Ease in Emergency Hospital Visits Due to Covid-19 Following Implementation of a Telemedicine Service in Ceará, Brazil
Background
The severe acute respiratory syndrome caused by the new coronavirus (SARS-CoV-2) infection is a worldwide phenomenon that has been termed a pandemic by the World Health Organization (WHO).1 The arrival of the pandemic reached Brazil in March 2020, arbitrarily termed a “first wave,” followed by a reduction in the number of cases by the end of the year. However, a “second wave,” with a greater number of individuals affected, developed in March 2021, reaching 100,000 daily cases by March 25.2
Tackling this emergency requires state-of-the-art health facilities and specialized trained personnel among carrying a high economic burden. Emergency services have become overwhelmed, given that the number of patients seeking care largely exceed the installed capacity. Thus, provisional health care facilities, including installations in tents, football stadiums, and parking lots, are set up.3–5 To manage those issues, the Brazilian government, by the Ministry of Health, issued an exceptional and temporary authorization for the provision of telemedicine aiming at fostering health care during the pandemic (as per ordinance no. 467 as of March 20, 2020, on an exceptional and temporary basis, to manage the COVID-19 pandemic, provided for in Art. 3 of Law No. 13,979, as of February 6, 2020).6
Despite being an already consolidated technology, telemedicine came at a relatively slow pace of implementation. However, the pandemic has significantly facilitated the use of this technology, and several initiatives with the use of telemedicine emerged after the onset of the COVID-19 pandemic.7–9 There are reports claiming that up to two-thirds of the need for outpatient care due to the pandemic was offset by telemedicine strategies.10
We report the impact after the establishment of a telemedicine service in UNIMED Fortaleza®, a private service of complementary health assistance, based in Fortaleza-CE, Brazil, revealing a reduction of admissions to the emergency room (ER) of patients seeking care for COVID-19, without jeopardizing clinical outcome.
Methods
This was a retrospective observational cohort study conducted from May 2020 to March 2021, at the Hospital Regional UNIMED (HRU) in Fortaleza, Ceará, Brazil. The HRU is a 330-bed general hospital managed by UNIMED Fortaleza, which was enlarged to become a 516-bed hospital after being adapted to face the increased need for hospitalization of COVID-19 patients. UNIMED Fortaleza currently provides health care for 334.502 people (www.ans.gov.br/anstabnet/cgi-bin/tabnet?dados/tabnet_cc.def; accessed on June 21, 2021). At the beginning of this pandemic, the administrative board took a decision to centralize the care for COVID-19 patients insured by UNIMED Fortaleza in the HRU, regardless of the initially contracted assistance.
A virtual emergency room (VER) was implemented to care for insured patients with suspected symptoms of COVID-19 on February 17, 2021, to provide patient support in a timely manner for patients with mild symptoms. The first decision to see remote attendance or to come instead to the ER was made by the patient or caregiver, without the interference of the UNIMED Fortaleza health system.
A specific mobile device, namely “Cliente Unimed Fortaleza,” was developed with free access to patients or caregivers, operating daily from 7:00 am to 7:00 pm. At first access, input data include contact information, symptoms, and a graded pain score. After checking and authorization, the client enters an automatic queue for attendance provided by a physician who received specific training in early care for COVID-19 patients. The training was provided by Unimed Fortaleza based on a panel of two family physicians, two general practitioners, one pulmonologist, and one otorhinolaryngologist accredited by the Unimed Fortaleza health system.
Data from patients seen in the ER and VER in May 2020 and March 2021 were collected directly from the medical records, gathering clinical data of all patients admitted to the outpatient care and emergency facilities structured at the HRU. Information on comorbidities included obesity (defined as body mass index >30), systemic arterial hypertension, cardiovascular disease, diabetes, non-dialysis chronic kidney disease, and previous stroke.
The number of absolute visits was recorded. The need for hospitalization and invasive interventions performed during hospitalization were recorded, including mechanical ventilation. The primary outcome was the number of patients needing hospitalization with data right-censored on Jun 15, 2020, and Apr 15, 2021. Secondary outcomes included the need for visits to the ER and ventilatory assistance, including mechanical ventilation.
