Department of Emergency Medicine, Columbia University Irving Medical Center, New York. ORCID: https://orcid.org/0000-0003-4446-7350.
Department of Emergency Medicine, Weill Cornell University Medical Center, New York.
J Emerg Manag. 2021;18(7):45-48. doi: 10.5055/jem.0528.
Prior to COVID-19, telemedicine and its applications to the emergency department (ED) had made significant inroads toward remote evaluation and care. During the local peak of the COVID-19 pandemic in New York City (NYC), there was a dramatic increase in telemedicine based patient encounters for suspected COVID-19 symptoms. In response, pathways were developed to promote a standardized telemedicine approach to remote evaluation and assessment of suspected COVID-19 patients.
A pathway was developed and implemented at two academic EDs in NYC, which collectively had approximately 8,300 telemedicine visits for suspected COVID-19 from March 2020 to June 2020. A protocol was developed by an expert consensus panel of four board-certified emergency physicians and two pediatric emergency physicians, all with telemedicine training/administrative roles.
The pathway was initiated for any telehealth patient with suspected COVID-19 symptoms (cough, fever, shortness of breath, and bodyaches). A standardized history solicited known or suspected risk factors for worse prognosis, including age > 50, cardiovascular or lung disease, obesity, immunosuppression, and living alone, as well as a focused assessment of symptom severity and exercise tolerance. An exam at rest included visual counting of breaths along with instruction on palpation of radial pulse. Saturation was included if pulse oximetry was available. If exam at rest was reassuring, providers were instructed to repeat the respiratory assessment on exertion by having the patient walk in place briskly for 1 minute. Patients with severe illness defined by resting or exertional respiratory rate greater than 30 and/or oxygen saturation less than 90 percent were instructed to go to the ED. Patients with moderate illness defined by exertional metrics of respiratory rate less than 22, oxygen saturation greater than 94 percent, and heart rate less than 125 were discharged from the virtual urgent care visit with a repeat telehealth follow-up call at either 12 or 24 hours depending on the number of risk factors. Patients without risk factors and with reassuring respiratory assessment were discharged from the telemedicine encounter with reassurance and standard discharge precautions for escalation of care.
Designing and disseminating a standardized pathway helped to provide a framework to approach patients suspected of COVID-19 over telemedicine. Future work focusing on patient outcome data will help guide and refine any standardized telehealth approach to the COVID-19-suspected patient.
在 COVID-19 之前，远程医疗及其在急诊科（ED）的应用已经在远程评估和护理方面取得了重大进展。在纽约市（NYC） COVID-19 本地高峰期期间，因疑似 COVID-19 症状而进行的远程医疗患者就诊数量急剧增加。为应对这一情况，制定了一些途径以促进远程评估和评估疑似 COVID-19 患者的标准化远程医疗方法。
在纽约市的两家学术 ED 中制定并实施了一条途径，这两家医院在 2020 年 3 月至 2020 年 6 月期间共进行了约 8300 次疑似 COVID-19 的远程医疗就诊。该途径由四名经过董事会认证的急诊医师和两名儿科急诊医师组成的专家共识小组制定，他们都具有远程医疗培训/管理角色。
该途径适用于任何出现疑似 COVID-19 症状（咳嗽，发烧，呼吸急促和身体疼痛）的远程医疗患者。通过标准化的病史来确定预后较差的已知或可疑危险因素，包括年龄> 50 岁，心血管或肺部疾病，肥胖，免疫抑制和独居，以及对症状严重程度和运动耐量进行重点评估。在休息时进行检查，包括视觉计数呼吸以及指导桡动脉脉搏的触诊。如果脉搏血氧仪可用，则包括饱和度。如果休息时的检查令人放心，则指示医生让患者在原地快速行走一分钟，以进行用力呼吸评估。休息时呼吸频率大于 30 次/分或血氧饱和度小于 90％，或运动时呼吸频率大于 22 次/分，血氧饱和度大于 94％，心率小于 125 次/分的患者，指示他们去急诊科就诊。没有危险因素且呼吸评估令人放心的中度疾病患者，在虚拟紧急护理就诊时出院，并根据危险因素的数量在 12 或 24 小时进行重复远程医疗随访。通过远程医疗就诊，对具有令人放心的呼吸评估且没有危险因素的患者感到放心，并提供标准的出院预防措施，以升级护理。
设计和传播标准化途径有助于为通过远程医疗治疗疑似 COVID-19 的患者提供框架。未来的工作将侧重于患者的结局数据，以帮助指导和完善针对疑似 COVID-19 患者的任何标准化远程医疗方法。
