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Virtual care program arrives in the nick of time for post-NICU care during pandemic

By CN Content posted 02-01-2021 00:00

  
https://infirmiere-canadienne.com/blogs/ic-contenu/2021/02/01/un-projet-pilote-de-soins-post-unsi-virtuels-juste
Feb 01, 2021, By: Karen Lasby, Shannon Viala, Laurel Morrison
mother holding baby while working on laptop at home
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The average virtual visit duration was 31 minutes. In comparison with our typical 60-minute in-person follow-up appointment, we estimate that the three-month virtual care pilot produced a reduction of 1,689 minutes (28 hours) of direct, hands-on nursing care. Using a combination of virtual and in-person home visits, each nurse could accommodate up to five appointments per day, compared to the previous two home visits per day.

Takeaway messages

  • The use of virtual care technologies has become more prevalent within neonatal care to facilitate family integration into care planning and discharge preparation.
  • Families of very-low-birth-weight infants were highly accepting of the opportunity to use virtual care following hospital discharge.
  • Neonatal nurses were pleasantly surprised to be able to assess breastfeeding, bottle feeding, tone, activity, overall state and most developmental milestones using virtual care; weigh scales were loaned to families and nurses used teddy bears as teaching tools.

Virtual care technology has been widely incorporated into health care; however, in comparison with other countries, Canada has been slow to implement it (Digital Health Canada, 2019; McGrail, Ahuja, & Leaver, 2017; Vogel, 2020). Virtual care uses technology (telephone, video, email and messaging) to connect health-care providers with their clients, when they are not in the same location, for health assessments, follow-up, education and counselling (Jamieson et al., 2015; McGrail et al., 2017; Olson, McSwain, Curfman, & Chuo, 2018). Client benefits of virtual care include improved access to equitable care for those unable to travel, improved experience, greater convenience by receiving care closer to or within their home, timely access to care, cost savings, improved safety by reducing or eliminating travel, and decreased work-related absences due to travel (Almeida & Montayre, 2019; Digital Health Canada, 2019; Kelley et al., 2020). The health-care system benefits from improved patient outcomes; improved patient flow; reduced wait times, emergency room visits and readmission rates; and cost savings (Almeida & Montayre, 2019; Digital Health Canada, 2019).

As with many health services, the use of virtual care technologies has become more prevalent within neonatal care to facilitate family integration into care planning and discharge preparation (Anwar Siani, Dol, & Campbell-Yeo, 2017; Gibson & Kilcullen, 2020; Hawkes, Livingstone, Ryan, & Dempsey, 2015; Yeo, Ho, Khong, & Lau, 2011). Parents of preterm infants are generally satisfied, experience less stress, feel more connected to their baby, and find virtual communications easy to use, with good visual and audio quality (Anwar Siani et al., 2017; Dol, Delahunty-Pike, Siani, & Campbell-Yeo, 2017; Garne Holm, Brødsgaard, Zachariassen, Smith, & Clemensen, 2019). There is limited research on virtual care for premature infants and their families beyond hospitalization. In a study by Willard et al. (2018), 75 per cent of families with infants recently discharged from a neonatal intensive care unit (NICU) stated that they preferred virtual care to clinic appointments. Benefits included reducing the need for travel; addressing knowledge gaps such as feeding, respiratory assessment and medication administration; reducing physician visits; and decreasing emergency department use (Willard et al., 2018).

An infant weigh scale was loaned to each participating family from a program inventory of six scales.

In 2019, the Neonatal Transition Team (NTT) in Calgary initiated a quality improvement project to explore the feasibility and acceptability of virtual care to augment service delivery for post-NICU clients. The target population consisted of very-low-birth-weight infants and their families living within the Calgary Zone. The NTT program follows approximately 120 ex-premature infants annually with a team of 2.8 full-time-equivalent registered nurses from Postpartum Community Services within Alberta Health Services (AHS). The addition of virtual care to the NTT service delivery model was postulated as a means to enhance workload capacity and reduce operating expenses for this small specialty team.

