Inpatient Telemedicine Implementation as an Infection Control Response to COVID-19: Qualitative Process Evaluation Study (Preprint)

Abstract

BACKGROUND The COVID-19 pandemic created new challenges to delivering safe and effective healthcare while minimizing staff and non-COVID-19 patient exposure to the virus. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect acutely ill patients with nearby clinicians, even in the next room. OBJECTIVE We provide an early example of inpatient telemedicine implementation and its perceived effectiveness through the perspectives of its physician and nurse end-users. METHODS Using purposive sampling, we conducted 15 semi-structured interviews with physician attendings (n=5), resident physicians (n=5), and nurses (n=5) on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. We structured interview protocols and qualitative analysis around the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework and identified key themes using a rapid analytic process and consensus approach. RESULTS All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all COVID-19 patients. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and PPE use without significantly compromising quality of care. Members of the clinical team viewed inpatient telemedicine as a feasible and acceptable complement to in-person care, telemedicine worked best when the patient was clinically stable, comfortable with the technology, and had normal cognition. Physician workflows remained relatively stable as most standard clinical activities were conducted via telemedicine following the initial intake examination. Nursing workflows required significant adaptations to cover non-nursing duties such as food delivery, and facilitating technology connections for patients and physicians alike. Resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included: training, technology support, integration of remote extended care team members, patient-clinician communication and connection, and conducting physical exams. Clinicians identified leveraging inpatient telemedicine to connect patients with remote visitors and to allow clinicians to check in on low-acuity patients remotely as potential future use cases for this technology, but were unable to assess the maintenance and sustainability given the short time frame. CONCLUSIONS Clinicians reported inpatient telemedicine encounters as acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses had to adapt their workflows more than physicians to implement the new technology. Specifically, nurses bore a higher burden of in-person care and technical support. Future research should examine other settings and incorporate patient perspectives. Recommendations for improved inpatient telemedicine use include IT support and training, increased technical functionality, and remote access for clinicians. CLINICALTRIAL N/A.