In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case-control study.

Purpose: Stroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment. Methods: Observational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients. Results: The in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0-2 at discharge was similar in both groups when adjusting for NIHSS score and age. Conclusion: The same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care.

Adherence to Emergency Department Referral Criteria in a Direct-to-Consumer Telemedicine Center.

Background: The safety of direct-to-consumer telemedicine (TM) is closely related to red flag detection and correct referrals. The adherence to referral criteria from current guidelines is not well quantified. Objective: To analyze the emergency department (ED) referral rate and adherence to referral guidelines in TM encounters of acutely ill patients calling a center that adopts stewardship protocols. Methods: This is a retrospective observational unicentric study, between March 2020 and March 2022, with patients who spontaneously sought direct-to-consumer urgent virtual medical assistance. A video-based teleconsultation was provided immediately after connection. Physicians managed situations according to their clinical judgment. Current guidelines, containing specific guidance for referral if red flags were identified, were available for consultation. Physicians' semiannual performance feedback was carried out. We analyzed the patterns for referral to immediate face-to-face medical evaluation and the agreement degree with the institutional guidelines. Results: A total of 232,197 patients were available, and 14,051 (6.05%) patients were referred to ED. A total of 8,829 (68.4%) referrals were based in specific guidelines according to the International Classification of Diseases hypothesis, and 8,708 (98.6%) were justified according to guidelines. Diarrhea had the highest guidelines' adherence to referral (97.6%), followed by COVID-19 (90%), headache (84.2%), and conjunctivitis (78.8%). Policies did not support 5,222 (31.6%) referrals, though 5,100 (97.6%) of these were justified according to the doctor's clinical judgment. Conclusion: TM doctors' assessment of acutely ill patients has high rates of adherence to guidelines regarding referral. Stewardship protocol adoption provides high rates of red flag description, even in the referral of nonpolicy diseases.

Clinical Features and Management of Patients Assessed by Cardiology Teleconsultation in the Brazilian Region with the Highest Number of Isolated Cities. / Características Clínicas e Manejo de Pacientes Avaliados por Teleconsulta Cardiológica na Região Brasileira com Maior Número de Cidades Isoladas.

BACKGROUND: Cardiovascular diseases are the leading cause of adult mortality. Geographically remote and low-income Brazilian regions lack specialized consultations. The telemedicine management of this population by cardiologists is not fully known. OBJECTIVES: To analyze cardiology teleconsultation in the Brazilian region with the highest number of isolated cities. METHODS: From February 2020 to October 2021, patients from the North Region of Brazil evaluated by local general practitioners were referred for cardiological evaluation by telemedicine. Referral reasons, demographics, clinical history, physical examinations, tests, medications, and prescriptions pre- and post-telemedicine were analyzed (p<0.05 was considered statistically significant). RESULTS: We analyzed 653 patients. The attendance rate was 85.7% (53.1% female, mean age: 54.2±6.5 years). The main reasons for referral were cardiovascular symptoms (58.1%) and risk factors among asymptomatic patients (13.3%). Only 12.6% had a diagnosed disease. Most patients had regular physical examinations and electrocardiograms. Few had recent complementary tests. The prescription of angiotensin receptor blockers (ARBs), calcium channel blockers and statins was significantly increased, while that of digoxin, noncardiac beta-blockers and acetylsalicylic acid (ASA) was decreased at the first teleconsultation. Most of the tests requested were of low complexity and cost: electrocardiogram (28.2%), chest X-ray (14%), echocardiogram (64.5%) and blood tests (71.8%). For 2.1% of patients, interventions were indicated, and 8% were discharged after the first consultation. CONCLUSION: On-demand cardiology teleconsultation contributes to heart disease treatment optimization. Most patients were referred with syndromic diagnoses without previous complementary tests. The specialist workup requested was usually available locally and at a low cost but precluded early discharge. Local training could optimize the referral.

