key: cord-1011923-5ij0nzjs authors: Navarro-Correal, Ester; Borruel, Natalia; Robles, Virginia; de Guise, Claudia Herrera; Ayala, Luis Fernando Mayorga; Martínez, Zahira Pérez; Casas, Arantxa Ibarz; Rodríguez, Sandra Agustino; Duelt, Irene Joana Batuecas; Alcaide, Jorge Garcia; Branchadell, Sara López; Zuriguel-Perez, Esperanza; Casellas, Francesc title: Impacto de la pandemia por COVID-19 en la actividad de la enfermera de práctica avanzada en enfermedad inflamatoria intestinal en una unidad de referencia date: 2021-01-27 journal: Gastroenterol Hepatol DOI: 10.1016/j.gastrohep.2020.11.018 sha: f223d2d05f97e90e1153d1200a2af84c9ca0210d doc_id: 1011923 cord_uid: 5ij0nzjs Objetivos: Describir el impacto de la pandemia COVID-19 en la actividad de la enfermera en EII de la Unidad e identificar las razones de la asistencia telemática y la relación con las variables recogidas. Antecedentes: La pandemia COVID-19 ha dado lugar a un aumento de la demanda de atención remota en pacientes con enfermedad inflamatoria intestinal que requieren un seguimiento y un acceso frecuente a los servicios de salud. Diseño - Métodos: Estudio retrospectivo de toda la actividad (presencia, llamada telefónica o correo electrónico). Realizado en la Unidad durante la fase aguda de la pandemia, en un hospital de referencia en España. Se recogió el número de actividades llevadas a cabo por la enfermera, motivo de asistencia telemática y datos sociodemográficos y clínicos. El análisis estadístico se realizó utilizando la prueba de frecuencia, chi-cuadrado y el análisis de varianza. Resultados: Resultados: Fueron registradas 1095 actividades por 561 pacientes atendidos, siendo 1042 (95,2%) actividades de telemedicina, lo que supuso un incremento del 47,3% con respecto al año anterior. Las demandas relacionadas con COVID-19 fueron 588 (59,5%). Por otro lado, 134 (13,7%) fueron consultas por brote de su enfermedad, un 145% más que en 2019. Se han encontrado diferencias significativas entre los motivos del uso de la telemedicina y el diagnóstico, la situación laboral, la semana en que se realizó el contacto y el tratamiento. Conclusión: La fase aguda de la pandemia ha cambiado la actividad gestionada por enfermería en la Unidad. Identificar y analizar estos cambios nos proporcionado información para conseguir una gestión más eficiente y de calidad al cuidado de los pacientes en situaciones excepcionales. Objective: To report the impact of the COVID-19 pandemic on the activity of nurses working on an inflammatory bowel disease (IBD) unit and to identify reasons for telehealth care and its relationship to certain characteristics. Background: The COVID-19 pandemic had led to an increase in demand for remote care in patients with inflammatory bowel disease who require monitoring and frequent access to health services. Design: Methods: A retrospective study of all activity (in person and by phone call or email) done on the unit during the acute phase of the pandemic at a reference hospital in Spain. Numbers of activities done by nurses, reasons for telehealth care and sociodemographic and clinical data were collected. Statistical analysis was performed using frequency, chi-squared and analysis of variance tests. Results: A total of 1,095 activities for 561 patients who received care were reported. Among them, 1042 (95.2%) were telemedicine activities, amounting to a 47.3% increase over the prior year. COVID-19-related activities numbered 588 (59.5%). Consultations due to disease flare-up numbered 134 (13.7%), representing a 145% increase compared to 2019. Significant differences were found between reasons for using telemedicine and diagnosis, occupational status, contact week and treatment. Conclusion: The acute phase of the pandemic has changed the activity managed by the nursing staff on the unit. Identifying and analysing these changes has yielded valuable information to achieve more efficient management and better care quality for patients in special situations. information to achieve more efficient management and better care quality for patients in special situations. Objetivos: Describir el impacto de la pandemia COVID-19 en la actividad de la enfermera en EII de la Unidad e identificar las razones de la asistencia telemática y la relación con las variables recogidas. Antecedentes: La pandemia COVID-19 ha dado lugar a un aumento de la demanda de atención remota en pacientes con enfermedad inflamatoria intestinal que requieren un seguimiento y un acceso frecuente a los servicios de salud. Diseño -Métodos: Estudio retrospectivo de toda la actividad (presencia, llamada telefónica o correo electrónico). Realizado en la Unidad durante la fase aguda de la pandemia, en un hospital de referencia en España. Se recogió el número de actividades llevadas a cabo por la enfermera, motivo de asistencia telemática y datos sociodemográficos y clínicos. El