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      Use of telecritical care for family visitation to ICU during the COVID-19 pandemic: an interview study and sentiment analysis


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          When the COVID-19 pandemic restricted visitation between intensive care unit patients and their families, the virtual intensive care unit (vICU) in our large tertiary hospital was adapted to facilitate virtual family visitation. The objective of this paper is to document findings from interviews conducted with family members on three categories: (1) feelings experienced during the visit, (2) barriers, challenges or concerns faced using this service, and (3) opportunities for improvements.


          Family members were interviewed postvisit via phone. For category 1 (feelings), automated analysis in Python using the Valence Aware Dictionary for sentiment Reasoner package produced weighted valence (extent of positive, negative or neutral emotive connotations) of the interviewees’ word choices. Outputs were compared with a manual coder’s valence ratings to assess reliability. Two raters conducted inductive thematic analysis on the notes from these interviews to analyse categories 2 (barriers) and 3 (opportunities).


          Valence-based and manual sentiment analysis of 230 comments received on feelings showed over 86% positive sentiments (88.2% and 86.8%, respectively) with some neutral (7.3% and 6.8%) and negative (4.5% and 6.4%) sentiments. The qualitative analysis of data from 57 participants who commented on barriers showed four primary concerns: inability to communicate due to patient status (44% of respondents); technical difficulties (35%); lack of touch and physical presence (11%); and frequency and clarity of communications with the care team (11%). Suggested improvements from 59 participants included: on demand access (51%); improved communication with the care team (17%); improved scheduling processes (10%); and improved system feedback and technical capabilities (17%).


          Use of vICU for remote family visitations evoked happiness, joy, gratitude and relief and a sense of closure for those who lost loved ones. Identified areas for concern and improvement should be addressed in future implementations of telecritical care for this purpose.

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          Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.

          Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design. To develop a checklist for explicit and comprehensive reporting of qualitative studies (in depth interviews and focus groups). We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed. Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.
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            Caring for Critically Ill Patients with the ABCDEF Bundle

            Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.
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              Telemedicine in the Era of COVID-19