FUNDAMENTO: As doenças cardiovasculares são a principal causa de morte no mundo. Regiões brasileiras geograficamente remotas e de baixa renda carecem de consultas especializadas. Não se tem conhecimento total acerca do manejo por telemedicina dessa população por parte de cardiologistas. OBJETIVOS: Analisar a teleconsulta cardiológica na região brasileira com maior número de municípios isolados. MÉTODOS: Entre fevereiro de 2020 e outubro de 2021, pacientes da Região Norte do Brasil avaliados por médicos generalistas locais foram encaminhados para avaliação cardiológica por telemedicina. Foram analisados os motivos do encaminhamento, dados demográficos, histórico clínico, exames físicos, exames complementares, medicamentos e prescrições pré e pós-telemedicina (considerou-se p<0,05 como estatisticamente significativo). RESULTADOS: Analisamos 653 pacientes. A taxa de frequência foi de 85,7% (53,1% do sexo feminino, idade média: 54,2±6,5 anos). Os principais motivos de encaminhamento foram sintomas cardiovasculares (58,1%) e fatores de risco entre pacientes assintomáticos (13,3%). Apenas 12,6% apresentava alguma doença diagnosticada. A maioria dos pacientes havia passado por exame físico e eletrocardiogramas regulares. Poucos tinham exames complementares recentes. A prescrição de bloqueadores dos receptores da angiotensina (BRA), bloqueadores dos canais de cálcio e estatinas aumentou significativamente, enquanto a de digoxina, betabloqueadores não cardíacos e ácido acetilsalicílico (AAS) diminuiu na primeira teleconsulta. A maioria dos exames complementares solicitados era de baixa complexidade e custo: eletrocardiograma (28,2%), radiografia de tórax (14%), ecocardiograma (64,5%) e exames de sangue (71,8%). Para 2,1% dos pacientes, foram indicadas intervenções, e 8% recebeu alta após a primeira consulta. CONCLUSÃO: A teleconsulta cardiológica sob demanda contribui para a otimização do tratamento das doenças cardíacas. A maioria dos pacientes foi encaminhada com diagnósticos sindrômicos sem exames complementares prévios. A avaliação especializada solicitada geralmente estava disponível localmente e com baixo custo, mas impedia a alta precoce. Capacitação local poderia otimizar o encaminhamento.

Características Clínicas e Manejo de Pacientes Avaliados por Teleconsulta Cardiológica na Região Brasileira com Maior Número de Cidades Isoladas / Clinical Features and Management of Patients Assessed by Cardiology Teleconsultation in the Brazilian Region with the Highest Number of Isolated Cities

Resumo Fundamento As doenças cardiovasculares são a principal causa de morte no mundo. Regiões brasileiras geograficamente remotas e de baixa renda carecem de consultas especializadas. Não se tem conhecimento total acerca do manejo por telemedicina dessa população por parte de cardiologistas. Objetivos Analisar a teleconsulta cardiológica na região brasileira com maior número de municípios isolados. Métodos Entre fevereiro de 2020 e outubro de 2021, pacientes da Região Norte do Brasil avaliados por médicos generalistas locais foram encaminhados para avaliação cardiológica por telemedicina. Foram analisados os motivos do encaminhamento, dados demográficos, histórico clínico, exames físicos, exames complementares, medicamentos e prescrições pré e pós-telemedicina (considerou-se p<0,05 como estatisticamente significativo). Resultados Analisamos 653 pacientes. A taxa de frequência foi de 85,7% (53,1% do sexo feminino, idade média: 54,2±6,5 anos). Os principais motivos de encaminhamento foram sintomas cardiovasculares (58,1%) e fatores de risco entre pacientes assintomáticos (13,3%). Apenas 12,6% apresentava alguma doença diagnosticada. A maioria dos pacientes havia passado por exame físico e eletrocardiogramas regulares. Poucos tinham exames complementares recentes. A prescrição de bloqueadores dos receptores da angiotensina (BRA), bloqueadores dos canais de cálcio e estatinas aumentou significativamente, enquanto a de digoxina, betabloqueadores não cardíacos e ácido acetilsalicílico (AAS) diminuiu na primeira teleconsulta. A maioria dos exames complementares solicitados era de baixa complexidade e custo: eletrocardiograma (28,2%), radiografia de tórax (14%), ecocardiograma (64,5%) e exames de sangue (71,8%). Para 2,1% dos pacientes, foram indicadas intervenções, e 8% recebeu alta após a primeira consulta. Conclusão A teleconsulta cardiológica sob demanda contribui para a otimização do tratamento das doenças cardíacas. A maioria dos pacientes foi encaminhada com diagnósticos sindrômicos sem exames complementares prévios. A avaliação especializada solicitada geralmente estava disponível localmente e com baixo custo, mas impedia a alta precoce. Capacitação local poderia otimizar o encaminhamento.