análisis estadístico se realizó utilizando la prueba de frecuencia, chi-cuadrado y el análisis de varianza. IBD is defined as a group of chronic inflammatory disorders of unknown cause affecting the gastrointestinal tract, comprising two diseases: Crohn's disease (CD) and Ulcerative Colitis (UC) 8 It is characterized by a chronic course that usually alternates periods of active disease (relapse) with periods of remission, with potential complications that often require urgent or less preferential care. IBD affects mainly young people from a productive or formative age, and has an impact on their quality of life 9 ; all this increases the use of health resources at an economic cost, and also has a great impact on the labor force 10 . The Crohn-Colitis Care Unit (UACC) of the Hospital Universitari de la Vall d'Hebron in Barcelona follows a model of comprehensive patient-centered care through face-to-face Page 7 of 27 J o u r n a l P r e -p r o o f 7 and distance care. It is the Advanced IBD Nurse (AIN) who takes an outstanding leadership role in telehealth assistance (TA), known as telemedicine, due to their clinical profile and professional skills 11,12 . As in other countries, this pandemic has had an impact on material and human resources of the UACC and has resulted in an increase of telemedicine provided to IBD patients [13] [14] [15] . This can probably be related to patient uncertainty, fear of treatments, health system collapse and home-stay, among other reasons. We think it is compulsory to analyze the type of activities carried out by the AIN, in order to improve the care of our patients in exceptional situations such as those we have experienced. Patients with IBD require continuity of care because of the chronic nature of their disease and need to be wellinformed 14, 18 . Telemedicine seems to be the best strategy for patient care in special situations because it provides flexibility and immediacy, and promotes patient autonomy. The objective of the study is to describe the impact of the pandemic on the activity managed by the UACC nurse during the acute phase of the pandemic produced by COVID-19, comparing this activity with the same period from the previous year. As secondary objectives, we want to examine the reasons for remote care of UACC patients during the acute phase of the pandemic and assess predictors of the reason for consultation according to sociodemographics as well as the clinical characteristics of patients. Telemedicine encompasses telephone service (automatic answering system from 4 PM to 9 AM) and email. Accredited as a unit of excellence 19 . UACC currently treats 2,500 IBD patients, who have been chosen as the study population. The analyzed sample consisted in all activities (face-to-face, by telephone or e-mail) made to the UACC during the acute phase of the COVID-19 pandemic in Spain (from 2 March to 17 April 2020). Due to the descriptive and retrospective nature of the study, no formal sample calculation was performed. All records that fulfilled the inclusion criterion, defined as any priming performed by patients or family members >14 years, have been included. Any contact made by a person who was not recorded in our general database was excluded. Ethical considerations of the study J o u r n a l P r e -p r o o f 9 This study has been approved by the Ethics Committee for Clinical Research of the Hospital Universitari Vall d'Hebron (reference 308/20). Throughout the investigation process, ethical and data protection protocols related to anonymity and data confidentiality were complied with. Patient data was exempted from a database, which includes patients treated at the UACC; and activity data was collected in a coded method from the electronic medical history of the patient. All activities were reviewed either face-to-face, via telephone or email during the study period. Four of the authors (EN, AI, IB, JA, SL) independently analyzed the records, and those activities whose activity type information was not complete were excluded. The activity managed by the AIN was defined into three categories: face-to-face, telephone and email. In addition, telemedicine was defined as any service through which IBD patients can consult health professionals via telephone or electronic means 21 A descriptive analysis of the data was performed using frequencies and percentages, to present the categorical data and the mean and standard deviation for quantitative variables. To contextualize the results obtained, they were compared to the activity carried out by the AIN in the UACC in the same period from March 2 to April 17, 2019. A comparative analysis was performed to detect significant differences between unit groups by testing chi-square for categorical variables and for quantitative variables, variance analysis (ANOVA) was used. A type I error of 0.05 was considered. SPSS software package