Pilot overview

The objectives of the pilot project were to improve access to NTT specialized care; enhance the patient, family and provider experience; and produce potential cost savings related to direct nursing time and travel. Patient safety was of the utmost importance while assessing this model of care. Guidance was sought from key AHS stakeholders, including Virtual Health (VH) and representatives in information technology and privacy. Through the partnership with VH, existing service gaps were identified and a co-design model was established to integrate video-conferencing technology into NTT workflows. This collaboration also involved the development of standardized processes and resources, including protocols, evaluation (including parent and provider surveys), staff training, and parent educational materials.

The project commenced on March 3, 2020. NTT parents were screened for inclusion and invited to participate in the virtual care model. Inclusion criteria included a computer with Internet Explorer or Google Chrome, high-speed internet, a webcam, email access, basic computer literacy and fluency in English. Upon receiving parental verbal agreement to participate in virtual care, instructional materials were provided, and an encrypted link for the virtual visit was emailed. An infant weigh scale was loaned to each participating family from a program inventory of six scales. Parents were instructed to weigh their infants before the virtual visit. Virtual video visits occurred between an NTT nurse (at clinic) and parents with their infants (at home) using Skype for Business on Android mobile devices or a Windows-based desktop or laptop computer. Within one month of initiating the pilot, a new secure video-conferencing platform (Zoom) became available across the AHS organization and replaced Skype for Business for this particular project. The Enterprise version of Zoom enabled encrypted and private access on all mobile devices and computers, expanding participation to parents who may have previously been excluded due to technology limitations.

The NTT program maintained a virtual visit log throughout the pilot to capture additional information, including image and audio quality, technical issues, appointment duration, distance and travel time saved, and parent feedback. Parents were emailed an online anonymous survey following the first and last virtual visit. NTT nurses were asked to complete online anonymous surveys at random intervals during the pilot.

Results

The average virtual visit duration was 31 minutes compared with our typical 60-minute in-person appointment.

Over the three-month pilot, 15 parents participated, for a total of 43 virtual visits. Initial post-NICU discharge appointments continued to be provided as in-person visits due to comprehensive assessment requirements. We discovered that virtual care was ideally suited for NTT follow-up appointments, including infants and families in isolation and infants needing frequent weight or feeding assessments. We were pleasantly surprised to be able to assess breastfeeding, bottle feeding, tone, activity, overall state and most developmental milestones using virtual care. Nurses used teddy bears as teaching tools to facilitate age-appropriate positioning and developmental guidance. The demand for virtual care quickly exceeded our inventory of six weigh scales, necessitating a loan of three additional scales from another department. A wait-list persisted for virtual care scale loans, a demand likely influenced by the pandemic environment.

The average virtual visit duration was 31 minutes. In comparison with our typical 60-minute in-person follow-up appointment, we estimate that the three-month virtual care pilot produced a reduction of 1,689 minutes (28 hours) of direct, hands-on nursing care. Using Google Maps to calculate travel distance and time, the virtual care NTT pilot program saved approximately 850 kilometres of travel, equating to a $429.25 program savings for travel expenses. The net savings in nurse travel time was 1,252 minutes (20.9 hours), improving NTT resource utilization, efficiency and program wait times to serve more families. Using a combination of virtual and in-person home visits, each nurse could accommodate up to five appointments per day, compared to the previous two home visits per day.

Initially, using Skype for Business, the learning curve for virtual care service was challenging for both parents and nurses. Parents were often unaware of how to turn on their microphone or video, and telephone support by the NTT team was often required to help resolve technical issues. Audio quality issues were common, interfering with conversation clarity and health education. In these instances, following standardized downtime procedures, the NTT nurse would contact the parent via telephone to facilitate communication. Educating parents about lighting conditions within the home environment became important for NTT nurses as it impacted the ability to perform virtual neonatal assessments. Video and/or audio freezing with Skype for Business was common and became more problematic as the worldwide demand for virtual technology increased amid the pandemic. Upon changing to Zoom, the audio and visual quality greatly improved for virtual visits. Over time, parents demonstrated greater ease of use with the technology and comfort with this model of care delivery, perhaps due to increased personal use of virtual technologies with family, friends and other health-care professionals during the pandemic.