Abstract Background Cardiovascular diseases are the leading cause of adult mortality. Geographically remote and low-income Brazilian regions lack specialized consultations. The telemedicine management of this population by cardiologists is not fully known. Objectives To analyze cardiology teleconsultation in the Brazilian region with the highest number of isolated cities. Methods From February 2020 to October 2021, patients from the North Region of Brazil evaluated by local general practitioners were referred for cardiological evaluation by telemedicine. Referral reasons, demographics, clinical history, physical examinations, tests, medications, and prescriptions pre- and post-telemedicine were analyzed (p<0.05 was considered statistically significant). Results We analyzed 653 patients. The attendance rate was 85.7% (53.1% female, mean age: 54.2±6.5 years). The main reasons for referral were cardiovascular symptoms (58.1%) and risk factors among asymptomatic patients (13.3%). Only 12.6% had a diagnosed disease. Most patients had regular physical examinations and electrocardiograms. Few had recent complementary tests. The prescription of angiotensin receptor blockers (ARBs), calcium channel blockers and statins was significantly increased, while that of digoxin, noncardiac beta-blockers and acetylsalicylic acid (ASA) was decreased at the first teleconsultation. Most of the tests requested were of low complexity and cost: electrocardiogram (28.2%), chest X-ray (14%), echocardiogram (64.5%) and blood tests (71.8%). For 2.1% of patients, interventions were indicated, and 8% were discharged after the first consultation. Conclusion On-demand cardiology teleconsultation contributes to heart disease treatment optimization. Most patients were referred with syndromic diagnoses without previous complementary tests. The specialist workup requested was usually available locally and at a low cost but precluded early discharge. Local training could optimize the referral.

Telemedicine can be a feasible means of guiding untrained general practitioners to perform point-of-care ultrasound in life-threatening situations: the case of a field hospital during the COVID-19 pandemic.

Objective: To evaluate the feasibility of telemedicine using a standardized multiorgan ultrasound assessment protocol to guide untrained on-site general practitioners at a field hospital during a life-threatening crisis. Materials and Methods: We evaluated 11 inpatients with shock, with or without acute dyspnea, for whom general practitioners spontaneously requested remote evaluation by a specialist. Results: All of the general practitioners accepted the protocol and were able to position the transducer correctly, thus obtaining key images of the internal jugular vein, lungs, and inferior vena cava when guided remotely by a telemedicine physician, who interpreted all of the findings. However, only four (36%) of the on-site general practitioners obtained the appropriate key image of the heart in the left parasternal long-axis view, and only three (27%) received an immediate interpretation of an image from the remote physician. The mean evaluation time was 22.7 ± 12 min (range, 7-42 min). Conclusion: Even in life-threatening situations, untrained general practitioners may be correctly guided by telemedicine specialists to perform multiorgan point-of-care ultrasound in order to improve bedside diagnostic evaluation.

Objetivo: Avaliar a viabilidade da orientação por telemedicina de médicos in situ não treinados na avaliação ultrassonográfica de múltiplos órgãos mediante protocolo padronizado, durante uma situação de risco de vida em hospital de campanha. Materiais e Métodos: Avaliamos 11 pacientes com choque e/ou dispneia de manifestação aguda durante a internação, cujos clínicos gerais solicitaram auxílio de especialista a distância. Resultados: Todos os médicos aceitaram o protocolo e, posicionando o transdutor, obtiveram imagens-chave da veia jugular interna, pulmão e veia cava inferior, quando guiados por um médico via telemedicina, que interpretou os achados desses órgãos. No entanto, apenas quatro (36%) médicos in situ obtiveram a imagem-chave apropriada do coração na janela paraesternal do eixo longo esquerdo e três (27%) tiveram imagem remotamente interpretada imediatamente. O tempo de avaliação variou de 7-42 minutos (média de 22,7 ± 12 minutos). Conclusão: Em situação de risco de vida, os clínicos gerais não treinados podem ser corretamente orientados por especialistas em telemedicina para realizar ultrassonografia multiórgãos in situ, melhorando o diagnóstico beira do leito.

Telemedicine can be a feasible means of guiding untrained general practitioners to perform point-of-care ultrasound in life-threatening situations: the case of a field hospital during the COVID-19 pandemic / O ultrassom guiado por telemedicina realizado por clínicos gerais não treinados pode ser viável em uma situação de risco de vida: o caso de um hospital de campanha durante a pandemia de COVID-19

Abstract Objective: To evaluate the feasibility of telemedicine using a standardized multiorgan ultrasound assessment protocol to guide untrained on-site general practitioners at a field hospital during a life-threatening crisis. Materials and Methods: We evaluated 11 inpatients with shock, with or without acute dyspnea, for whom general practitioners spontaneously requested remote evaluation by a specialist. Results: All of the general practitioners accepted the protocol and were able to position the transducer correctly, thus obtaining key images of the internal jugular vein, lungs, and inferior vena cava when guided remotely by a telemedicine physician, who interpreted all of the findings. However, only four (36%) of the on-site general practitioners obtained the appropriate key image of the heart in the left parasternal long-axis view, and only three (27%) received an immediate interpretation of an image from the remote physician. The mean evaluation time was 22.7 ± 12 min (range, 7-42 min). Conclusion: Even in life-threatening situations, untrained general practitioners may be correctly guided by telemedicine specialists to perform multiorgan point-of-care ultrasound in order to improve bedside diagnostic evaluation.