version 21.0 (SPSS, Chicago IL) has been used for statistical analysis. During the 7 weeks of study, 1095 activities were generated by 561 patients (22% of the study population), 5 of whom did not have IBD and were excluded from the analysis. The description of the demographics and clinical characteristics can be found in table 1. [Insert Table 1 about here] Regarding the type of activity managed by the AIN, 1042 (95.2%) were telemedicine activities, and 53 (4.8%) were face-to-face at the UACC. In 2019, 743 activities were conducted from 409 patients (17% of the study population), of which 614 (82.6%) were telemedicine contacts and 129 (17.4%) being face-to-face at the UACC ( Figure 1 ). Therefore, in the same period this year, an increase of 352 activities in total has been recorded, which is 47.3% more than 2019. Specifically, telemedicine has grown by 70% whereas face-to-face activity has decreased by 41%. [Insert Figure 1 about here] The evolution of activity in the acute period of the pandemic can be observed in Figure 2 , reaching its peak during the 3rd week (16) (17) (18) (19) (20) (21) In the study, 970 of the 1042 telemedicine activities have been analyzed, and 72 have not due to missing data. The analysis of contact reasons has demonstrated that differences have been found in relation to employment situation, diagnosis, week of contact and treatment. Differences have also been found in the test carried out to assess the differences between biological treatments (not so with the variables of age and gender Table 2 ). [Insert Table 2 about here] results. The results of this study suggest that the acute phase of the pandemic by COVID-19 modified the activity managed by the AIN in the UACC, in a public hospital of reference in Barcelona (Spain). The 1,095 activities recorded in the study interval clearly stand out in quantity, representing almost 50% more activity than in 2019 (p< 0,001); 53.7% of them were related to aspects arising from the pandemic. There has also been a change in proportions depending on the type of interaction with the UACC, in favor of telemedicine to the detriment of face-to-face activity, as seen in the study of Spanish group, when talking about the global work of the interdisciplinary team 20 . Telemedicine has emerged as one of the best tools to maintain the quality of care for IBD patients, as demonstrated in previous studies 21, 22 Due to the preventive measures of lockdown, which have made accessibility to our services difficult, the use of telemedicine resources has been promoted. From the patient's point of view, it is vital to have flexible and fast access to health professionals 25 , and this resource has been essential during the pandemic. Several studies suggest that chronic disease management through telemedicine is acceptable and provides cost-effective solutions at a time when national health systems in European countries are experiencing problems with funding or sustainability 26 . Currently, with the pandemic caused by COVID-19, there are also problems of accessibility to health services. What has been surprising is the high number of consultations related to disease relapses, which has tripled in reference to the previous year, where 64% of patients had UC. Although more research would be required, it could be argued that as seen in other investigations, emotional and/or psychological factors such as anxiety or stress may be related to this augmented disease activity in our sample 5 . A relation appears to be drawn in the profile of the active labor patient, under treatments that work on the immune system, since in the analysis stratified by The increased activity of the UACC AIN has been shown effective, especially in telemedicine, which has been defined in the approach guidelines as a minimum and priority service 6 . Historically, nurses have led the field of telematic assistance 11, 21 With this study we join the international Nursing Now campaign promoted by the WHO and the International Council of Nurses (ICN) 28 , emphasizing the visibility in the management of AINs. We must go on focusing our work on accompanying patients in the emotional management of this health crisis, fostering the confidence of our patients through truthful and up-to-date information, and promoting adherence to treatments. J o u r n a l P r e -p r o o f 16 The Spanish health system appears to have shown sufficient resilience to absorb the blow of this pandemic, although many are the considerations to take into account 29,30 . One of them could be the implementation of telemedicine, which, although it is not new, seems to have encountered many pitfalls along its implementation in the area of health care, as reflected by the Aguas M group 31 . Studies like Taxonera C et al have demonstrated that patients reported a very high degree of satisfaction with and acceptance of telephone