This pilot incorporated the Telehealth Usability Questionnaire within the parent and NTT nurse surveys to capture user satisfaction with the video technology. As shown in Table 1, 92 per cent of parents rated the technology as easy to use and indicated satisfaction with virtual visits. Nearly half of the NTT parents included in the pilot found virtual visits to be equal to in-person appointments. Despite the limitations of virtual visits, 92 per cent felt comfortable communicating with NTT nurses, and 92 per cent would use virtual care again.

Karen Lasby and her newborn baby
Courtesy of Karen Lasby
Families of very-low-birth-weight infants were highly accepting of the opportunity to use virtual care following hospital discharge.

Tables

(Tables are best viewed on a desktop computer.)

Table 1: NTT virtual care parent survey results

Parent Survey (N = 13) Disagree/Strongly Disagree Neutral Agree/Strongly Agree
The virtual care platform improves my access to health-care services     13 (100%)
The virtual care platform provides for my health-care needs 1 (8%)   12 (92%)
It was simple to use this system   1 (8%) 12 (92%)
It was easy to learn to use the system     13 (100%)
I believe I could become more productive quickly using the virtual care platform   2 (15%) 11 (85%)
The way I interact with this system is pleasant 1 (8%)   12 (92%)
I like using the system 1 (8%) 1 (8%) 11 (85%)
The system is simple and easy to understand 1 (8%)   12 (92%)
The system is able to do everything I would want it to be able to do 1 (8%) 2 (15%) 10 (77%)
I can easily talk to the clinician using the virtual care platform     13 (100%)
I can hear the clinician clearly using the virtual care platform 1 (8%) 2 (15%) 10 (77%)
I felt I was able to express myself effectively     13 (100%)
Using the virtual care platform , I can see the clinician as well as if we met in person 1 (8%) 2 (15%) 10 (77%)
I think the visits provided over the virtual care platform are the same as in-person visits 4 (31%) 2 (15%) 7 (53%)
Whenever I made a mistake using the system, I could recover easily and quickly (4 chose “not applicable”)   1 (8%) 8 (62%)
The system gave error messages that clearly told me how to fix problems (3 chose “not applicable”) 1 (8%) 4 (31%) 5 (39%)
I feel comfortable communicating with the clinician using the virtual care platform   1 (8%) 12 (92%)
The virtual care platform is an acceptable way to receive health-care services 1 (8%) 1 (8%) 11 (84%)
I would use the virtual care platform again   1 (8%) 12 (92%)
Overall, I am satisfied with the virtual care platform 1 (8%)   12 (92%)

(Survey adapted with permission from Parmanto, Lewis, Graham, & Bertolet, 2016)

Feedback from the NTT nursing team was also generally positive (Table 2). The system was easy to learn, and nurses were able to provide support to infants and their families. However, NTT nurses indicated that their virtual care assessments were limited (e.g., they could not examine head shape and provide complete evaluations of developmental milestones). This may explain why more than half of the nurses surveyed (74 per cent) acknowledged that virtual visits were not the same as in-person appointments. Overall, all the nurses reported feeling satisfied and would provide virtual care again.

Table 2: Virtual Health nurse survey results

Nurse Survey (N = 19) Disagree/Strongly Disagree Neutral Agree/Strongly Agree
The virtual care platform improves my access to provide health-care services     19 (100%)
The virtual care platform supported the care of the patient 1 (5%)   18 (95%)
It was simple to use this system     19 (100%)
It was easy to learn to use the system 1 (5%) 1 (5%) 17 (90%)
I believe I could become more productive quickly using the virtual care platform   1 (5%) 18 (95%)
The way I interact with this system is pleasant   3 (16%) 16 (84%)
I like using the system   1 (5%) 18 (95%)
The system is simple and easy to understand   1 (5%) 18 (95%)
The system is able to do everything I would want it to be able to do 4 (21%) 4 (21%) 11 (58%)
I can easily talk to the patient using the virtual care platform   1 (5%) 18 (95%)
I can hear the patient clearly using the virtual care platform 2 (11%)   17 (89%)
I felt I was able to express myself effectively     19 (100%)
Using the virtual care platform, I can see the patient as well as if we met in person 9 (47%) 6 (32%) 4 (21%)
I think the visits provided over the virtual care platform are the same as in-person visits 14 (74%) 4 (21%) 1 (5%)
Whenever I made a mistake using the system, I could recover easily and quickly (12 chose “not applicable”)   2 (11%) 5 (26%)
The system gave error messages that clearly told me how to fix problems (13 chose “not applicable”; 1 did not respond) 1 (5%) 3 (16%) 1 (5%)
I feel comfortable communicating with the patient using the virtual care platform     19 (100%)
The virtual care platform is an acceptable way to provide health-care services   2 (11%) 17 (89%)
I would use the virtual care platform again     19 (100%)
Overall, I am satisfied with the virtual care platform     19 (100%)