Resumo Objetivo: Avaliar a viabilidade da orientação por telemedicina de médicos in situ não treinados na avaliação ultrassonográfica de múltiplos órgãos mediante protocolo padronizado, durante uma situação de risco de vida em hospital de campanha. Materiais e Métodos: Avaliamos 11 pacientes com choque e/ou dispneia de manifestação aguda durante a internação, cujos clínicos gerais solicitaram auxílio de especialista a distância. Resultados: Todos os médicos aceitaram o protocolo e, posicionando o transdutor, obtiveram imagens-chave da veia jugular interna, pulmão e veia cava inferior, quando guiados por um médico via telemedicina, que interpretou os achados desses órgãos. No entanto, apenas quatro (36%) médicos in situ obtiveram a imagem-chave apropriada do coração na janela paraesternal do eixo longo esquerdo e três (27%) tiveram imagem remotamente interpretada imediatamente. O tempo de avaliação variou de 7-42 minutos (média de 22,7 ± 12 minutos). Conclusão: Em situação de risco de vida, os clínicos gerais não treinados podem ser corretamente orientados por especialistas em telemedicina para realizar ultrassonografia multiórgãos in situ, melhorando o diagnóstico beira do leito.

Telemedicine diagnosis of acute respiratory tract infection patients is not inferior to face-to-face consultation: a randomized trial.

OBJECTIVE: To analyze telemedicine diagnostic accuracy in patients with respiratory infections during COVID-19 pandemic compared to face-to-face evaluation in the emergency department. METHODS: Randomized, unicentric study between September 2020 and November 2020 in patients with any respiratory symptom (exclusion criteria: age >65 years, chronic heart or lung diseases, immunosuppressed). Patients were randomized 1:1 for brief telemedicine followed by face-to-face consultation or direct face-to-face evaluation. The primary endpoint was the International Classification of Diseases code. The secondary analysis comprised length of stay, diagnostic test ordering, medical prescription, and proposed destination. RESULTS: Ninety-eight patients were enrolled. The mean age was 36.3±9.7 years old, 57.1% were women, and 81.6% had diagnostic test ordered. Mean grouped by International Classification of Diseases code for upper respiratory tract infection, pharyngotonsillitis, and sinusitis showed no difference between study groups or secondary endpoints. The Telemedicine Group was representative of the population usually evaluated in this center. In the Telemedicine Group (n=48), 18.7% patients would be referred for evaluation at the emergency department. The distribution of diagnoses by telemedicine was 67.4% for upper respiratory tract infection, 2.3% for pharyngotonsillitis, and 0% for sinusitis, being statistically similar to the subsequent face-to-face assessment, respectively: 72.1%, 11.6% and 7% (Kappa 0.386 [95%CI: 0.112-0.66]; p=0.536). Telemedicine ordered COVID-19 molecular (RT-PCR) tests in 76.5% versus 79.4% in face-to-face evaluation (Kappa 0.715 [95%CI: 0.413-1]; p>0.999). CONCLUSION: Diagnostic telemedicine consultation of low-risk patients with acute respiratory symptoms is not inferior to face-to-face evaluation at emergency department. Telemedicine is to be reinforced in the health care system as a strategy for the initial assessment of acute patients. ClinicalTrials.gov Identifier: NCT04806477.

Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial. / Plano de análise estatística de um ensaio clínico randomizado em cluster em unidades de terapia intensiva geral adulto no Brasil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE).

OBJECTIVE: The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care. METHODS: The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia. CONCLUSION: According to the trial's best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results.ClinicalTrials.gov registration: NCT03920501.

