Virtual Daily Rounding for COVID-19 Facility Outbreaks: A Standardized Telehealth-Centered Approach May Reduce Hospital Transfers and Mortality.

Background: Residents of nursing homes are among the most vulnerable to COVID-19. There is no standardized approach for integration with hospitals for outbreak response. Previously, we described collaboration between a hospital and regional facilities. As a component of our COVID-19 Outbreak Response, we describe the impact of virtual daily rounds as an efficient and effective tool for facility outbreak in Central Virginia. Methods: At this facility, 82 (60%) residents were infected. Our team rapidly deployed technology to support staff at the facility. Virtual daily rounds created a systematic approach for patient care. The goals of virtual daily rounds include (1) efficiently facilitating HIPAA-compliant communication between nursing and all licensed independent providers, (2) rapid identification of clinical decline, (3) facilitation of care escalation, (4) facilitating bidirectional transfers, and (5) rapid and efficient identification of patients appropriate for telemedicine pulmonary consultation. Results: The outbreak remained active 6 weeks; 82 of 136 (60%) residents were infected, and 36 (44%) COVID-19 positive residents were seen by telemedicine consultation. Fifty-seven (70%) residents remained in-facility for treatment. Twenty-one residents died (15%); 10 in facility, 11 in hospital. Of those seen in telemedicine consultation, 24 (69%) remained on the treat-in-place protocol with goal-concordant care. These hospitalization and mortality rates are significantly lower than similar outbreaks reported. Discussion and Conclusion: We have since instituted this system at seven other facilities. A model of virtual daily rounding holds promise for decreasing mortality/hospitalization in this vulnerable population through systematically identifying patients most appropriate for telemedicine and cultivating close collaboration between hospitals and nursing homes.

Rapid Telehealth-Centered Response to COVID-19 Outbreaks in Postacute and Long-Term Care Facilities.

Purpose: The vulnerability of postacute and long-term care (PA/LTC) facility residents to COVID-19 has manifested across the world with increasing facility outbreaks associated with high hospitalization and mortality rates. Systematic protocols to guide telehealth-centered interventions in response to COVID-19 outbreaks have yet to be delineated. This article is intended to inform PA/LTC facilities and neighboring health care partners how to collaboratively utilize telehealth-centered strategies to improve outcomes in facility outbreaks. Methods: The University of Virginia rapidly developed a multidisciplinary telehealth-centered COVID-19 facility outbreak strategy in response to a LTC facility outbreak in which 41 (out of 48) facility residents and 7 staff members tested positive. This strategy focused on supporting the facility team remotely using rapidly deployed technologic solutions. Goals included (1) early identification of patients who need their care escalated, (2) monitoring and treating patients deemed safe to remain in the facility, (3) care coordination to facilitate bidirectional transfers between the skilled nursing facility (SNF) and hospital, and (4) daily facility needs assessment related to technology, infection control, and staff well-being. To achieve these goals, a standardized approach centered on daily multidisciplinary virtual rounds and telemedicine consultation was provided. Results: Over a month since the outbreak began, 18 out of 48 (38%) facility residents required hospitalization and 6 (12.5%) died. Eleven facility residents have since returned back to the SNF after recovering from their hospitalization. No staff required hospitalization. Conclusions: Interventions that reduce hospitalizations and mortality are a critical need during the COVID-19 pandemic. The mortality and hospitalization rates seen in this PA/LTC facility outbreak are significantly lower than has been documented in other facility outbreaks. Our multidisciplinary approach centered on telemedicine should be considered as other PA/LTC facilities partner with neighboring health care systems in responding to COVID-19 outbreaks. We have begun replicating these services to additional PA/LTC facilities facing COVID-19 outbreaks.

Comparison of a Novel Handheld Telehealth Device with Stand-Alone Examination Tools in a Clinic Setting.

Background and Objective: Research demonstrates that telemedicine is effective in pediatric settings but little is published to validate the quality of the data acquired by remote peripheral examination devices to accurately inform clinical decision-making.Introduction: The primary aim was to compare a novel Food and Drug Administration (FDA)-cleared multifunctional remote examination device (Tyto) with other stand-alone digital examination devices. The secondary aim was to ascertain whether either device produced images or sounds better able to provide clinical information to clinicians caring for children.Materials and Methods: Otoscopic images and heart and lung sounds from 50 patients of ages 2-18 years were acquired using the novel device and a stand-alone digital otoscope and stethoscope. Data were stored on a secure server for review by physicians (two pulmonary faculty, two general faculty, two cardiology faculty, and two cardiology fellows). Reviewers were blinded and they reviewed images and audio files in a randomized manner. Images and sounds were scored in terms of quality using a Likert scale. Means and standard deviations (and t-tests to compare those means) were calculated. Individual (heart sounds, lung sounds, and otoscopic images) and aggregate scores were compared.Results: The novel device provided higher sound and image quality with less chance of an inability to make a diagnosis than the stand-alone devices. The novel device had a superior mean comparative diagnostic score with a high intra- and inter-reliability of cardiac, pulmonary, and otoscopic diagnosis.Discussion and Conclusions: The novel device outperformed the stand-alone digital stethoscope and otoscope and was better able to provide usable data to support a clinical encounter.