Data are presented as means or percentages, as appropriate. Normality was assessed by using Kolmogorov-Smirnov test. Categorical and numerical variables were compared by using the chi-Square and Mann-Whitney test, respectively. Data for the temporal trend of the number of consultations were evaluated by using generalized linear models with robust error estimators. Data obtained in May 2020 and March 2021 were compared by using Moses’ test for extreme reactions. Values of p < 0.05 were considered significant. The data obtained in the collection were tabulated and analyzed by using the IBM software, SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. IBM Corp. Released 2015.
This protocol was approved by the Unichristus Ethics Committee that follows the guidelines of CONEP, the Brazilian system for the ethical assessment of human research.
Results
Ten thousand four hundred thirty-nine ER visits were evaluated in May 2020, and 11,977 ER visits and 10,466 VER visits were evaluated in March 2021. In total, 32,882 visits were evaluated. Table 1 presents the demographic and clinical characteristics of the patients who either used VER or were seen at the ER evaluated in March 2021, as well as their main outcomes. It can be seen that patients using VER were slightly younger (40.4 years-old) and had more comorbidities. The prevalence of obesity, asthma, and hypertension/diabetes was roughly 5, 3, and 2 times higher in the VER group, respectively, compared w patients of the ER face-to-face group.
| ER | VER | p | |
|---|---|---|---|
 (SD) OR n (%) |
 (SD) OR n (%) |
||
| Demographics and clinical data | |||
Age, years,  (SD) |
42.8 (17.7) | 40.4 (13.7) | <0.001 |
| Obesity, n (%) | 174 (2.3) | 688 (11.2) | <0.001 |
| Hypertension, n (%) | 517 (6.9) | 654 (10.6) | <0.001 |
| Asthma, n (%) | 86 (1.1) | 190 (3.1) | <0.001 |
| CKD, n (%) | 29 (0.4) | 12 (0.2) | 0.04 |
| Coronary disease, n (%) | 93 (1.2) | 86 (1.4) | 0.404 |
| Diabetes, n (%) | 218 (2.9) | 273 (4.4) | <0.001 |
| Stroke (previous), n (%) | 20 (0.3) | 4 (0.1) | 0.005 |
| Smoking, n (%) | 28 (0.4) | 24 (0.4) | 0.863 |
| Outcomes | |||
| Hospitalization, n (%) | 1,262 (17.0) | 219 (5.1) | <0.001 |
| Mechanical ventilation, n (%) | 121 (1.6) | 13 (0.3) | <0.001 |
| Visit to emergency department, n (%) | 881 (8.4) | — | |
The hospitalization rate in patients of the VER group was more than three times less, and the need for mechanical ventilation was more than five times in patients of the ER group. Further, <10% of patients in the VER group needed to go to the ER.
Figure 1A depicts the temporal trends of confirmed COVID-19 cases in Ceará, illustrating the first and second waves, as mentioned earlier. It can be seen that the incidence is much higher during the second wave. Figure 1B illustrates that the number of visits to the ER was similar in both periods (waves) mentioned in Figure 1A, whereas the number of visits to the ER dropped significantly during the second wave, as shown in Figure 1C. This drop coincides with the installation of the VER service, showing a great number of patients seen using the remote system developed (Fig. 1C). Interestingly, the fall coefficient in the second wave, concomitant with the use of the VER system, was about 50% higher than that of the first wave in the same period.
Fig. 1. (A) Temporal variation of the daily number of confirmed cases of COVID-19 in Ceará; the periods evaluated in this analysis are depicted in gray. p-Value for the mean number of cases in each evaluated period. (B) Temporal variation of the daily number of visits to the emergency sector of HRU in the two evaluated periods. Dashed line represents the first wave; solid line represents the second wave. (C) Temporal variation and trends in the number of visits to the emergency sector in May 2020 and March 2021 and to telemedicine VER. HRU, Hospital Regional UNIMED; VER, virtual emergency room.
Discussion
This study provides evidence that the implementation of a telemedicine service based on visits to a VER system significantly reduced the need for patients to seek in-person care for mild COVID-19 patients. Development of the mobile applicative was rapidly adopted by patients and/or caregivers, given that usually some patients needed assistance from family members, particularly in the first attempts.