OBJETIVO: O ensaio TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) visa avaliar se uma intervenção complexa por telemedicina em unidades de terapia intensiva, que se concentra em rondas multidisciplinares diárias realizadas por intensivistas a distância, reduzirá o tempo de permanência na unidade de terapia intensiva em comparação com os cuidados habituais. MÉTODOS: O TELESCOPE é um ensaio nacional, multicêntrico, controlado, aberto, randomizado em cluster. O estudo testa a eficácia de rondas multidisciplinares diárias realizadas por um intensivista por meio de telemedicina em unidades de terapia intensiva brasileiras. O protocolo foi aprovado pelo Comitê de Ética em Pesquisa local do centro coordenador do estudo e pelo Comitê de Ética em Pesquisa local de cada uma das 30 unidades de terapia intensiva, de acordo com a legislação brasileira. O ensaio está registado no ClinicalTrials.gov (NCT03920501). O desfecho primário é o tempo de internação na unidade de terapia intensiva, que será analisado considerando o período basal e a estrutura dos dados em cluster, sendo ajustado por covariáveis predefinidas. Os desfechos exploratórios secundários incluem a classificação de desempenho da unidade de terapia intensiva, a mortalidade hospitalar, a incidência de infecções nosocomiais, o número de dias sem ventilação mecânica aos 28 dias, a taxa de pacientes que recebem alimentação oral ou enteral, a taxa de pacientes sob sedação leve ou em alerta e calmos e a taxa de pacientes sob normoxemia. CONCLUSÃO: De acordo com as melhores práticas do ensaio, divulgamos nossa análise estatística antes de bloquear a base de dados e iniciar as análises. Esperamos que essa prática de notificação evite o viés das análises e aprimore a interpretação dos resultados apresentados.Registro no ClinicalTrials.gov: NCT03920501.

Plano de análise estatística de um ensaio clínico randomizado em cluster em unidades de terapia intensiva geral adulto no Brasil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) / Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial

RESUMO Objetivo: O ensaio TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) visa avaliar se uma intervenção complexa por telemedicina em unidades de terapia intensiva, que se concentra em rondas multidisciplinares diárias realizadas por intensivistas a distância, reduzirá o tempo de permanência na unidade de terapia intensiva em comparação com os cuidados habituais. Métodos: O TELESCOPE é um ensaio nacional, multicêntrico, controlado, aberto, randomizado em cluster. O estudo testa a eficácia de rondas multidisciplinares diárias realizadas por um intensivista por meio de telemedicina em unidades de terapia intensiva brasileiras. O protocolo foi aprovado pelo Comitê de Ética em Pesquisa local do centro coordenador do estudo e pelo Comitê de Ética em Pesquisa local de cada uma das 30 unidades de terapia intensiva, de acordo com a legislação brasileira. O ensaio está registado no ClinicalTrials.gov (NCT03920501). O desfecho primário é o tempo de internação na unidade de terapia intensiva, que será analisado considerando o período basal e a estrutura dos dados em cluster, sendo ajustado por covariáveis predefinidas. Os desfechos exploratórios secundários incluem a classificação de desempenho da unidade de terapia intensiva, a mortalidade hospitalar, a incidência de infecções nosocomiais, o número de dias sem ventilação mecânica aos 28 dias, a taxa de pacientes que recebem alimentação oral ou enteral, a taxa de pacientes sob sedação leve ou em alerta e calmos e a taxa de pacientes sob normoxemia. Conclusão: De acordo com as melhores práticas do ensaio, divulgamos nossa análise estatística antes de bloquear a base de dados e iniciar as análises. Esperamos que essa prática de notificação evite o viés das análises e aprimore a interpretação dos resultados apresentados. Registro no ClinicalTrials.gov:NCT03920501

ABSTRACT Objective: The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care. Methods: The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia. Conclusion: According to the trial's best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results. ClinicalTrials.gov registration:NCT03920501

Telehealth for Supporting Referrals to Specialized Care During COVID-19.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic led to the suspension or postponement of care for non-urgent conditions worldwide. Regula Mais Brasil is an initiative of the Unified Health System (SUS) in Brazil to optimize the management of referrals to specialized care by using telehealth. Objectives: To report the expansion of telehealth activities of Regula Mais Brasil in response to COVID-19 and to assess qualification of referrals in primary health care (PHC) units as well as the added value of teleconsultation in qualifying referral cases. Methods: Descriptive study of the teleconsultations carried out as an additional strategy to the remotely operated referral management system, responsible for navigating cases from PHC units to specialized care in Recife, Brazil, between May 6, 2020 and September 30, 2020. Teleconsultation was implemented as a tool for reducing delays in the access to health care due to COVID-19 and ultimately allowed for reclassification of the referral adequacy and priority. Changes in referral priority ratings and referral decisions after teleconsultation were analyzed. Results: A total of 622 referral cases were analyzed. Approved referrals represented 51.9% of cases. The main reason for approved referrals was the need for diagnostic resources. There was a reduction in priority ratings in 449 cases (72.2%) after teleconsultation. There was a statistically significant association between the change of priority ratings and the decision on referral (Pearson's χ2, p-value <0.0001). Results show that telemedicine had an impact on the prioritization and qualification of cases referred to specialized services. Conclusions: A need was detected to rapidly adapt tools available for telemedicine in Brazil. Our results demonstrate that teleconsultation as an additional strategy to the remotely operated referral management system has contributed toward improving equitable access to specialized services.