(Survey adapted with permission from Parmanto et al., 2016)

Discussion

Outpatient follow-up is often fragmented within health-care organizations (Willard et al., 2018), posing challenges for clients and continuity of care. This pilot project demonstrated that virtual care enables NTT nurses to evaluate very-low-birth-weight infants safely, identify areas of concern and provide appropriate and timely interventions and anticipatory guidance to parents, as also described by Robinson, Gund, Sjöqvist, and Bry (2016). Although virtual care is not equivalent to in-person appointments, we were able to maintain a high level of care while accommodating additional challenges during a pandemic. Our pilot commenced two weeks before provincial SARS-CoV-19 guidelines were put into place, restricting non-urgent outpatient appointments. Fortunately, the pilot program groundwork was already established to immediately accommodate the increased service demand. During the pandemic, this pilot provided unanticipated benefits of decreased need for personal protective equipment and reduced risk to health-care providers and patients, which was also shown in a study done by Umoren et al. in 2020.

Our findings of parent comfort and satisfaction with virtual visits are comparable to results noted in other research (Anwar Siani et al., 2017; Bhatia & Falk, 2018; McGrail et al., 2017). Family feedback highlighted the importance of the NTT’s virtual care and weight assessments being shared with pediatricians and outpatient clinics as their virtual outreach programs were not yet operational early in the pandemic. Two families were particularly appreciative of virtual care availability as one was self-isolating with family outside our region and the second was mandated to self-quarantine due to illness. In both cases, virtual visits promoted seamless, community-based care. The NTT’s newly established virtual care service delivery model positively addresses the key national goal to optimize health system performance through improved population health, reduced care costs and higher patient and provider satisfaction (Bhatia & Falk, 2018; Bodenheimer & Sinsky, 2014).

Conclusion

Although virtual care is not equivalent to in-person appointments, we were able to maintain a high level of care while accommodating additional challenges during a pandemic.

Families of very-low-birth-weight infants were highly accepting of the opportunity to use virtual care following hospital discharge. Parents acquired skills to independently weigh their infant while also navigating the technological process to engage in virtual care with NTT nurses. Overall, both families and NTT nurses were satisfied with the virtual care model. The pilot project enabled program flexibility to care for high-priority newborns and expand program capacity. The NTT virtual care model demonstrated optimization of health-care resources by providing safe, high-quality care at a reduced operational cost. With the successful completion of this three-month pilot project, virtual care has been fully operationalized into the NTT service delivery model. Work is currently underway to expand the NTT virtual care model to other high-needs newborns in the community.

References

Almeida, S., & Montayre, J. (2019). An integrative review of nurse-led virtual clinics. Nursing Praxis in New Zealand, 35(1), 18-28. doi:10.36951/NgPxNZ.2019.003

Anwar Siani, S., Dol, J., & Campbell-Yeo, M. (2017). Impact of parent-targeted eHealth on parent and infant health outcomes: A scoping review. Journal of Perinatal and Neonatal Nursing, 31(4), 332-340. doi:10.1097/JPN.0000000000000265

Bhatia, R. S., & Falk, W. (2018, May 23). Modernizing Canada’s healthcare system through the virtualization of services. (C.D. Howe Institute e-Brief 277). SSRN.. doi:10.2139/ssrn.3184876

Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. doi:10.1370/afm.1713.Center

Digital Health Canada. (2019, November). Virtual care in Canada: Snapshots of innovative virtual care. Retrieved from https://digitalhealthcanada.com/publications/whitepaper-virtual-care-in-canada/

