Article, Emergency Medicine

iPad deployment for virtual evaluation in the emergency department during the COVID-19 pandemic

Journal logoUnlabelled imageAmerican Journal of Emergency Medicine 38 (2020) 2733-2734

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American Journal of Emergency Medicine

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iPad deployment for virtual evaluation in the emergency department during the COVID-19 pandemic

  1. Objective

Emergency Medicine clinicians are rapidly adapting to new ways of operating and delivering care in the era of the COVID-19 pandemic and limited Personal protective equipment availability [[1]]. At our hospital, a quaternary care academic and level one trauma center, we explored digital care delivery methods to reduce unnecessary exposure and conserve PPE. One method involved the deployment of iPads to evaluate and manage patients using a HIPAA-compliant virtual video and voice application.

  1. Development

With support from our information technology team, the Emergency Department (ED) equipped 15 iPads with the VirtualVisit app (SBR Health, Inc.), which creates Virtual healthcare delivery Networks to in- tegrate existing information technology infrastructures and clinical workflows. ED clinicians then used iPhones, previously deployed for staff communication, to connect to the patient-facing iPad using VirtualVisit.

  1. Functioning

The iPad, mounted on a mobile IV pole (Fig. 1), is positioned 6-8 ft from the patient. The iPads on IV poles can be moved as needed or

anchored in a high patient-turnover room. Clinicians initiate the virtual encounter and access the iPad interface from their iPhone through the VirtualVisit app, immediately appearing on the patient-facing iPad. This does not require patient initiative. The clinician can then obtain a virtual HPI and exam. The iPad is decontaminated between encounters using Sani-Cloth wipes.

  1. Barriers

There were few barriers to clinician adoption of iPads to evaluate pa- tients with COVID-19 symptoms, attributable to a unified understand- ing of the need to reduce the risk of transmission and to preserve PPE. iPhone-mediated communication, already in widespread use among ED clinicians, translated to seamless implementation in already- existing work flows while using the VirtualVisit app.

  1. Initial results

Overall, iPad use was feasible for most patients and clinician feed- back gathered during ED administrative rounds was positive. Most re- ported a greater sense of safety with added physical isolation from suspected COVID patients, of respite from donning and doffing PPE mul- tiple times per day, and of stewardship to save PPE for higher risk en- counters such as those involving intubation or central line placement. iPad use decreased the frequency and duration of time that a clinician needed to be at the bedside, as the majority of ED faculty reported prac- tice patterns shifting to neither the attending, APP (advanced practice provider) or resident examining at-risk COVID patients in person for those triaged to lower acuity units. The magnitude of reduction of expo- sure and PPE use for these patients was estimated at 50-75%; few en- counters required an MD or APP/resident at the bedside. However, some components of the evaluation still required physical contact for

Image of Fig. 1

Fig. 1. An iPad mounted on a mobile IV pole (a), a close-up of the VirtualVisit app used for patient communication and virtual examination (b), and view of the clinician (bottom) interfacing with patient (top) in (c).

https://doi.org/10.1016/j.ajem.2020.04.025

0735-6757/(C) 2020

2734 iPad deployment for virtual evaluation in the emergency department during the COVID-19 pandemic

tasks traditionally done by nursing, such as obtaining vital signs, an EKG, or drawing labs.

This intervention generated robust discussions regarding the utility and value of various aspects of the physical examination (e.g., ‘virtual’ or ‘doorway’ exams vs. lung auscultation) in different patient popula- tions, and thoughtful approaches to overcome potential gaps in care (e.g., ambulatory O2 saturations and use of chest x-ray imaging).

Initial challenges included communicating effectively with foreign- language-speaking or deaf patients requiring 3-way interfacing with an interpreter (now resolved issues), difficulty hearing muffled voices if the patient wore a mask or if the iPad was too far away to capture sound, mal-positioning of the iPad (e.g., not facing the patient in the same way each time or if patient’s position in the room changed), and clinician inability to control the iPad’s camera view. Additional chal- lenges include reliability of the patient self-assessment (e.g., self- palpation of the abdomen) – and that virtual evaluation may not be ap- propriate for all patients (e.g., certain Psychiatric patients or patients re- quiring interventions such as intubation). In addition, there is variability in patient receptiveness to technology as the care delivery interface.

  1. Future considerations

While deploying iPad technology to facilitate safer care during COVID-19 is a major step forward, greater opportunity exists for more agile implementation of digital technology and infrastructure to deliver contact-free care. Potential exists in the design and architecture of healthcare facilities, and the equipment with which they are outfitted for optimal digital interactions, including 360-degree-view two-way video and surround-sound microphone and audio capabilities. Patient rooms could be equipped with automated note-generation from ambi- ent audio/visual technology to increase work-efficiency and decrease administrative burdens. A video laryngoscope’s screen could be linked via Bluetooth to a wall-mounted television inside the room or behind glass doors for remote intubation guidance.

Beyond facilities and equipment, the ability to provide care remotely to anywhere beyond our traditional brick and mortar hospital walls is of paramount importance as we face a daunting Supply and demand

mismatch in healthcare system capacity and population needs, espe- cially under pandemic circumstances. Our experiences with COVID-19 will undoubtedly catalyze additional digitally-driven care for our pa- tients in the future.

Source of support

This work did not receive any specific grant from funding agencies in the public, commercials, or not-for-profit sectors.

Declaration of competing interest

None.

Acknowledgements

Names redacted for blinded peer review.

References

[1] Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med 11 March 2020. https://doi.org/10.1056/NEJMp2003539. https://www.nejm.org/doi/ full/10.1056/NEJMp2003539, Accessed date: 11 March 2020.

Kelley A. Wittbold MD? Joshua J. Baugh MD, MPP Brian J. Yun MD, MBA, MPH Ali S. Raja MD, MBA, MPH

Benjamin A. White MD

Department of Emergency Medicine, Massachusetts General Hospital, 55

Fruit St., Boston, MA 02114, USA

?Corresponding author at: Department of Emergency Medicine, Massachusetts General Hospital, 5 Emerson Place, Suite 101, Boston, MA

02114, USA.

E-mail address: [email protected] (K.A. Wittbold).

6 April 2020

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