Telemedicine diagnosis of acute respiratory tract infection patients is not inferior to face-to-face consultation: a randomized trial

ABSTRACT Objective To analyze telemedicine diagnostic accuracy in patients with respiratory infections during COVID-19 pandemic compared to face-to-face evaluation in the emergency department. Methods Randomized, unicentric study between September 2020 and November 2020 in patients with any respiratory symptom (exclusion criteria: age >65 years, chronic heart or lung diseases, immunosuppressed). Patients were randomized 1:1 for brief telemedicine followed by face-to-face consultation or direct face-to-face evaluation. The primary endpoint was the International Classification of Diseases code. The secondary analysis comprised length of stay, diagnostic test ordering, medical prescription, and proposed destination. Results Ninety-eight patients were enrolled. The mean age was 36.3±9.7 years old, 57.1% were women, and 81.6% had diagnostic test ordered. Mean grouped by International Classification of Diseases code for upper respiratory tract infection, pharyngotonsillitis, and sinusitis showed no difference between study groups or secondary endpoints. The Telemedicine Group was representative of the population usually evaluated in this center. In the Telemedicine Group (n=48), 18.7% patients would be referred for evaluation at the emergency department. The distribution of diagnoses by telemedicine was 67.4% for upper respiratory tract infection, 2.3% for pharyngotonsillitis, and 0% for sinusitis, being statistically similar to the subsequent face-to-face assessment, respectively: 72.1%, 11.6% and 7% (Kappa 0.386 [95%CI: 0.112-0.66]; p=0.536). Telemedicine ordered COVID-19 molecular (RT-PCR) tests in 76.5% versus 79.4% in face-to-face evaluation (Kappa 0.715 [95%CI: 0.413-1]; p>0.999). Conclusion Diagnostic telemedicine consultation of low-risk patients with acute respiratory symptoms is not inferior to face-to-face evaluation at emergency department. Telemedicine is to be reinforced in the health care system as a strategy for the initial assessment of acute patients. ClinicalTrials.gov Identifier: NCT04806477

Assessment of patients with acute respiratory symptoms during the COVID-19 pandemic by Telemedicine: clinical features and impact on referral.

OBJECTIVE: To characterize variables associated with referral to the emergency department following Telemedicine consultation during the COVID-19 pandemic. METHODS: Cross-sectional retrospective study conducted between March and May 2020, with a sample of 500 adult patients. The inclusion criterion was the manifestation of respiratory symptoms, regardless of type. RESULTS: The mean age of patients was 34.7±10.5 years, and 59% were women. Most patients (62.6%) perceived their own health status as malaise and some (41.4%) self-diagnosed COVID-19. Cough (74.4%), rhinorrhea (65.6%), sore throat (38.6%) and sneezing (20.6%) were the most common infection-related symptoms. Overall, 29.4% and 16% of patients reported dyspnea and chest pain, respectively. The Roth score was calculated for a sizeable number of patients (67.6%) and was normal, moderately altered or severely altered in 83.5%, 10.7% and 5.6% of patients, respectively. The percentage of suspected COVID-19 cases was 67.6%. Of these, 75% were managed remotely and only one quarter referred for emergency assessment. CONCLUSION: Telemedicine assessment is associated with reclassification of patient's subjective impression, better inspection of coronavirus disease 2019 and identification of risk patients. Referral is therefore optimized to avoid inappropriate in-person assessment, and low-risk patients can be properly guided. Telemedicine should be implemented in the health care system as a cost-effective strategy for initial assessment of acute patients.

