key: cord-0779885-tv2q4nz9 authors: Mahmoud, Muhammad Abdelhafez; Daboos, Mohammad; Gouda, Samir; Othman, Alsayed; Abdelmaboud, Mohamed; Hussein, Mohamed Elsayed; Akl, Mabrouk title: Telemedicine (Virtual Clinic) Effectively Delivers the Required Healthcare Service for Pediatric Ambulatory Surgical Patients During the Current Era of COVID-19 Pandemic: A Mixed Descriptive Study() date: 2021-11-27 journal: J Pediatr Surg DOI: 10.1016/j.jpedsurg.2021.11.018 sha: ba5b563b385dcca0a561192a48f1d97f9de292be doc_id: 779885 cord_uid: tv2q4nz9 BACKGROUND: Children often suffer from congenital or acquired diseases. Ambulatory cases represent the vast majority of pediatric surgical cases. COVID-19 pandemic-associated regulatory precautions had made the process of seeking medical advice at a suitable appointment such a big problem. We utilized telemedicine (online encounter) to deliver the required healthcare service for sorting and guiding pediatric ambulatory surgical patients. In this article, we aimed to: (1) present our experience, (2) evaluate the effectiveness, and (3) document the results of this technology to solve the problem of difficult healthcare accessibility. MATERIALS AND METHODS: In this study, we compared the utilization of telemedicine (virtual clinic via video consultation) prospectively in the current era of the COVID-19 pandemic in the period from June 2020 to July 2021 to the in-person clinic encounter at the outpatient department (OPD) retrospectively in the previous year (from June 2019 until the end of May 2020) for perioperative management of pediatric ambulatory surgical patients. The study was conducted at 3 tertiary care pediatric surgery centers. The information recorded for analysis included: demographic data, surgical condition distribution, time interval from the appointment request till the actual encounter with the surgeon, conversation duration, distance traveled, and ultimate fate of the consultations. For both groups, service was evaluated after the first follow-up visit by a patient survey questionnaire (Patient Experience Assessment form) including questions relevant to each encounter. RESULTS: A total of 1124 pediatric patients with various ambulatory surgical conditions had been scheduled for virtual clinic video encounters. Of them, 1056 cases were evaluated by video consultation, supervised by their parents or caregivers, thus, achieving an attendance rate of 94%. Of the remaining cases, 2% (n=23) were canceled and 4% (n=45) did not attend the virtual clinic. Two-thirds of the cases live in rural /remote areas. Patients’ overall satisfaction was 92%. This was in comparison to 872 pediatric ambulatory surgical patients scheduled for in-person clinic visits before the implementation of the virtual clinic. Of them, only 340 cases had attended the clinic, thus, achieving an attendance rate of 39%. Of the remaining cases, 450 cases (51.6%) were canceled and 82 cases (9.4%) did not attend the clinic (no show). About 48% of the cases live in rural areas. For this group, patients’ overall satisfaction was 63%. The mean encounter duration was similar for both groups (∼ 5 minutes). Surgical condition distribution was also similar (p-value: 0.694). For new cases, the time interval from appointment request till the actual encounter was very short for the virtual clinic group (range: 6-15 days) as compared to the in-person clinic group (range: 30-180 days). Patients were followed up for a median period of 14±3.25 months (range: 6-22 months) with no patient loss to follow-up. CONCLUSION: Telemedicine can effectively bridge the patient-physician communication gap caused by the regulatory precautions mandated by the current COVID-19 pandemic. It achieved an attendance rate of 94% and parents’ / patients’ overall satisfaction of 92%. surgical patients. In this article, we aimed to: (1) present our experience, (2) evaluate the effectiveness, and (3) document the results of this technology to solve the problem of difficult healthcare accessibility. In this study, we compared the utilization of telemedicine (virtual clinic via video consultation) prospectively in the current era of the COVID-19 pandemic in the period from June 2020 to July 2021 to the in-person clinic encounter at the outpatient department (OPD) retrospectively in the previous year (from June 2019 until the end of May 2020) for perioperative management of pediatric ambulatory surgical patients. The study was conducted at 3 tertiary care pediatric surgery centers. The information recorded for analysis included: demographic data, surgical condition distribution, time interval from the appointment request till the actual encounter with the surgeon, conversation duration, distance traveled, and ultimate fate of the consultations. For both groups, service was evaluated after the first follow-up visit by a patient survey questionnaire (Patient Experience Assessment form) including questions relevant to each encounter. Results: A total of 1124 pediatric patients with various ambulatory surgical conditions had been scheduled for virtual clinic video encounters. Of them, 1056 cases were evaluated by video consultation, supervised by their parents or caregivers, thus, achieving an attendance rate of 94%. Of the remaining