Stagg A, Giglia TM, Gardner MM, Offit BF, Fuller KM, Natarajan SS, Hehir DA, Szwast AL, Rome JJ, Ravishankar C, Laskin BL, Preminger TJ.Pediatr Cardiol. 2023 Jan;44(1):196-203. doi: 10.1007/s00246-022-02993-y. Epub 2022 Sep 1.PMID: 36050411
Take home points:
- The addition of telemedicine visits in lieu of entirely in-person visits for interstage monitoring of single ventricle patients is feasible, safe, prevents unplanned ER visits, and is associated with high levels of satisfaction by both families and clinicians
- Larger studies as well as adjunct use of remote diagnostic technologies will help determine the full capabilities of TM in this population
Commentary from Dr. Jared Hershenson (Greater Washington DC), section editor of Pediatric Cardiology Journal Watch: The interstage period between stage 1 and stage 2 surgical palliation for single ventricle congenital heart disease has historically been considered high risk for morbidity and mortality. The development of home monitoring and dedicated single ventricle teams have been instrumental in improving outcomes. Especially due to the COVID pandemic, telemedicine visits have been more frequently used for routine care, but its efficacy and safety in a higher risk subgroup has not been fully evaluated.
This study assessed the use of TM in the interstage period along with the standard home monitoring protocols. In their program called interstage single ventricle monitoring program (ISVMP), weekly visits were performed alternating between the PCP and cardiologist. TM replaced at least one in-person PCP visit and was not used at nights or over the weekend. The TM visit tracked clinical concerns, interim ED visits or hospitalizations, visual assessment of patient color, activity, work of breathing, and respiratory rate, along with documentation of the HR and O2 sat using the home pulse oximeter. The clinician also discussed the daily weights, nutrition, and medications with the primary caregiver. The monthly frequency of ED visits per patient and estimated costs were tracked by comparing the standard ISVMP (Aug 2018-May 2019) with ISVMP + TM (Aug 2019- May 2020). Additional tracking included hospitalizations, identification of clinical concerns, whether TM prevented unnecessary ED visits or expedited in-person visits, and clinician and caregiver satisfaction.
60 TM visits were conducted for 29 patients with a median monitoring time of 199 days. The median number of TM visits/patient was 2 (range 1-5). 98% of visits had a successful audiovisual connection at the first attempt, and the average length of the visit was 20 minutes. In 6 TM visits (6 different patients), significant clinical findings (decreased O2 sats, tachypnea, poor feeding) were identified that led to therapeutic changes that avoided an ED visit (as these findings prior to TM would have been associated with an automatic referral to the ED). Expedited follow-ups were subsequently performed in 3 of the 6 patients. An additional 5 TM visits led to expedited follow-up with one of these patients being hospitalized. There were no missed events or deaths. There was a reduction in median monthly ED visits (see Table 2). 6 hospitalizations occurred in 2 patients who were unable to be seen via TM due to night/weekend events. All visits identified at least one non-urgent issue. 97% of caregivers were satisfied with TM visits, were interested in future TM visits, and only about 17% experienced some technical difficulties that were resolved quickly. Clinicians were also highly satisfied, thought the caregivers were receptive, and the visits effective for patient care. Family/patient education and troubleshooting home equipment problems were markedly improved using TM than from in-person visits.
The use of TM greatly expanded during the COVID pandemic but is likely to continue to be a useful resource, even for the highest risk patients. There is a significant saving of time and money from the family’s perspective, and if there is not an increase in patient events or negative effects on outcomes, this should be considered in more centers if medical reimbursement remains. The authors noted that there are significant logistical and staffing needs when using TM, along with the need for technical support and translation services.