Assessment of patients with acute respiratory symptoms during the COVID-19 pandemic by Telemedicine: clinical features and impact on referral / Avaliação de pacientes com sintomas respiratórios agudos durante a pandemia de COVID-19 via Telemedicina: características clínicas e impacto no encaminhamento

ABSTRACT Objective: To characterize variables associated with referral to the emergency department following Telemedicine consultation during the COVID-19 pandemic. Methods: Cross-sectional retrospective study conducted between March and May 2020, with a sample of 500 adult patients. The inclusion criterion was the manifestation of respiratory symptoms, regardless of type. Results: The mean age of patients was 34.7±10.5 years, and 59% were women. Most patients (62.6%) perceived their own health status as malaise and some (41.4%) self-diagnosed COVID-19. Cough (74.4%), rhinorrhea (65.6%), sore throat (38.6%) and sneezing (20.6%) were the most common infection-related symptoms. Overall, 29.4% and 16% of patients reported dyspnea and chest pain, respectively. The Roth score was calculated for a sizeable number of patients (67.6%) and was normal, moderately altered or severely altered in 83.5%, 10.7% and 5.6% of patients, respectively. The percentage of suspected COVID-19 cases was 67.6%. Of these, 75% were managed remotely and only one quarter referred for emergency assessment. Conclusion: Telemedicine assessment is associated with reclassification of patient's subjective impression, better inspection of coronavirus disease 2019 and identification of risk patients. Referral is therefore optimized to avoid inappropriate in-person assessment, and low-risk patients can be properly guided. Telemedicine should be implemented in the health care system as a cost-effective strategy for initial assessment of acute patients.

RESUMO Objetivo: Caracterizar as variáveis associadas ao encaminhamento à emergência após consulta de Telemedicina durante a pandemia de COVID-19. Métodos: Estudo transversal e retrospectivo, realizado entre março e maio de 2020, com amostra de 500 pacientes adultos. O critério de inclusão foi apresentação de sintomas respiratórios, independente do tipo. Resultados: A média de idade dos pacientes foi de 34,7±10,5 anos, e 59% eram do sexo feminino. A maioria dos pacientes (62,6%) se classificou subjetivamente como tendo um mal-estar, e alguns (41,4%) autodiagnosticaram COVID-19. Tosse (74,4%), rinorreia (65,6%), dor de garganta (38,6%) e espirros (20,6%) foram os sintomas mais comuns relacionados à infecção. Dispneia e dor torácica foram relatados por 29,4% e 16% dos pacientes, respectivamente. Foi calculado o escore de Roth de um número considerável de pacientes (67,6%), obtendo resultado normal em 83,5%, moderadamente alterado em 10,7% e grave em 5,6%. A percentagem de casos suspeitos de COVID-19 foi de 67,6%, e 75% desses foram gerenciados remotamente, com apenas um quarto sendo encaminhado para avaliação imediata na emergência. Conclusão: A avaliação da Telemedicina está associada à reclassificação da impressão subjetiva do paciente, melhor inspeção da COVI-19 e identificação de pacientes de risco. O encaminhamento é otimizado, para evitar avaliação presencial inadequada, e permite que os pacientes de baixo risco sejam orientados de forma apropriada. A Telemedicina deve ser implementada no sistema de saúde como estratégia com boa relação custo-efetividade para a avaliação inicial de pacientes agudos.

Barriers and Benefits in Telemedicine Arising Between a High-Technology Hospital Service Provider and Remote Public Healthcare Units: A Qualitative Study in Brazil.

BACKGROUND: In Brazil, the Program for Institutional Development of the Unified Healthcare System (PROADI-SUS) has implemented a telemedicine service for urgent situations and emergencies. It is delivered by a high-technology (HT) hospital to 15 remote healthcare units (RUs) in 11 different Brazilian states. The aim of this study was to investigate possible barriers and benefits in telemedicine service among these units. MATERIALS AND METHODS: We performed a qualitative study on the perceptions of physicians involved in telemedicine service in their role as providers and consultants. An individual, semistructured recorded interview was conducted with 28 physicians (17 HT; 11 RU) encompassing telemedicine resources and interaction among HT and RU physicians. Data analysis was performed by Discourse of Collective Subject. RESULTS: We identified the following barriers in the telemedicine service: (1) lack of experience in the use of technology or the quality of the internet signal; (2) the multiplicity of different telemedicine platforms; (3) the quality of the image sent to the HT hospital; (4) the misunderstanding that telemedicine is a time-consuming technology instead of a resource that may help to save lives; (5) not feeling comfortable exposing doubts to other HT colleagues; (6) problems in the management of telemedicine use in the RUs; and (7) political and legal issues. However, important benefits in telemedicine service were also described. CONCLUSIONS: The structural barriers should be the target of hospital managers. Development of standard remote care protocols may increase the use of telemedicine and create new work routines. Given the relationship difficulties among the RU and HT doctors during telemedicine consultations, other meetings should be organized to allow more interpersonal interactions. These meetings may also have the goal of sharing outcome indicators of their joint activity in telemedicine to stimulate and make them aware of the benefits of their interaction.

