Keep Calm and Log On: Telemedicine for COVID-19 Pandemic Response

Direct Care

Virtual care, specifically synchronous video and audio provider-­initiated services, is a well-established modality to provide direct care to patients in acute care and ambulatory settings.⁷ Telemedicine can be deployed to care for hospitalized patients in most locations as long as they meet the operational requirements described below. With a bedside nurse or other facilitator, patients can be interviewed and examined using a high definition camera and digital peripherals, including stethoscopes, otoscopes, ophthalmoscopes, and dermatoscopes. COVID-19 patients or patients under investigation may be seen in this manner. In-person visits should remain part of patients’ care as an important part of the provider-patient relationship⁸; however, telemedicine could still be deployed to provide direct care and monitoring to these patients while minimizing exposure to healthcare personnel. Additionally, telemedicine can be used for specialist consultations that are likely in high demand with COVID-19, including infectious disease, cardiology, and pulmonology.

Exposure Reduction and Resource Allocation

Currently in the United States there are concerns for shortages of PPE including surgical masks and N95 respirators. Telemedicine can reduce provider exposure, increase provider efficiency, and curtail PPE utilization by minimizing the number and frequency of in-room visits while still allowing virtual visits for direct patient care. For instance, our nursing staff is currently using telemedicine to conduct hourly rounding and limit unnecessary in-room visits.

We recommend keeping telemedicine equipment within individual isolation rooms intended for COVID-19 patients in order to eliminate the need for repeated cleaning. For other patients, a mobile cart could be used. Most commercial video software can autoanswer calls to allow for staff-free history taking. For a thorough physical exam, a bedside facilitator is need for use of digital stethoscopes and similar peripherals.

Provider Shortages and Reducing Burnout

Because SARS-CoV-2 is a highly contagious pathogen that can spread prior to symptom presentation, current CDC guidelines recommend self-monitoring at home for health care workers who have a healthcare-related exposure to a COVID-19 patient.⁹ This can leave significant gaps in coverage for healthcare systems. For example, in Vacaville, California, one positive case resulted in over 200 health care workers unable to work on site.¹⁰

Large volumes of acutely ill patients, coupled with the risk of ill or quarantined providers, means provider shortages due to PRPO are likely to occur and threaten hospitals’ ability to care for patients with or without COVID-19. Furthermore, given increased patient loads, frontline staff are at exceptionally high risk of burnout in pandemic situations. Hospital medicine teams will need contingency plans to meet the needs. Using telemedicine to protect the workforce and maintain staffing levels will reduce that risk.

Telehospitalists can see and examine patients, write orders, and maintain patient service lines much like in-person providers. Recently, we have used it when providers are ill or self-monitoring. In multisite systems, telehospitalists who are privileged in multiple hospitals can be efficiently deployed to meet patient care needs and relieve overburdened providers across hundreds of miles or more.

Enabling patient rooms for telemedicine allows telehospitalists and other providers to see hospitalized patients. Furthermore, quarantined hospitalists can continue to work and support in-person clinical services during PRPO. Providers in high-risk groups (eg, older, immunosuppressed, pregnant) can also continue caring for patients with telemedicine while maintaining safety. As schools close, telemedicine can help providers navigate the challenge between patient care and childcare responsibilities.