited manner. From a resource conservation standpoint, each avoided in-person visit conserved a surgical mask, gown, pair of gloves, and disposable eye protection. The presence of the carts also enabled those who are otherwise restricted from isolation rooms, such as social workers and patient services representatives, to support these patients more effectively compared to the limited phone interactions before this initiative. In addition, ED staff anecdotally reported an improved ability to deliver ED telepalliative care with this resource.

From the patient perspective, the teleisolation carts eliminated the need to physically manipulate a communication device and anecdotally decreased feelings of loneliness and anxiety. Before this initiative, only one visitor per patient was permitted to wear PPE and enter the ED isolation rooms. During periods in the pandemic when family visitation was possible, the carts enabled family members visiting an isolated ED patient to virtually interact with their loved one as a group without the barrier of PPE. Both patients and their families reported that these video interactions, even when only tens of feet apart physically, helped to quell their fear in a chaotic clinical environment. Moreover, these interactions may have reduced family exposure to COVID-19. Given the widespread patient isolation required during this pandemic, addressing the psychological distress common among COVID-19 patients is among the most impactful potential benefits of telemedicine interventions such as ours. However, the discontinuation of HCAHPS surveys during the pandemic prevented the capture of quantitative patient experience data to systematically test this feedback.

Discussion

Over half of U.S. EDs utilize telemedicine in some manner, which provides considerable opportunity to redeploy existing telemedicine resources to improve ED management of COVID-19.18 In particular, the use of telemedicine carts to treat patients in ED isolation rooms has been pioneered by both academic and community hospitals in COVID-19 epicenters, including northern California and our initiative at NYP/WCMC and NYP/LMH in New York, NY.29,30 Strong support from NYP/WCMC ED leadership facilitated the development of an ED-based telemedicine infrastructure well before COVID-19, substantially easing our implementation process and making a swift response to the crisis possible. We were able to rapidly integrate new carts, repurpose existing carts from other hospital areas, and configure them to work with a software system already deemed HIPAA-compliant by the institution. At NYP/WCMC, we allocated carts specifically for COVID-19 isolation rooms, while in our urban community hospital, carts remained mobile to allow for transport to rooms where COVID-19 patients were being treated. Deploying different placement strategies in the two EDs maximized cart availability for isolation patients and demonstrates the utility of telemedicine in any ED setting. The carts facilitated communication between clinical providers and patients at various points of their ED course, from reporting of initial laboratory results to telepalliative care. In fact, this model of ED telepalliative care served as a crucial extension to inpatient telepalliative care services that have been implemented elsewhere.31 The carts also provided residents with valuable real-time education on conducting telemedicine encounters, as encouraged by the Accreditation Council for Graduate Medical Education (ACGME).32

Between both hospitals, our teleisolation carts conducted 261 provider/patient interactions, with 79% occurring during March when New York City was reaching its peak of COVID-19 cases, resulting in a commensurate number of fewer direct provider exposures to infected patients. When accounting for exposures between patients and family members under the one visitor per patient policy in our EDs, the teleisolation program likely avoided more than 400 COVID-19 exposures in total, translating into 400 or more sets of PPE conserved.

The high-risk nature of these exposures for health care providers is well-documented. In one California hospital, 36% of providers exposed to a patient who later tested positive for COVID-19 became symptomatic, and 2.5% tested positive within 2 weeks.33 If transmission was similar in our hospitals, the exposure reduction from our teleisolation initiative may have helped to avoid dozens of symptomatic providers and a potential estimated six COVID-positive cases, which would have greatly exacerbated staffing constraints on an already overtaxed workforce.

While the teleisolation carts proved useful in the adult ED, the pediatric ED utilized the carts more frequently, accounting for 52% of all patient encounters despite only having access to 3 of the 19 total carts. There are several possible explanations for this high utilization relative to the adult ED. Pediatric ED physicians in both hospitals had preexisting familiarity with the teleisolation cart interface, as the same Avizia platform is used for telemedical screening examinations in the pediatric triage areas. As a result, the onboarding process for many pediatric ED physicians only entailed providing login information and headsets. The pediatric ED also worked without residents during the peak of COVID-19 cases in March. The consolidated team environment may have enabled providers to teach colleagues in real-time and increase cart utilization more quickly than in the adult ED. Finally, providers may have recognized the increased hardship that isolation places on minors, which has been documented in previous infectious disease outbreaks, and prioritized communication with pediatric patients and their adult guardians.34

Hospitals without preexisting telemedicine resources could implement similar systems using off-the-shelf, commercially available hardware and software, a possibility made even more feasible by the loosening of HIPAA constraints during the current pandemic.15 Placing landline phones in isolation rooms, which we did as a backup system to the carts, can provide value via remote audio interactions.

These important benefits came with a few practical difficulties that hospitals implementing similar programs should address in their planning. While in theory the carts required little ongoing maintenance, they were often unplugged or repositioned during room cleanings and overnight to minimize disruption for patients. Minimizing the extent that these adjustments needed to be made required separate education and frequent reminders for both clinical staff and EVS. Hardware and software design that reverted to last-known settings would have made these devices more user-friendly for an ED environment. From the patient standpoint, those who had not used videoconferencing previously faced a steeper learning curve to adjust to this communication method. While we have previously shown that patients older than 60 years report satisfaction with ED-based telemedicine equivalent to patients from 21 to 59 years of age,25,35 we found that older adults may take longer to adjust to this communication method, and strategies for increasing engagement should be considered. Finally, there was a significant time investment required to remind users to incorporate a new feature into their workflow and convince them of its benefits, especially when they were already heavily burdened with changes in a pandemic full of unknowns. The high utilization of the carts in the pediatric ED relative to the adult ED underscores the rapid adoption possible when providers are already familiar with the telemedicine platform hosting a new care delivery method.

Conclusions

The COVID-19 pandemic has brought telemedicine to the forefront of health care delivery, and more than 50 U.S. health care systems have mobilized to increase their telemedicine services in the weeks since the crisis reached the United States.14 The valuable lessons learned from the COVID-19 response in New York City should be leveraged to improve care delivery in infectious disease outbreaks requiring patient isolation, as well as any other scenarios in which PPE requires rationing. In particular, hospital systems should invest in the expansion of emergency telemedicine services, which may reduce the strong psychological toll of isolation and address safety risks by decreasing barriers to effective communication between patients and clinical staff. Given the current regulatory flexibility, tablets, carts, personal communication devices, or even landline phones are all feasible options, and the choice of device and telemedicine strategy can be tailored for any ED setting. Using teleisolation carts in a model similar to those described here could reduce exposure and improve communication in other EDs, intensive care units, and general inpatient floors housing patients with symptoms suggestive of COVID-19. Future integration of cart software with smartphones outside of hospital networks could enable family members to interact with hospitalized patients without visiting in person. Teleisolation carts could also be installed in locations such as nursing homes, rehabilitation centers, and other long-term care facilities whose residents are most susceptible to COVID-19 and at high risk for extreme isolation due to visitor restrictions.36,37 Even if the current pandemic abates, health systems should recognize the critical role of telemedicine in future disaster preparedness planning. Building telemedicine infrastructure and vendor relationships with hospital leadership support well in advance of an infectious disease outbreak or a mass casualty event allows for the agile scaling needed to manage such catastrophic scenarios.18,38

Acknowledgments

The authors acknowledge the Department of Emergency Medicine, NewYork-Presbyterian/Weill Cornell Medicine and NewYork-Presbyterian/Lower Manhattan Hospital, and NYP Innovations.

Disclosure Statement

No competing financial interests exist.

Funding Information

The authors have no funding information to disclose.

References





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