Clinicians at The Children’s Hospital of Philadelphia care for patients with complex medical and surgical conditions, and many rely on sophisticated technology long after they return home. The initial transition from hospital to home can be a daunting time for parents, as they take charge of operating this equipment, such as responding to ventilator alarms or keeping gastrostomy tubes in place.
A pilot quality improvement project underway at CHOP aims to reduce the emotional and operational stress on these families by conducting virtual visits via video chat on mobile devices a few days after children are discharged. Lead investigator John Chuo, MD, MS, hopes that by describing and characterizing the kind of issues that parents are facing, the implementation team will be able to better understand how telemedicine could be of value to augment the standard of care and perhaps avoid urgent care or emergency room visits and readmissions.
“The providing staff at CHOP are excellent at educating parents before discharge, but it can be overwhelming for parents who overnight become the sole caretakers for their child,” said Dr. Chuo, who is an attending neonatologist and medical director of telemedicine at CHOP. “It is a vulnerable time, for the patient and their quality of care, so we want to use telemedicine to help them make the transition.” The research project methodology centers on a quality improvement framework, which gives investigators the flexibility to problem-solve using “plan-do-study act” cycles based on the data learned during the remote check-ins. They already have engaged several CHOP teams such as the Chronic Lung Disease Program in the Division of Neonatology, the Division of Plastic and Reconstructive Surgery, General Surgery, Home Care, and Compass Care, which seeks to improve the health of the most medically complex patients.
Those teams each have dedicated clinicians to participate in the project. Together with the telemedicine team, they will follow specific “swimlane” workflows that include identifying families willing to take part in the study, setting up parents’ mobile phones or tablets, and making appointments for the video chats before discharge. When it is time for the appointment, the clinicians will use a hosted service to connect with the families by video call and interview the parents based on a checklist of questions that are pertinent to their child’s care.
These are typical questions that would be asked via a telephone call with one addition – now, the clinicians can ask “show me” questions that may uncover issues not discoverable before with voice only calls. The items will help to reinforce education and resolve parents’ questions, focusing specifically on use of equipment and supplies, certain medical and surgical screening, compliance with medications and appointments, and unanticipated events and complications.
For example, the clinician will ask, “Are you having any problems administering the medication?” and then follow up with, “Please show me how to draw up one of your medications.” Having parents demonstrate their technique using the syringe could help to avoid medication errors. Another example is asking parents to show the clinician the child’s feeding tube site. Most mobile devices’ cameras have high enough resolution, Dr. Chuo pointed out, that the clinician potentially could see the condition of the insertion site.
Afterward, the clinician will document the virtual patient encounter in a database and communicate information to other providers, as they normally would do. Over a 12-month period, the researchers will track call rates, home visit rate, emergency room referrals, readmission rates, patient and provider satisfaction, and the number of equipment and patient issues that were identified and resolved.
In the end, Dr. Chuo expects to identify clinical scenarios where the use of video calls would have greatest value and learn how to better implement telemedicine in those situations as a way to optimize care coordination and overcome geographic barriers to access. Some families do not have an easy means of seeing a specialist should something unexpected arise, and most go to the emergency room when problems escalate.
“We are dedicated to providing children access to the right care at the right time,” Dr. Chuo said. “From a healthcare community standpoint, better and quicker access can reduce healthcare costs. The use of telemedicine has avoided patient transports by ambulance, thereby from a quality improvement perspective, it reduces travel time, which is non-value added work.”
Dr. Chuo, who also is an assistant professor of Clinical Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, is appreciative that CHOP already has in place the clinical infrastructure and support for patient care to make this project possible. He gave kudos to CHOP’s Information Technology and Telemedicine groups for facilitating the study team’s easy access to a simple-to-use, reliable communications platform. Dr. Chuo also expressed special thanks to Verizon for their ongoing financial support of telemedicine research initiatives at CHOP.