Mobile Telestroke During Ambulance Transport Is Feasible in a Rural EMS Setting: The iTREAT Study.

BACKGROUND: The use of telemedicine in the diagnosis and treatment of acute stroke, or telestroke, is a well-accepted method of practice improving geographic disparities in timely access to neurological expertise. We propose that mobile telestroke assessment during ambulance transport is feasible using low-cost, widely available technology. MATERIALS AND METHODS: We designed a platform including a tablet-based end point, high-speed modem with commercial wireless access, external antennae, and portable mounting apparatus. Mobile connectivity testing was performed along six primary ambulance routes in a rural network. Audiovisual (AV) quality was assessed simultaneously by both an in-vehicle and an in-hospital rater using a standardized 6-point rating scale (≥4 indicating feasibility). We sought to achieve 9 min of continuous AV connectivity presumed sufficient to perform mobile telestroke assessments. RESULTS: Thirty test runs were completed: 93% achieved a minimum of 9 min of continuous video transmission with a mean mobile connectivity time of 18 min. Mean video and audio quality ratings were 4.51 (4.54 vehicle; 4.48 hospital) and 5.00 (5.13 in-vehicle; 4.87 hospital), respectively. Total initial cost of the system was $1,650 per ambulance. CONCLUSIONS: In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.

Assessing and Addressing the Determinants of Appalachian Population Health: A Scoping Review.

Introduction: Residents of Appalachia experience elevated rates of morbidity and mortality compared to national averages, and these disparities are associated with inequitable exposures to various determinants of population health. Social and environmental determinants of health are a useful lens through which to develop and evaluate programs to mitigate regional health disparities. Methods: This 2023 scoping review was conducted of studies linking determinants of Appalachian health with leading causes of regional mortality and morbidity. The search strategy employed a keyword search that included geographic terms for the Appalachian Region and the primary adverse health outcomes in that region. Studies meeting the following inclusion criteria were reviewed: original article, published in the last five years, involving an Appalachian population, and includes a rigorous assessment of an association between a population health determinant and one or more leading causes of Appalachian morbidity and mortality. Results: The search returned 221 research articles, including 30 interventional studies. The top three health outcomes included cancer (43.59%), diseases of despair (23.08%), and diabetes (12.82). Access to care (27.3%), rurality (18.9%), and education (14.8%) were the most common population health determinants identified. Interventional studies were categorized by program types: education, technology, partnerships, and multilevel interventions. Due to the heterogeneity of study types, the studies were combined using a narrative synthesis. Implications: The results of this work can inform the development and evaluation of additional programs to promote Appalachian population health. Our study team will use these results to inform community-based discussions that develop strategic plans to mitigate health disparities in Central and Southcentral Appalachian Virginia.

Telehealth stroke education for rural elderly Virginians.

OBJECTIVE: Stroke is a prevalent condition found in elderly, rural populations. However, stroke education, which can be effective in addressing the risks, is often difficult to provide in these remote regions. The objective of this study is to evaluate the effectiveness of delivering stroke education to elderly individuals through telehealth versus in-person stroke prevention education methods. MATERIALS AND METHODS: A quasi-experimental nonequivalent control group design was used in this study. A convenience sample of 11 elderly adults (36% men, 64% women) with a mean age of 70 was selected from an Appalachian Program for All Inclusive Care for the Elderly (day care) facility. Subjects completed preintervention surveys, received a 20-min group in-person or telehealth delivered education session, and then completed the postintervention surveys. RESULTS: Satisfaction with delivery method and post-education knowledge was equivalent between the two groups. Knowledge increased in both groups after the educational programs. Likelihood of reducing risk factors showed no differences pre-posttest. However, there were significant improvements in the pre-post likelihood scores of the telehealth group in contrast to the in-person group. CONCLUSIONS: This project provided a rural, high-risk population access to telehealth stroke education, thus enabling these individuals to receive education at a distance from experts in the field. The telehealth program was found to be equivalent to in-person stroke education in regards to satisfaction, knowledge, and likelihood of making changes to decrease vascular risk factors. The study demonstrated feasibility in providing effective stroke education through telehealth, thus suggesting an often overlooked route for providing patient education at a distance.

A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study.

OBJECTIVES: In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations. METHODS: We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval). RESULTS: We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to -0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites. CONCLUSIONS: Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.