cases, 2% (n=23) were canceled and 4% (n=45) did not attend the virtual clinic. Two-thirds of the cases live in rural /remote areas. Patients' overall satisfaction was 92%. This was in comparison to 872 pediatric ambulatory surgical patients scheduled for in-person clinic visits before the implementation of the virtual clinic. Of them, only 340 cases had attended the clinic, thus, achieving an attendance rate of 39%. Of the remaining cases, 450 cases (51.6%) were canceled and 82 cases (9.4%) did not attend the clinic (no show). About 48% of the cases live in rural areas. For this group, patients' overall satisfaction was 63%. Since WHO declared COVID-19 as a pandemic disease, the whole healthcare sector had become enormously affected, including the field of pediatric surgery. Parents usually seek clinic appointments for medical advice. Obtaining an OPD appointment for pediatric ambulatory surgical problem at a suitable date is a challenging issue. The first appointment could often be available after 3-6 months and even may exceed. The COVID-19 pandemic-associated restrictions and regulatory precautions had complicated the accessibility and physical attendance of outpatient clinics. Moreover, early during the crisis, OPD appointment employees were instructed to cancel many cases to avoid patient overcrowding and achieve social distancing in an attempt to limit the disease spread. Approximately, only the emergency cases were allowed to receive medical care [1,2]. Telemedicine enables remote access to healthcare services and mutual interaction between the physician and patient /parent. It avoids transportation, parking, and school and work missed days; therefore, it saves both money and time. By its implementation in the field of pediatric ambulatory surgery, the chain of care will be preserved and the waiting list will be reduced. Thanks to its simplicity, attendance rate can be maximized while no show and cancelation rates can be minimized [1,3,4]. Video consultation, being superior to text messaging and voice conversation, is and will remain the proper alternative for the gold standard face-to-face clinic visit. It maintains the required relationship between the physician and the patients /parents including audio-visual communication, enables revision of the medical file data, and yields a constructive conversation. Finally, it ensures that the patients /parents have understood the instructions and agreed to the management plan [4] . To the best of our knowledge, no previous study in our region had searched the role of telemedicine with its multipurpose potentials (preoperative assessment, sorting, possible referral of irrelevant cases, and postoperative follow-up) for the management of pediatric ambulatory surgical cases. So, we performed this precautions. Its link was sent to the parents via a short message service (SMS) or an e-mail from the official account of Press Ganey international company or Health Links local company. These companies act as official third-party agencies, dedicated to assessing the patients' experience and satisfaction rate independently to avoid any selection bias. Survey request was preceded by the preface "Dear customer: kindly fill the following survey questionnaire honestly and comfortably. We emphasize that the collected data will be handled with extreme confidentiality, security, and respected privacy. It will be used only for scientific research purposes to improve the healthcare and medical service quality". All guardians of patients enrolled in the study had electronically signed informed consent before the start of the video consultation. The study was approved by the Institutional Review Board and ethics committee (IRB00012367-20-05-016) and also registered at ClinicalTrials.gov (ID: NCT04990570 Surgeons, parents, and older patients were trained and instructed on how to use the applications. Surgeons were trained in their respective institutions to be professional, strict, and committed to the policy and ethics of the video encounter. In addition, they were trained to respect patients' data privacy and security, how to start and how to finish the encounter politely, and how to adequately answer the patients' questions and discuss with them the management plan including post-operative follow-up instructions. Patients were instructed via the application's notifications or SMS explaining their rights and responsibilities, how to electronically sign the informed consent, how to manage the conversation, and how to evaluate the service. They can use either a smartphone, tablet, or laptop with a stable internet connection. Parents /older patients were sent a reminder message via SMS, e-mail, or the application notifications the day before the encounter to save date and time and prepare themselves. As a general governmental policy, all patients were requested to register on the MOH eligibility and registration online site (including ID, phone number, address, and e-mail). Notably important is the location on the GPS that should be activated during the initial registration to help determine the nearest pediatric surgical center for possible online referral or ambulance transportation. Also, pediatric surgery specialists were continuously allocated on duty (on a 