key: cord-0734864-7t8vrxcj
authors: REFORMA, Liberty G.; DUFFY, Cassandra; COLLIER, Ai-ris Y.; WYLIE, Blair J.; SHAINKER, Scott A.; GOLEN, Toni H.; HERLIHY, Mary; LYDEARD, Aisling; ZERA, Chloe A.
title: A multidisciplinary telemedicine model for management of COVID-19 in obstetric patients
date: 2020-07-25
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2020.100180
sha: 14e612631ce32cf795d1e5c530d93a47ef542002
doc_id: 734864
cord_uid: 7t8vrxcj

ABSTRACT Background The COVID-19 pandemic caused by the SARS-CoV-2 virus has increased the demand for inpatient healthcare resources; however, approximately 80% of patients with COVID-19 have a mild clinical presentation and can be managed at home. Objective To describe the feasibility, clinical and process outcomes associated with a multidisciplinary telemedicine surveillance model to triage and manage obstetric patients with known exposures and/or symptoms concerning for COVID-19. Study Design We implemented a multidisciplinary telemedicine surveillance model with obstetric physicians and nurses to standardize ambulatory care for obstetric patients with confirmed or suspected COVID-19 based on symptoms or exposures at an urban academic tertiary care center with multiple hospital and community-based affiliated practices. All pregnant or postpartum patients with COVID-19 symptoms, exposures or hospitalization were eligible for inclusion in the program. Patients were assessed via regular nursing phone calls and were managed according to illness severity. Patient characteristics, clinical and process outcomes were abstracted from the electronic medical record. Results A total of 135 patients were enrolled in the multidisciplinary telemedicine model from March 17-April 19, 2020, of whom 130 were pregnant and 5 recently postpartum. The majority (N=116, 86%) were managed solely in the outpatient setting and did not require in-person evaluation; 9 were ultimately admitted after ambulatory or urgent evaluation and 10 patients were followed after hospital discharge. Although only 50% of the patients were tested secondary to limitations in ambulatory testing, 1 in 3 of those was PCR-positive for SARS-CoV-2 (N=22, 16% of entire cohort). Patients were enrolled in the telemedicine model for a median of 7 days (IQR 4-8) and averaged one phone call daily, resulting in 891 nursing calls and 20 physician calls over 1 month. Conclusion A multidisciplinary telemedicine surveillance model for outpatient management of obstetric patients with COVID-19 symptoms and/or exposures is feasible and resulted in rates of ambulatory management similar to those seen in non-pregnant patients. A centralized model for telemedicine surveillance of obstetric patients with COVID-19 symptoms may preserve inpatient resources and prevent avoidable staff and patient exposures, particularly in centers with multiple ambulatory practice settings.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has created unprecedented demand for inpatient 81 healthcare resources, increasing the need for ambulatory evaluation and management of pregnant patients 82 with symptoms. Hospital-based triage requires personnel, space and personal protective equipment. Inperson evaluation also increases the risk of staff and patient exposure to SARS-CoV-2; in one study, 84 nosocomial transmission was responsible for COVID-19 infections in 29% of health care workers and 12% of 85 hospitalized patients. 1 Measures that decrease unnecessary in-person visits may therefore be valuable to 86 preserve resources and protect patients and staff. 

We implemented a multidisciplinary telemedicine surveillance model for patients with concern for COVID-19, 

We arranged ambulatory testing for all eligible patients; the criteria for testing expanded over the 147 course of the month as our institutional testing capacity grew. All symptomatic patients were treated as 148 presumed SARS-CoV-2 positive unless testing was negative. Patients referred for surveillance after an 149 inpatient hospitalization were called by a physician until they were considered to be symptomatically 150 improved; patients from community hospital affiliates were followed until their primary obstetric provider 151 assumed responsibility for follow up. If a patient tested negative for SARS-CoV-2 but remained symptomatic, 152 they were also continued to be followed until an alternative diagnosis was determined and/or symptoms 

The intervention was implemented as a practice change to improve quality of care. This study (protocol # 186 2020P000306) was considered exempt research by the BIDMC Institutional Review Board. Data were 187 collected and stored using REDCap, a HIPAA compliant, web-based data collection tool stored in a

From March 17 to April 19, 2020, 135 patients with COVID exposures and/or symptoms were monitored utilization, we estimate that some fraction of the 116 patients who were completely managed as outpatients 

Research Implications

Telemedicine models may also have a role in improving access to high quality prenatal and postpartum number; a limitation to all phone-based telemedicine surveillance models are that patients must have access 275 to a phone. Nonetheless, we did not have any patients who were unable to be followed after referral, and 276 found that even patients who experienced housing insecurity during the time they were followed were multidisciplinary telemedicine model, gives us limited opportunity to observe any impact on morbidity. We 279 note that one patient with febrile illness presumed to be COVID-19 was diagnosed with endocarditis after 

Telemedicine only 116 (85.9) Recommended ambulatory evaluation 13 Recommended urgent evaluation (ED or L&D) 6

Unplanned emergent evaluation 0 Hospital admission 9 (6.6) Admission after ambulatory evaluation 5

Admission after urgent evaluation 4 Readmission 1 (0.7) 

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center

Disease Control and Prevention

Telephone triage of influenza-like illness during pandemic 314 2009 H1N1 in an obstetric population

Massachusetts Department of Health. COVID-19 Response Reporting. Information on the Outbreak 317 of Coronavirus Disease

Massachusetts Department of Health. Coronavirus Disease 2019 (COVID-19) Cases in MA

The American College of Obstetricians and Gynecologists and Society for Maternal Fetal Medicine

Outpatient Assessment and Management for Pregnancy Women with Suspected or Confirmed Novel 324

Design and Implementation of a Statewide Influenza Nurse 327

Triage Line in Response to Pandemic H1N1 Influenza

Patient Preferences for Prenatal 330 and Postpartum Care Delivery: A Survey of Postpartum Women

Patient Satisfaction with Virtual Obstetric Care

Treatment of Opioid Use Disorder in Pregnant Women via 335

Optimizing Postpartum Care