Dol, J., Delahunty-Pike, A., Anwar Siani, S., & Campbell-Yeo, M. (2017). eHealth interventions for parents in neonatal intensive care units: A systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports, 15(7), 1835-1849. doi:10.11124/JBISRIR-2016-003246

Garne Holm, K., Brødsgaard, A., Zachariassen, G., Smith, A. C., & Clemensen, J. (2019). Parent perspectives of neonatal tele-homecare: A qualitative study. Journal of Telemedicine and Telecare, 25(4), 221-229. doi:10.1177/1357633X18765059

Gibson, R., & Kilcullen, M. (2020). The impact of web-cameras on parent-infant attachment in the neonatal intensive care unit. Journal of Pediatric Nursing, 52, e77-e83. doi:10.1016/j.pedn.2020.01.009

Hawkes, G. A., Livingstone, V., Ryan, C. A., & Dempsey, E. M. (2015). Perceptions of webcams in the neonatal intensive care unit: Here’s looking at you kid! American Journal of Perinatology, 30(2), 131-136. doi:10.1055/s-0034-1376388

Jamieson, T., Wallace, R., Armstrong, K., Agarwal, P., Griffin, B., Wong, I., & Bhatia, S. (2015, June 11). Virtual care: A framework for a patient-centric system. Retrieved from https://www.womenscollegehospital.ca/assets/pdf/wihv/WIHV_VirtualHealthSymposium.pdf

Kelley, L.T., Phung, M., Stamenova, V., Fujioka, J., Agarwal, P., Onabajo, N., . . . , Bhattacharyya, O. (2020). Exploring how virtual primary care visits affect patient burden of treatment. International Journal of Medical Informatics, 141, 104228. doi:10.1016/j.ijmedinf.2020.104228

McGrail, K. M., Ahuja, M. A., & Leaver, C. A. (2017). Virtual visits and patient-centered care: Results of a patient survey and observational study. Journal of Medical Internet Research, 19(5), e177. doi:10.2196/jmir.7374

Olson, C. A., McSwain, S. D., Curfman, A. L., & Chuo, J. (2018). The current pediatric telehealth landscape. Pediatrics, 141(3),e20172334. doi:10.1542/peds.2017-2334

Parmanto, B., Lewis, Jr., A. N., Graham, K. M., & Bertolet, M. H. (2016). Development of the Telehealth Usability Questionnaire (TUQ). International Journal of Telerehabilitation, 8(1), 3-10. doi:10.5195/ijt.2016.6196

Robinson, C., Gund, A., Sjöqvist, B., & Bry, K. (2016). Using telemedicine in the care of newborn infants after discharge from a neonatal intensive care unit reduced the need of hospital visits. Acta Paediatrica, 105(8), 902-909. doi:10.1111/apa.13407

Umoren, R. A., Gray, M. M., Handley, S., Johnson, N., Kunimura, C., Mietzsch, U., Billimoria, Z., & Lo, M. D. (2020). In-hospital telehealth supports care for neonatal patients in strict isolation. Americal Journal of Perinatology, 37(8), 857-860. doi: 10.1055/s-0040-1709687

Vogel, L. (2020). Canada has long way to go on virtual care. CMAJ, 192(9), E227-E228. doi:10.1503/cmaj.1095851

Willard, A., Brown, E., Masten, M., Brant, M., Pouppirt, N., Moran, K., . . . Chuo, J. (2018). Complex surgical infants benefit from postdischarge telemedicine visits. Advances in Neonatal Care, 18(1), 22-30. doi:10.1097/ANC.0000000000000460

Yeo, C. L., Ho, S. K. Y., Khong, K. C., & Lau, Y. Y. (2011). Virtual visitation in the neonatal intensive care: Experience with the use of Internet and telemedicine in a tertiary neonatal unit. The Permanente Journal, 15(3), 32-36. doi:10.7812/tpp/11-063


The authors of this article work at Alberta Health Services.
Karen Lasby, RN, MN, CNeoN(C), is a clinical nurse specialist with the Neonatal Transition Team in Postpartum Community Services.
Shannon Viala, RN, BN, BA, is a clinical facilitator with Virtual Health.
Laurel Morrison, RN, BScN, is a senior business consultant with Virtual Health.

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#nursing-practice
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