24/7-time basis). All children from 1 month to 14 years of age with ambulatory surgical issues and motivated parents were included. Parent's refusal of the service, uncooperative parents or patients, patients older than 14 years, and cases with proximal hypospadias with chordee were excluded from the study. These ethics should be followed by the physician during the video consultation and are summarized in Table 2 . Data were analyzed using the statistical package for social sciences (SPSS) version 24.0 (IBM Corp, IBM SPSS Statistics for Windows, Armonk, NY, USA). Continuous variables were expressed as mean± standard deviation (SD), range, and average while categorical variables were expressed as frequency count and percent. Fisher's exact test was used to compare frequency count and percent. The t-test was used to compare the mean values as appropriate. A two-sided p-value less than 0.05 was considered statistically significant. A total of 1124 pediatric patients with various ambulatory surgical conditions had been scheduled for virtual clinic encounters via video consultation. Of them, 1056 cases were evaluated by video consultations, supervised by their parents /caregivers, thus, achieving an attendance rate of 94%. They were 570 males and 486 females. About two-thirds of them live in rural or remote areas ( This study aimed to present our experience, evaluate the effectiveness, and report the outcomes of the application of telemedicine (virtual clinic) to provide the required healthcare services for pediatric ambulatory surgical patients during the current era of the COVID-19 pandemic, in comparison to the in-person clinic encounter. COVID-19 pandemic has greatly augmented the implementation of telemedicine for providing healthcare service, especially in the outpatient settings, to protect the patients and their caregivers from exposure to SARS- Among the known various forms of telemedicine, we have chosen the video consultation modality to manage the virtual clinic and approach our patients in all phases of ambulatory surgical care. In the current study, we found that telemedicine can effectively be used in preoperative diagnosis and sorting of patients. Most cases were easily diagnosed by "spot diagnosis", except cases with unclear diagnoses such as In the current study, the encounter duration was similar between virtual consultations and in-person clinic visits. This was contrary to Postuma et al. who utilized telephone-based videoconferencing for plastic surgery consultations and found that telehealth assessments consumed longer time than the in-person visits, but with time and increased experience, the duration of both became similar [8] . In the current study, we found that telemedicine effectively offers an adequate post-operative follow-up service, . In our study, we also used videoconferencing for follow-up purposes. In the current study, surgical outcomes (complication and re-admission rates) were found to be similar in both groups. Presumably, this may be due to similarity in perioperative circumstances including preoperative diagnoses either via telemedicine or in-person visit, same surgeons and allied surgical teams, operations, hospital facilities, and follow-up. Preoperative visits did not detect any risk factors or missed diagnoses. Only, diagnosis changed to hydrocele (n=7), palpable undescended testis (n=4), and inguinal lipoma (n=2) when examined on the operative day morning. However, no surgery was canceled or required any adjustment. In agreement with the high parents /patients' attendance rate of the telemedicine encounter found in the current study, Chang et al. conducted a prospective study to evaluate the efficacy of a Chinese smartphone app (WeChat)-assisted medical care for post-operative compliance to follow-up after pediatric cataract surgery. They found significantly higher compliance (93.6%) in the subsequent appointments in the WeChat group, as compared to 80.5% in the control group [11] . Also, Liu et al. conducted a randomized controlled trial to investigate the influences of WeChat-assisted perioperative instructions for pediatric ambulatory hernia repair regarding parents' knowledge, cancelation rate, lost-to-follow-up rate, and complication rate by the end of the first postoperative week. They found a significant difference in the mean knowledge score and cancelation rate between the WeChat group and the control group, a significantly lower lost-to-follow-up rate in the WeChat group (0.54%) than the control group (3.66%), and a higher complication rate in the control group [12] . Both previous studies confirmed that telemedicine offered an easily suitable encounter and achieved a higher attendance rate. As noted in the current study, the rates of cancelation and no-show were higher in the in-person clinic group than the virtual clinic group, presumably due to the regulatory precautions mandated by the COVID-19 pandemic. These regulatory precautions had been started in Saudi Arabia on 2nd March 2020 and included: social distancing, the curfew (movement restriction), and later on, the vaccination campaign. However, initially, the vaccination campaign was met by reluctance, so, people were ineligible to enter the healthcare institutions unless being