Safaeinili Nadia, Vilendrer Stacie, Williamson Emma, Zhao Zicheng, Brown-Johnson Cati, Asch Steven M, Shieh Lisa
Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States.
Department of Engineering, Stanford University, Stanford, CA, United States.
JMIR Form Res. 2021 Jun 16;5(6):e26452. doi: 10.2196/26452.
The COVID-19 pandemic created new challenges to delivering safe and effective health care while minimizing virus exposure among staff and patients without COVID-19. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect patients who are acutely ill with nearby clinical team members, even in the next room.
To inform these efforts, this paper aims to provide an early example of inpatient telemedicine implementation and its perceived acceptability and effectiveness.
Using purposive sampling, this study conducted 15 semistructured interviews with nurses (5/15, 33%), attending physicians (5/15, 33%), and resident physicians (5/15, 33%) on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. Semistructured interview protocols and qualitative analysis were framed around the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, and key themes were identified using a rapid analytic process and consensus approach.
All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all patients with COVID-19. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and use of personal protective equipment (PPE) without significantly compromising quality of care. Physician workflows remained relatively stable, as most standard clinical activities were conducted via telemedicine following the initial intake examination, though resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Nurse workflows required significant adaptations to cover nonnursing duties, such as food delivery and facilitating technology connections for patients and physicians alike. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included patient-clinical team communication and personal connection with the patient, perceptions of patient isolation, ongoing technical challenges, and certain aspects of the physical exam.
Clinical team members reported inpatient telemedicine encounters to be acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses adapted their workflows more than physicians in order to implement the new technology and bore a higher burden of in-person care and technical support. Recommendations for improved inpatient telemedicine use include information technology support and training, increased technical functionality, and remote access for the clinical team.
新型冠状病毒肺炎（COVID-19）大流行给提供安全有效的医疗保健带来了新的挑战，同时要尽量减少未感染COVID-19的医护人员和患者接触病毒的机会。全球卫生系统迅速采取行动，在不同环境中实施远程医疗以减少感染，但对于如何最好地将急重症患者与附近的临床团队成员（即使是隔壁房间的）联系起来，人们了解甚少。
为这些努力提供信息，本文旨在提供一个住院患者远程医疗实施的早期实例及其可接受性和有效性。
本研究采用目的抽样法，对斯坦福医疗保健中心一个COVID-19病房的护士（15名中的5名，33%）、主治医生（15名中的5名，33%）和住院医生（15名中的5名，33%）进行了15次半结构化访谈，以评估住院患者远程医疗的实施结果和感知效果。半结构化访谈方案和定性分析围绕RE-AIM（覆盖范围、有效性、采用率、实施和维持）框架展开，并使用快速分析过程和共识方法确定关键主题。
所有临床团队成员报告称住院患者远程医疗的覆盖范围广泛，几乎对所有COVID-19患者都有一定程度的使用。住院患者远程医疗被认为在减少COVID-19暴露和个人防护装备（PPE）使用方面有效，且不会显著影响护理质量。医生的工作流程保持相对稳定，因为大多数标准临床活动在初次检查后通过远程医疗进行，不过住院医生报告称由于进行体格检查的机会有限，教育机会减少。护士的工作流程需要进行重大调整以承担非护理职责，如送餐以及为患者和医生提供技术连接便利。患者感知的影响包括护理质量一致，但存在一些隐私方面的考虑。报告的挑战包括患者与临床团队的沟通以及与患者的个人联系、患者隔离感、持续的技术挑战以及体格检查的某些方面。
临床团队成员报告称住院患者远程医疗接触在减少COVID-19暴露和PPE使用方面是可接受且有效的。护士比医生更多地调整了他们的工作流程以实施新技术，并且承担了更高的面对面护理和技术支持负担。改善住院患者远程医疗使用的建议包括信息技术支持和培训、增强技术功能以及临床团队的远程访问权限。