UNIMED Fortaleza has implemented a protocol to guide health care professionals, particularly physicians in the front line of COVID-19 care, offering orientation regarding the decision of hospitalization based on clinical and laboratory data. As a privately run service, UNIMED Fortaleza can only ask for patients to limit their visits to hospital facilities. However, patients usually perceive coming to an ER during the current pandemic as a last resource, aiming not at jeopardizing their health. Therefore, the implementation of this telemedicine initiative received a higher than anticipated acceptance by the clients. As expected, patients using the VER system were younger, mirroring previous studies, stating that willingness to accept such novelties is less enthusiastic among older adults.11
It is worth noticing that the number of cases during the so-called “second wave” was higher than those in the “first wave.” Crowding of ER was always an issue last year, but most of the patients could actually have received orientation without coming to the hospital. The fact that the number of ER visits actually dropped this year after the implementation of the VER strategy claims for a highly positive impact by reducing the number of ER visits despite the increase in the number of affected individuals. To the best of our knowledge, this is the first evidence of the effect of using telemedicine as a measure to reduce crowding in emergency services.
One of the main concerns with the use of telemedicine systems is related to the safety and outcomes of assisted patients. A study carried out in New York, in 2017, evaluated the safety and satisfaction of users with the use of a telemedicine system for emergency medical care for low severity cases, identifying that this care was safe and well rated by users.11 In keeping with these data, despite a higher prevalence of comorbidities, patients who chose the VER service had a highly significant lower number of severe outcome surrogates, namely need for hospitalization and use of ventilatory assistance, as compared with patients who chose to go right to the ER. Notwithstanding, <10% of such VER initially seen patients had to seek the ER service. This suggests that milder cases could satisfactorily be captured by our telehealth system and, also, orientation provided by the physicians helped to keep them away from the ER room. We presented these data to show that the expected pattern of fewer complications in patients who used VER was demonstrated; in other words, the patients did not present a higher rate of bad outcomes, which suggests that the VER can be considered safe. One of the main criticisms of the VER is a possible increase in the patients’ risk, but our study adds a piece of initial evidence that this may not be a very impactful additional risk.
Social distancing and lack of specialized staff in intensive care units have been an issue during the COVID-19 pandemic, meaning Outpatient Care Delivery as well as remote valuable alternatives.6,10 Previous studies have shown that the use of telemedicine in the United States was essential to ensure the care of outpatients during social distancing policies.10 In addition, telemedicine for inpatients improves the efficiency of the sectors while contributing to the safety of health care professionals.12,13 A study with cancer patients showed that the expansion of telemedicine services in TN, USA allowed patients in clinical trials to continue their follow-up satisfactorily.14 Our data are the first to provide evidence that such strategies are highly efficient and gather fast acceptance of the clients, leading to substantial optimization of the use of health care facilities.
Limitations of this study include the fact that although we used individual data from all patients, we did not have full access to clinical records as well as complete laboratory data. Thus, information on virus characteristics, such as Sars-Cov-2 variants, which may modify the clinical course, was not collected. Although unpublished, the experience of other centers in Brazil with the “second wave” of COVID-19, which had a higher prevalence of the P1 variant (gamma), suggests a higher demand for visits to the ER, as compared with data from the “first wave.” Although we believe that health care professionals are more experienced with the care of COVID-19 patients, particularly in ventilatory assistance, definitive medication strategies are yet to be defined, making us believe that treatment of milder cases did not significantly differ in our period of evaluation.
Conclusion
This is the first report of a quasi-experimental, pre–post evaluation of a successful implementation of a telemedicine strategy leading to a significant reduction of visits to the ER during the peak of the second wave of the COVID-19 pandemic. Data suggest the safety of such strategies, thus contributing to improving patient care while reducing the anxiety of visiting an ER facility as well as costs. More research using randomized studies is suggested. Although it can always be improved, our telemedicine strategy surely merits replication in other scenarios, including public services.
Authors’ Contributions
All authors have made substantial contributions to the study conception and design, reviewed the article critically for relevant intellectual content, and drafted the article. All authors approved the final article as submitted and agreed to be accountable for all aspects of the work.
Internal Review Board Approvals/Waivers
This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Comitê de Ética da Unichristus.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
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