Published onNeonatology Update
By Hallam Hurt, MD, Education Director, Neonatal Follow-Up Program (NFP)
As it did with many endeavors at Children’s Hospital of Philadelphia, the COVID-19 pandemic brought unprecedented challenges to patient care in our Neonatal Follow-up Program. All in-person appointments were suspended as of March 16, 2020. We then began working to determine how to best serve our patient population. On March 30, 2020, we began using telemedicine exclusively, and we extended that practice until June 17, 2020, at which time we began to blend in-person visits with telemedicine visits.
So, how did we transition to telemedicine? Here, we detail start-up steps, share some successes, and describe some “bumps in the road.”
Making the transition to telemedicine
Once the decision for this transition was made, providers were trained in how to use the telemedicine application in the electronic medical record. Families were contacted to determine their interest in participating in telemedicine visits. At this juncture, we learned of some concerns related to internet connectivity, as well as concerns regarding providers visiting patient homes virtually. For families with the latter concern, telephone encounters were offered provided it was not a new patient visit (organizational policy). For those families who agreed to a telemedicine visit, clinic coordinators used a script to help parents prepare for the visit, in particular, as related to the patient’s age. For example, if the patient was an infant, it was suggested that the parent have a
blanket to place on the floor and, if available, several of the baby’s toys.
For those patients younger than 12 months corrected age, both a medical provider and a physical therapist participated in the visit. Parents were instructed that, if possible, it was preferable to have two caregivers participate: one to hold the camera and one to interact with the baby. In general, parents proved to be great partners. With scripted instructions, they were able to assist in such assessments as:
- Head lag in pull to sit
- Adductor angle
- Ankle dorsiflexion
- Scarf sign
Providers also were able to assess eye movements, response® to sound, presence of retractions, umbilical hernias, and any dermatologic findings. The two providers then discussed their assessments and made a plan with the family as to whether an expedited in-person appointment should be scheduled, with appropriate precautions, or whether the next visit could be per usual clinic schedule.
For infants older than 12 months of age, developmental evaluations were conducted by our developmental team in conjunction with a medical provider and physical therapist, as indicated. Initial preparation for the developmental assessments required collaboration and coordination with the CHOP neuropsychology team and developmental pediatric group to develop guidelines. Following development of the guidelines, parents were sent a list of possible toys to have available for the visit. For example, in the cognitive domain for a 12-month-old, the parent was asked to read a board book to their child.
The child was then observed for attention to the book, such as whether the child looked at pictures or attempted to turn the pages.
In general, the developmental assessment occurred first, followed by a medical evaluation. Then, the two providers communicated with each other and made a plan with the family for next steps.
How did this endeavor perform?
In the initial week, we scheduled only 18 patients. Subsequently, we scheduled as many as 36 per week. Not surprisingly, our initial show rate was only 40%, but it increased to as high as 95%, on occasion, with the overall show rate being 72%, which is similar to our in-person show rate. While we were not able to see our typical number of patients, we were able to see approximately 74% of our usual in-person volume during this period of exclusive telemedicine visits. Thus, utilizing this new tool, we felt, indeed, that we were able to serve our population during a time of unprecedented challenges.
What about “bumps in the road”?
There were issues with connectivity that, at times, delayed or even precluded completion of visits. When only one parent was available, assessments were more difficult given the dual tasks for the parent. And, given this new venture, providers often heard random music, phone calls and doorbells as well as views of ceilings, floors, lamps, pets, siblings and various family members.
Taken together, however, there were many positives. Parents were our partners, often eager to be included in assessments and voicing a better understanding of their child’s progress or of any concerns. In turn, we were surprised at the richness of what we gleaned from these in-home assessments — to include concerns that merited referrals for in-person visits with primary care or subspecialists.
While I was somewhat skeptical at the outset of this endeavor, I was happily surprised with the generosity of our families allowing us into their homes and with how much we could learn about our patients. Overall, our team felt that while telemedicine was not as good as an in-person visit, it was much better than no visit at all.
How might we utilize telemedicine in the future?
There are several important opportunities for us to use telemedicine in the future. These include:
- When there is a last-minute cancellation for a family with an unexpected issue with transportation or childcare for siblings
- For non-urgent interim visits such as for screeners in lieu of full developmental evaluations
- For families with medically complex children who are reluctant to bring their child in for an in-person visit
- In instances of inclement weather, given adequate lead time
- For future pandemic issues, if indicated
For all the above instances, we now have a template for moving forward in provision of “virtual” care for our babies and children and their families.
NOTE: Much of this contribution is drawn from the full-length chapter referenced below.
DeMauro SB, Duncan AF, Hurt H. Telemedicine use in neonatal follow-up programs: What can we do and what we can’t — Lessons learned from COVID-19. Semin Perinatol. 2021;45(5):151430.