              About once in a generation, a global pandemic emerges and wreaks havoc on a vulnerable world population. This is why most of us have limited personal experience with such events. The present outbreak of a coronavirus-associated acute respiratory disease called coronavirus disease 19 (COVID-19) is the third documented spillover of an animal coronavirus to humans that is causing a major epidemic in the last 2 decades. 1 Recent outbreaks such as severe acute respiratory syndrome in 2003 and Middle East respiratory syndrome in 2012 were successfully confined to small regions of the planet. As such, they were of peripheral concern to allergists practicing in the United States because we and our patients were not exposed to them. Now that COVID-19 is affecting us and our patients directly, concerns about this novel emerging infection have gone, well… viral. It was only a matter of time until a global pandemic affected us, and our time has run out. Our initial response to COVID-19, now that disputes over whether it is real and who is to blame for it are over, is to slow its spread to avoid overwhelming the ability of our health care system to handle sick patients. COVID-19 is proving to be more infectious than severe acute respiratory syndrome, leading to 10 times as many cases in one-quarter of the time. 1 A significant portion of cases in China were due to hospital-related transmission, 2 and skilled nursing facilities in Washington state have followed suit. Without proper containment measures, the fear is that hospitals will be overrun with COVID-19 cases. Not only does this limit our ability to treat seriously ill patients infected with the virus but it also could prevent uninfected individuals suffering from more mundane life-threatening conditions, such as myocardial infarction and stroke, from receiving timely treatment that they would routinely get in “normal” times. COVID-19 is a respiratory virus, which means that patients who are at increased risk of morbidity include our patients with asthma, chronic obstructive pulmonary disease, and also with immunodeficiency. Because it is the spring allergy season, many patients with allergic rhinitis may mistake their symptoms for those of COVID-19. We need to educate our patients to recognize this fact. As health care professionals, we must take appropriate measures to ensure that individuals with low-risk diseases, as well as the “worried well,” do not take up our already limited health care resources while ensuring that those who are seriously ill receive appropriate triage and treatment. Telemedicine Can Help Telemedicine (TM) has the potential to help by permitting mildly ill patients to get the supportive care they need while minimizing their exposure to other acutely ill patients. After all, the only infection that one can catch while using TM is a computer virus. To encourage the TM approach, nearly all health plans and large employers offer some form of coverage for TM services. Although the use of TM has increased over the last 2 to 3 years, rates of TM adoption among allergists are still low. 3 In response to the current COVID-19 situation, the Centers for Medicare & Medicaid Services and commercial health plans largely have waived co-pays for TM visits as a means to encourage utilization in this time of need, and allergists need to pay attention to this. 4 , 5 A recent survey demonstrated that patients are willing to use telehealth, but barriers still exist, namely: (1) At a time of need, many people revert to what they are used to doing and the way in which they previously interacted with the health care system. (2) Patients would prefer that they see their own provider through TM versus someone with whom they do not have a previously established relationship. (3) Patients may be unaware that they have TM as an option and do not know how to access it. 6 Health plans, employers, hospital systems, and media outlets should work to overcome these barriers by (1) educating people that TM is an effective alternative and safer under the current circumstances, (2) expanding network reimbursement coverage for physicians to see their patients through TM, (3) making people aware that a TM benefit exists, with step-by-step instructions on how it can be accessed, (4) helping people understand how TM works, and (5) continuing to reduce cost barriers to accessing TM. To promote the use of TM in the age of COVID-19, various online resources have been developed both from regulatory agencies and from the major allergy professional societies (Table I ). In addition, because of the public health emergency, as of March 6, 2020, Medicare will pay to treat COVID-19 (and for other medically reasonable purposes) using TM services for patients if they have seen a provider in the same practice from offices, hospitals, and places of residence (such as homes, nursing homes, and assisted living facilities). 7 There also has been a relaxation of Health Insurance Portability and Accountability Act (HIPAA) regulations to permit providers to use their personal phones to see patients. In addition, in an effort to get COVID-19 tests to the public more quickly, the US Food and Drug Administration has waived the normal regulations to expedite allowing test makers to market scientifically valid products in the United States. 8 Table I TM resources available from professional and regulatory agencies during the age of COVID-19 TM resource Link American Telemedicine Association COVID-19 resources https://info.americantelemed.org/covid-19-news-resources ACAAI Guidelines to support telemedicine as an effective tool for allergists https://acaai.org/news/guidelines-support-telemedicine-effective-tool-allergists ACAAI COVID-19 and asthma, allergy, and immune deficiency patients https://college.acaai.org/acaai-statement-covid-19-and-asthma-allergy-and-immune-deficiency-patients-3-12-20 AAAAI Resources for A/I clinicians during the COVID-19 pandemic https://education.aaaai.org/resources-for-a-i-clinicians/covid-19 AAAAI Telemedicine learning resources https://www.aaaai.org/practice-resources/running-your-practice/practice-management-resources/telemedicine Medicare Coronavirus and telehealth https://www.medicare.gov/medicare-coronavirus Medicare Telehealth coverage https://www.medicare.gov/coverage/telehealth CDC COVID-19 resources https://www.cdc.gov/coronavirus/2019-ncov/index.html CMS COVID-19 partner toolkit https://www.cms.gov/outreach-education/partner-resources/coronavirus-covid-19-partner-toolkit CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare & Medicaid Services. Office-Based Encounters to Isolate Providers The use of TM can allow allergy providers who are older and who may have an underlying health condition to avoid contact with potentially infected patients. This can be done by seeing patients with a facilitated visit in the allergy office. 