vaccinated by at least one dose. In Egypt, the regulatory precautions had been started in mid-March 2020. In the current study, assessment survey questions for both groups (virtual and in-person) were made nearly similar to unify the points of interest. Also, they were formulated in a clear, understandable manner to be easily answered by the audience, regardless of their financial income or educational level. Canon et al. found that telemedicine facilitates and maintains the strong link between patients /parents and the healthcare provider (HCP) [9] . This is consistent with the aim and results of the current study. In the present study, we found telemedicine effectively facilitated easy access to healthcare services for a wide range of patient populations even from remote or peripheral areas, and minimized the cost of traveling long distances. Also, it avoided work or school missed days and reduced the rate of unexpected hospital readmission, as supported by other studies [3, 8, 9, 11] . From the authors' point of view, telemedicine (specifically the virtual clinic) can bridge the communication gap resulted from COVID-19 pandemic regulatory precautions and approximates the distances between patients and physicians. It mimics the in-person OPD encounter, provided that the rules and ethics are similarly considered. The relatively short duration of the study may be a drawback. Like any new technology, telemedicine has some limitations, including that (1) it is relatively not widespread, (2) it is not uniformly accepted, (3) it necessitates the presence of communication equipment with a stable internet connection, and (4) it requires training of the physicians and parents or caregivers, assuming that they have an adequate cultural background, which is not always the case. Also, regarding the results of the Patient Experience Assessment form obtained retrospectively from the in-person clinic group, they may be liable to recall bias. As this study was conducted in 2 Middle East countries, patient perceptions of telehealth as well as its potential benefits were influenced by the cultural and regulatory characteristics that may be specific to this region and population. Therefore, some findings of this study may not be generalizable. We recommend further long-term randomized controlled trials to be conducted on more specific points of research; such as a certain disease or condition, postoperative follow-up, or the feasibility of application of telemedicine in trauma settings, to widen the scope of thinking and expand the field of research about this valuable technology. Tailoring the application of telemedicine via virtual clinic for the field of pediatric ambulatory surgery effectively maintains the patient-physician relationship, saves time, increases parents' /patients' satisfaction, and helps record better experiences as compared to the in-person clinic visit. Video consultation is a reliable surrogate encounter, especially during global health and social crises. The study design was approved by the Institutional Review Board and ethics committee of the hospitals and met all the guidelines of their responsible governmental agency. It was performed according to the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Study conception and design: Muhammad Abdelhafez Mahmoud, Mohammad Daboos The processes of registration and further activation of the medical file were easy. I was asked to sign the consent before the video consultation. The physician adequately introduced himself to me. The physician then verified my identity. The physician gave me enough time to describe the case and express my fears and inquiries. The physician was calm and used clear easily understandable terms during his discussion. The physician was kind and empathic with me as he listened carefully and paid adequate attention to my concerns. The physician respected my privacy. The physician was competent, well-trained, and trustworthy. He treated me in a very friendly courteous manner. Any other concerns such as parking, cleanliness, time in the waiting area, physician or nurse attitude in the clinic, OPD reception office or admission office employees' care and attention. There was no significant difference between in-person clinic visits and video consultation encounters. Overall, the service was excellent and it met my expectations. Do you have any suggestions or comments to improve the service? Free text……. I recommend this service to the others (as my relative's or friend's kids). □ 1 = Very unlikely, □ 2 = Unlikely, □ 3 = Uncertain, □ 4 = Likely, □ 5 =, Strongly (very likely) □ 1 = extremely dissatisfied, □ 2 = dissatisfied, □ 3 = uncertain, □ 4 = satisfied, □ 5 =, extremely satisfied c-He should be professional and self-confident. d-Firstly, he should identify himself (state his name, title, and position) and then verify the patient's identity. e-He should reassure the patient that his/her data will remain private, respected, and protected. f-He should keep eye contact with the patient /parent on the screen, and simultaneously revise the patient's medical file. g-He should ensure that the management plan has been understood and agreed upon by the parent or older patient. 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