Impact of telemedicine in hospital culture and its consequences on quality of care and safety.

OBJECTIVE: To describe the impact of the telemedicine application on the clinical process of care and its different effects on hospital culture and healthcare practice. METHODS: The concept of telemedicine through real time audio-visual coverage was implemented at two different hospitals in São Paulo: a secondary and public hospital, Hospital Municipal Dr. Moysés Deutsch, and a tertiary and private hospital, Hospital Israelita Albert Einstein. RESULTS: Data were obtained from 257 teleconsultations records over a 12-month period and were compared to a similar period before telemedicine implementation. For 18 patients (7.1%) telemedicine consultation influenced in diagnosis conclusion, and for 239 patients (92.9%), the consultation contributed to clinical management. After telemedicine implementation, stroke thrombolysis protocol was applied in 11% of ischemic stroke patients. Telemedicine approach reduced the need to transfer the patient to another hospital in 25.9% regarding neurological evaluation. Sepsis protocol were adopted and lead to a 30.4% reduction mortality regarding severe sepsis. CONCLUSION: The application is associated with differences in the use of health services: emergency transfers, mortality, implementation of protocols and patient management decisions, especially regarding thrombolysis. These results highlight the role of telemedicine as a vector for transformation of hospital culture impacting on the safety and quality of care.

Impact of telemedicine in hospital culture and its consequences on quality of care and safety / Impacto da telemedicina na cultura hospitalar e suas consequências na qualidade e segurança do cuidado

ABSTRACT Objective To describe the impact of the telemedicine application on the clinical process of care and its different effects on hospital culture and healthcare practice. Methods The concept of telemedicine through real time audio-visual coverage was implemented at two different hospitals in São Paulo: a secondary and public hospital, Hospital Municipal Dr. Moysés Deutsch, and a tertiary and private hospital, Hospital Israelita Albert Einstein. Results Data were obtained from 257 teleconsultations records over a 12-month period and were compared to a similar period before telemedicine implementation. For 18 patients (7.1%) telemedicine consultation influenced in diagnosis conclusion, and for 239 patients (92.9%), the consultation contributed to clinical management. After telemedicine implementation, stroke thrombolysis protocol was applied in 11% of ischemic stroke patients. Telemedicine approach reduced the need to transfer the patient to another hospital in 25.9% regarding neurological evaluation. Sepsis protocol were adopted and lead to a 30.4% reduction mortality regarding severe sepsis. Conclusion The application is associated with differences in the use of health services: emergency transfers, mortality, implementation of protocols and patient management decisions, especially regarding thrombolysis. These results highlight the role of telemedicine as a vector for transformation of hospital culture impacting on the safety and quality of care.

RESUMO Objetivo Analisar o impacto da aplicação de telemedicina no processo clínico de cuidado e seus diferentes efeitos sobre a cultura hospitalar e na prática assistencial. Métodos O conceito de telemedicina, por meio de uma cobertura integral em tempo real, foi implementada em dois hospitais diferentes em São Paulo, um secundário e público, o Hospital Municipal Dr. Moysés Deutsch, e um terciário e privado, o Hospital Israelita Albert Einstein. Resultados Os dados foram obtidos a partir de 257 teleconsultas registradas ao longo de um período de 12 meses e comparados a igual período antes da implementação. Em 18 pacientes (7,1%), a telemedicina influenciou no diagnóstico e, para 239 pacientes (92,9%), a consulta contribuiu para o manejo clínico. Após a implementação da telemedicina, o protocolo de trombólise para acidente vascular cerebral foi aplicado em 11% dos pacientes com acidente vascular cerebral. A introdução da telemedicina reduziu a necessidade de transferir pacientes para avaliação neurológica externa em 25,9%. O protocolo de sepse foi adotado, sendo observada redução da mortalidade em 30,4% nos casos de sepse grave. Conclusão A aplicação da telemedicina está associada com diferenças na utilização dos serviços de saúde: transferências, mortalidade, implementação de protocolos e apoio à decisão médica, especialmente em relação à trombólise. Estes resultados destacam o papel da telemedicina como um vetor de transformação da cultura hospitalar e seu impacto sobre a segurança e na qualidade assistencial.