9 The provider would need a computer, tablet, or smart phone for 2-way video interaction with patients, and the office nurse could be trained to be a telefacilitator. For established patients where a physical examination is not required, any HIPAA-compliant video platform would work. 10 In such situations, if a procedure is needed, patients could even be seen from their home if they have the appropriate video equipment. Because new patients require a physical examination, they may not be appropriate for this type of encounter unless digital examination equipment is available in the allergy office. If non–high-risk providers are present in the office, low-risk procedures such as skin testing can be performed. Home-Based Video Encounters for Triage TM also can be used to assess and triage for COVID-19. This type of encounter should be video-based and must be initiated by the patient to be billable. Although a facilitated visit may permit a physical examination to be performed, it also increases the risk of exposure to COVID-19 for patients and health care workers. With a home-based video interaction, the patient can have an interaction with a provider, who, in addition to obtaining a thorough history of symptoms and exposure risk, can perform an observational assessment. 11 This assessment should include the following: • Temperature with a home thermometer • Observation of general appearance, noting if the patient is ill appearing, is exhibiting diaphoresis, pallor, or flushing • Calculation of respiratory rate • Observation of respirations and deep breath and whether there is use of accessory respiratory muscles, labored breathing, interrupted speech • Presence or absence of cough; dry or productive • Observation of the oropharynx, with assessment of oropharyngeal erythema, exudate, enlarged or absent tonsils or lesions • Patient-directed palpation of anterior and posterior cervical chains to assess for presence or absence of prominent lymphadenopathy Clinicians should use their judgment as to whether the patient is appropriate for COVID-19 testing. Priority should be given to patients with chronic medical conditions, individuals older than 65 years, and those who have come into contact with a COVID-19 positive patient within 14 days. A history of travel to a highly affected area is likely to become irrelevant as more areas become affected. The patient can be directed to the appropriate facility for testing, home testing can be arranged, or if the patient is acutely ill, an emergency protocol should be in place to call 911 with transfer to the nearest emergency department. Appropriate state and local reporting authorities should be contacted, just as if they had been seen in the office setting. TM for Management of Chronic Conditions TM can be used for ongoing management of chronic diseases such as asthma and immunodeficiency, particularly during a time when social distancing is encouraged. Individuals with these conditions are particularly susceptible to COVID-19, and medication compliance and disease optimization are important ways to mitigate severity. TM can serve as a safe and effective alternative to in-person care. Recent studies have demonstrated similar health outcomes for patients whether delivered in person or synchronously by a remote provider for various conditions including asthma. 12 A 2015 Cochrane systematic review examined the impact of telehealth involving remote monitoring or videoconferencing compared with in-person or telephone visits for chronic conditions including diabetes and congestive heart failure. This review found similar health outcomes for patients with these conditions. 13 So, although the presence of a pandemic is an unfortunate, though inevitable occurrence, it is also an opportunity to set up an infrastructure for providing care using TM. Once the current pandemic is over, TM can continue to be used to provide more convenient, cost-effective care to patients. In this way, we will already be prepared for the next, inevitable, infectious disease to emerge.

                Author and article information

                BMJ Qual Saf
                BMJ Qual Saf
                BMJ Quality & Safety
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                September 2021
                7 October 2020
                7 October 2020
                : 30
                : 9
                : 715-721
                [1 ]departmentIndustrial and Systems Engineering , Texas A&M University , College Station, Texas, USA
                [2 ]departmentCenter for Outcomes Research , Houston Methodist Hospital , Houston, Texas, USA
                [3 ]departmentDepartment of Surgery , Houston Methodist Hospital , Houston, Texas, USA
                [4 ]departmentSchool of Public Health , Texas A&M University , College Station, Texas, USA
                [5 ]departmentCenter for Critical Care , Houston Methodist Hospital , Houston, Texas, USA
                Author notes
                [Correspondence to ] Dr Farzan Sasangohar, Department of Industrial and Systems Engineering, Texas A and M University, College Station, TX 77843, USA; sasangohar@ 123456tamu.edu
                Author information
                © Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.

                This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

                : 21 May 2020
                : 03 September 2020
                : 18 September 2020
                Original Research
                Custom metadata

                Public health
                visiting,critical care,human factors,qualitative research,quality improvement
                Public health
                visiting, critical care, human factors, qualitative research, quality improvement


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