Introduction

Welcome to the APSA Quality and Safety committee Telehealth Toolkit. This page is intended to help anyone who is interested in quality improvement initiatives pertaining to telehealth.

Available toolkit projects are listed below. Many of the approaches described are evidence-based - some are not. These approaches have not been approved by APSA.

Telehealth Quality Improvement Initiatives

Nationwide Children’s Hospital (NCH) developed a Quality Improvement (QI) initiative aimed at providing a telemedicine bowel management program (BMP) during the COVID-19 pandemic, and thereafter, in order to provide services to patients who are unable to come to the hospital to undergo a traditional, in-person BMP. Services are provided by either the hybrid model (one in-person clinic visit with the rest of the visits via telemedicine) or a completely remote model (all telemedicine visits). Patients/caregivers are able to choose between two telemedicine BMP types: remote and hybrid. Similar to the standard, in-person BMP, each patient is individually addressed and a custom treatment plan using dietary changes, laxatives, rectal enemas, and/or antegrade continence enemas are used and adjusted throughout the week to achieve social continence. Patients with any underlying etiology for constipation and/or fecal incontinence can undergo the program (for example, patients with Hirschsprung disease, anorectal malformations, functional constipation). The remote BMP consists of patients who undergo video and/or phone calls only during the bowel management week, with no in-person visits. X-rays are obtained by the families, at a local location, several times during the week, which are then uploaded from a disc, submitted as a screenshot of the image via e-mail or through the electronic medical record patient application (MyChart). The radiologist’s interpretation is obtained from the local radiology office via fax. The hybrid BMP consists of patients who are seen at a single in-person clinic visit at the beginning of the BMP week, followed by video and/or phone calls the remainder of the program, similar to the remote BMP. X-rays are also obtained locally during the hybrid BMP as described above. Follow-up occurs at 1 month, 3 months, 1 year, and then yearly after the BMP is done via a telemedicine visit or an in-person visit.

Protocol:

Resources:

• NCH APSA Telemedicine BMP During COVID-19 Presentation
• NCH Bowel Management Parent Lecture (2020)
• NCH Enema Teaching Presentation

Stakeholders: surgery, nursing

Challenges and Solutions:

• Obtaining and submitting X-rays prior to the telemedicine appointment that day. To address this problem, we began to schedule patients who might have difficulty traveling to a local imaging facility and obtaining the film and read quickly, to later in the day, so that they had more time prior to the appointment.
• Hands-on, face-to-face interaction and social bonding. During the in-person BMP, parents/patients stay at the Ronald McDonald House on NCH’s campus. Here, they are able to socialize and develop a social connection with other families who are going through similar difficulties. Since patients do not need to stay close to the hospital for the telemedicine BMP, they miss out on this aspect as well as meeting and interacting with staff in-person. However, we do have a Zoom meeting for all patients/parents at the beginning of each telemedicine bowel management week where they are informed of what to expect during the week and can bring up any questions or concerns they have. Additionally, they are encouraged to call our office or reach out to us on MyChart if they have any concerns.

Links to published data (used to develop the protocol):[1]

Submitted by: Maria Knaus, MD

Additional Implementer: Ihab Halaweish, MD

Prior to the COVID-19 pandemic (2019), the pediatric surgery group at Medical College of Wisconsin/Children’s Wisconsin (MCW) introduced Epic video visits for routine outpatient visits. During the pandemic, video visit use increased dramatically. Initially all in-person visits that could be delayed were converted to a video visit, and in-person visits were scheduled only as necessary for physical examinations. As the pandemic waned, in-person visits were again offered, but video visits were still encouraged for those visits not requiring in-person physical examinations. The group used this opportunity to evaluate whether the care provided via video visits was adequate, and sought to assess how it compared to traditional in-person visits with regard to no-shows, cancellations, and patient demographics.

In order to perform a video visit, the family must sign up for Epic MyChart (the electronic patient portal). The video visit can be scheduled with a physician or physician assistant. The majority of video visits are for established patients, when an in-person physical exam is unnecessary, or for basic high-volume postoperative follow-up visits such as appendectomies, hernias (inguinal, epigastric, and umbilical). Some new consultations are also offered as video visits (e.g., chest wall deformities, gastrostomy tube placement evaluations). Specifically, for postoperative visits, famlilies are provided an appointment, in-person or video, per their preference. Prior to the visit, they are sent a questionnaire via MyChart. Families can answer the questionnaire and provide wound photos to confirm the absence of any concerns, at which point the surgical team cancels the visit. If there are concerns or the family still prefers follow up, then the postoperative visit remains as planned.

Protocol:

Resources:

• MCW PPT - Utilization and Adequacy of Telemedicine for Outpatient Pediatric Surgical Care

Stakeholders: surgeons, surgery APP’s, surgery clinic nurses, families

Challenges and Solutions:

• Getting families enrolled in MyChart (necessary to complete video visits)
  • Enrollment is encouraged at each point in the care process, especially at the preoperative visit.
    • Thus far, video visits have only been provided for English-speaking families given the challenge of arranging interpreters for video visits. We hope to expand this in the future. Disparities in video visit use have been demonstrated - less frequently used by minorities, those in disadvantaged neighborhoods, and those with public insurance -- we need to ensure that all families have the resources necessary to use video visits, when desired.

Links to published data (used to develop the protocol): [2]

Submitted by: Kyle Van Arendonk, MD, PhD

The APSA Education committee Telehealth subcommittee developed a guide intended to offer a taxonomy of sorts for the virtual patient visit in pediatric surgery highlighting advantages and disadvantages of a such visits, as well as conditions and situations that can lend themselves to telemedicine, Telehealth in Pediatric Surgery guidelines.

Recent Research

For recent research pertaining to telehealth, please refer to references: [3][4][5][6][7][8][9]

References