The Use of Telemonitoring in Managing the COVID-19 Pandemic: Pilot Implementation Study

Abstract

Background Most people with COVID-19 self-manage at home. However, the condition can deteriorate quickly, and some people may develop serious hypoxia with relatively few symptoms. Early identification of deterioration allows effective management with oxygen and steroids. Telemonitoring of symptoms and physiological signs may facilitate this. Objective The aim of this study was to design, implement, and evaluate a telemonitoring system for people with COVID-19 who are self-managing at home and are considered at significant risk of deterioration. Methods A multidisciplinary team developed a telemonitoring protocol using a commercial platform to record symptoms, pulse oximetry, and temperature. If symptoms or physiological measures breached targets, patients were alerted and asked to phone for an ambulance (red alert) or for advice (amber alert). Patients attending COVID-19 assessment centers, who were considered fit for discharge but at risk of deterioration, were shown how to use a pulse oximeter and the monitoring system, which they were to use twice daily for 2 weeks. Patients could interact with the system via app, SMS, or touch-tone phone. Written guidance on alerts was also provided. Following consent, patient data on telemonitoring usage and alerts were linked to data on the use of service resources. Subsequently, patients who had either used or not used the telemonitoring service, including those who had not followed advice to seek help, agreed to brief telephone interviews to explore their views on, and how they had interacted with, the telemonitoring system. Interviews were recorded and analyzed thematically. Professionals involved in the implementation were sent an online questionnaire asking them about their perceptions of the service. Results We investigated the first 116 patients who used the service. Of these patients, 71 (61.2%) submitted data and the remainder (n=45, 38.8%) chose to self-monitor without electronic support. Of the 71 patients who submitted data, 35 (49%) received 152 alerts during their 2-week observation. A total of 67 red alerts were for oxygen saturation (SpO2) levels of ≤93%, and 15 red alerts were because patients recorded severe breathlessness. Out of 71 patients, 14 (20%) were admitted to hospital for an average stay of 3.6 (SD 4.5) days. Of the 45 who used written guidance alone, 7 (16%) were admitted to hospital for an average stay of 4.0 (SD 4.2) days and 1 (2%) died. Some patients who were advised to seek help did not do so, some because parameters improved on retesting and others because they felt no worse than before. All patients found self-monitoring to be reassuring. Of the 11 professionals who used the system, most found it to be useful and easy to use. Of these 11 professionals, 5 (45%) considered the system “very safe,” 3 (27%) thought it “could be safer,” and 3 (27%) wished to have more experience with it before deciding. In total, 2 (18%) felt that SpO2 trigger thresholds were too high. Conclusions Supported self-monitoring of patients with COVID-19 at home is reassuring to patients, is acceptable to clinicians, and can detect important signs of deterioration. Worryingly, some patients, because they felt well, occasionally ignored important signs of deterioration. It is important, therefore, to emphasize the importance of the early investigation and treatment of asymptomatic hypoxia at the time when patients are initiated and in the warning messages that are sent to patients.

Telemedicine and virtual respiratory care in the era of COVID-19

“…Community-based telemonitoring of symptoms scores, temperature, oximetry, and blood pressure supported by self-management information and/or remote monitoring proved to be a cost-effective alternative to hospitalisation. [15,16,18,[154][155][156][157][158] Although a rapid systematic review was unable to confirm safety due to lack of standardised reporting, [18] mixed-method evaluation of individual programmes concluded that they were reassuring to patients (especially the oximetry), [15,155,158] acceptable to clinicians, [15,154,158] able to detect signs of deterioration, [15,158,159] and a safe approach for selected high-risk patients with mild-to-moderate COVID-19. [15,16,18,[157][158][159] Economic analysis was limited to reporting resources used and the amount spent per patient monitored.…”

“…[15,16,18,[154][155][156][157][158] Although a rapid systematic review was unable to confirm safety due to lack of standardised reporting, [18] mixed-method evaluation of individual programmes concluded that they were reassuring to patients (especially the oximetry), [15,155,158] acceptable to clinicians, [15,154,158] able to detect signs of deterioration, [15,158,159] and a safe approach for selected high-risk patients with mild-to-moderate COVID-19. [15,16,18,[157][158][159] Economic analysis was limited to reporting resources used and the amount spent per patient monitored. [18] Contact tracing smartphone-based applications potentially helped control the spread of COVID-19, but the effectiveness of this technology depends on high levels of adoption among the population.…”

“…[12,13] Whilst we are mindful of this wider perspective, in this clinical review we focus on selected examples to provide an expert perspective on the potential of telemedicine to deliver virtual respiratory care. We will consider how the COVID-19 pandemic has had a major influence on this story, promoting implementation of remote ways to monitor the progress of COVID in people at risk, [14][15][16][17][18] highlighting the potential of safely maintaining the care of people with non-communicable respiratory diseases, [19,20] and of supporting self-management during times of lockdown. [21] The imperative to contain the spread of infection resulted in an overnight shift to remote consulting (illustrated in Figure 1); [14][15][16] as COVID-19 gradually moves to endemic rather than pandemic status, we will discuss the "new norm" and the legacy that the pandemic has given to telemedicine.…”

The MedConnect Program: Symptomatology, Return Visits, and Hospitalization of COVID-19 Outpatients Following Discharge From the Emergency Department

“…Unfortunately, the design of these studies precluded the determination of what percentage of repeat visits were related to COVID-19 or what factors may have been responsible for the high rate of return (e.g., worsening symptoms, inadequate follow-up, and anxiety). Nonetheless, efforts have been made to monitor patients remotely in the hope of identifying those with evidence of disease progression, and therapeutic strategies have targeted "high-risk" patients discharged from the ED in an effort to reduce subsequent hospitalization [10][11][12]. A better understanding of symptom progression in these patients and the impact of various demographics and/or comorbidities might improve these efforts and assist providers caring for these patients following an ED visit.…”

Use of home pulse oximetry with daily short message service messages for monitoring outpatients with COVID-19: The patient's experience

“…4 These results suggest a role for FDA-approved pulse oximeters in both remote monitoring and triaging of COVID-19 infected outpatients. There have been a variety of remote monitoring studied for COVID, 5,6 though few have assessed patient experience.…”