consultations 20 . In time, we will have the opportunity to lead the unstoppable shift towards more universal and equitable health care. Our study has some limitations: sociodemographic and clinical characteristics of our sample may not be comparable to other communities. While this study has provided us with information on telemedicine, it would also be interesting to analyze other determinants such as psycho-emotional aspects, perceived quality of life or sociocultural issues. The pandemic has completely changed the paradigm of health care worldwide. With our study we have been able to verify the impact it has had in the activity managed by Crohn's-Colitis Care Unit nurses during the first wave of the pandemic. We have the opportunity to improve patient care, especially those patients' profiles who were actively working, and also received immunosuppressive treatment. Finally, the identification of AIN activity in the UACC during the pandemic has provided useful information which will allow more efficient and quality planning and care  We have shown a considerable increase in nurse activities with a decrease in human resources during the acute phase of the COVID-19 pandemic. This study has provided useful information that will allow be more efficient and quality planning and management of chronic condition's patients.  COVID-19 Pandemic has completely changed the paradigm of healthcare. This must now be the point of departure to lead unstoppable shift towards more universal and equitable health care.  There must now be a greater emphasis and responsibility placed upon the role of nurses in healthcare management. Our value is to be next to the patient to listen, teach and help to manage their emotions. Tables Table 1 Description Reasons for telemedicine activities managed by Advanced IBD Nurse Hospitalized Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China World Health Organization. Situation Report-18 SITUATION IN NUMBERS total and new cases in last 24 hours COVID-19 and inflammatory bowel disease: questions arising from patient care and follow-up during the initial phase of the pandemic British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary Pathophysiology of Inflammatory Bowel Disease: An Overview Impairment of health-related quality of life in patients with inflammatory bowel disease: a Spanish multicenter study The global burden of IBD: From 2015 to 2025 Second N-ECCO consensus statements on the European nursing roles in caring for patients with crohn's disease or ulcerative colitis El papel de enfermería en una unidad monográfica de enfermedad inflamatoria intestinal, una visión de 360° Maintaining the Quality Standards of Care for Inflammatory Bowel Disease Patients During the COVID-19 Pandemic Concerns related to COVID-19 pandemic among patients with Inflammatory Bowel Disease, and its influence on patients management Management of COVID-19 Pandemic in Spanish Inflammatory Bowel Disease Units: Results From a National Survey Inflammatory Bowel Disease Care in the COVID-19 Pandemic Era: The Humanitas, Milan, Experience Management of inflammatory bowel disease patients in the COVID-19 pandemic era: a Brazilian tertiary referral center guidance Views of patients with inflammatory bowel disease on the COVID-19 pandemic: a global survey Delphi consensus statement: Quality Indicators for Inflammatory Bowel Disease Comprehensive Care Units Innovation in IBD Care During the COVID-19 Pandemic: Results of a Cross-Sectional Survey on Patient-Reported Experience Measures Systematic review: advice lines for patients with inflammatory bowel disease Unidad de Atención Crohn-Colitis: 3 años de actividad Real Decreto 463/2020, de 14 de marzo, por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el COVID-19. BOE n o 67 de 14 de marzo de 2020 Consumo y Bienestar Social -Profesionales -Situación actual Coronavirus s. f An exploration of the follow-up up needs of patients with inflammatory bowel disease Telemedicine in inflammatory bowel disease: Opportunities and approaches Patient decision-making in severe inflammatory bowel disease : the need for improved communication of treatment options and preferences 2019:1-9. 28. Nursing Now. Who we are -Nursing Now 1%) 110 (48,9%) Occupational status, n (%) Work Retired / Disable School Inactive 203 (61,3%) 85 (25,7%) Note: a Unidad Atención Crohn y Colitis ulcerosa, b intravenous, c subcutaneus, d Oral Characteristics COVID-19 Adm. visits COVID-19 a Outbreak Other p-value Note: a administrative visit COVID-19 We want to recognize both the general population, who have been able to act at this extraordinary moment, professionals, and agencies, who helped to deal with this crisis.The authors also acknowledge Coral, Isabel and Matthew for writing English assistance. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. This work has been conducted with no funding.