October 2020Telehealth

Telehealth becomes vital nursing tool in monitoring patients’ health at home

Visual element helps nurses provide more effective clinical and emotional support

When Patricia Spragg came down with COVID-19 this past June, she knew—especially as a breast cancer survivor—how badly she could be affected by over-exertion. Even so, she experienced exhaustion and headaches because, as she readily admits, she’s the kind of person who just can’t sit still.

Patricia Spragg

Patricia Spragg

It took a firm but patient phone call from Natalie Leon, an Oncology Nurse Navigator in the Segal Cancer Centre at the JGH, to set Ms. Spragg straight.

“She told me, ‘You know what, Patricia? You need to pick three things that you want to do,’” Ms. Spragg recalls. “‘Then choose the most important of them and go do it. And then take a rest.’

“Things went much better for me after that, instead of me going on and on like the Energizer bunny.’”

When the pandemic first struck, Ms. Leon and her fellow Nurse Navigator, Gabrielle Chartier, prepared a stack of 108 names and phone numbers of outpatients who had been served by the Segal Cancer Centre and had also been struck by COVID-19.

Gabrielle Chartier, a Nurse Navigator in the Head and Neck Oncology section of the Segal Cancer Centre.

Gabrielle Chartier, Nurse Navigator in the Head and Neck Oncology section of the Segal Cancer Centre.

Then they, along with Nurse Navigator Tiziana Vadacchino, called each of them—in some instances, as often as twice a day—to make sure the patients had the support and resources they needed.

“In a way, we were lucky,” Ms. Chartier says. “Since we were among the last in the world to get hit hard by the pandemic, we were able to see what was happening elsewhere, review the literature, and use the information to develop our own routines.”

Due to the unique nature of the Segal Cancer Centre, this telehealth service for cancer patients with COVID-19 was the only one of its kind in Quebec, Ms. Chartier says. To ensure that patients could receive advice in a wide range of fields, the team included a psychologist, nutritionist and occupational therapist. Nurses also had prompt access to experts from Infection Prevention and Control.

This concerted effort to maintain contact through telehealth—over the phone or with video meetings on platforms such as Zoom—has given nurses a key role to play during the pandemic in such areas as Oncology, Pulmonary Medicine and Cardiology.

In some respects, nurses were actually ahead of the game. Back in 2017, they had already launched a telephone triage hotline to help cancer outpatients at home to manage their symptoms and the side-effects of their treatments.

Ms. Spragg, an employee at a long-term care centre in Montreal, was on Ms. Leon’s list, because she had been diagnosed with breast cancer in 2015, followed by chemotherapy, surgery and radiation therapy.

That was when she first experienced the personal nursing care at the JGH that she now describes as “phenomenal. For the first couple of weeks, it was devastating. But as I got to know the staff, my fears just washed away.

“There were so many patients with the same problems that I was going through, but the nursing staff made me feel like I was the only one they were focusing on.”

Those same feelings returned when Ms. Spragg began hearing from Ms. Leon during the pandemic. Having to communicate over the phone did not diminish the power of their connection.

“You don’t have to see her to feel her,” says Ms. Spragg, who is in good health today. “Some people, you talk to them and you can feel the true spirit in them. She was patient, clear, to-the-point, and she knew what she was doing. All those nurses, they’re angels without wings!”

It’s this sort of patient experience that has made nurses’ participation in telehealth so invaluable throughout the pandemic, says Lucie Tremblay, Director of Nursing.

“Despite the distance, nurses have been able to stay close to their patients throughout the pandemic,” Ms. Tremblay says. “The use of digital technology by these professionals has contributed greatly to the support that we have been able to provide, safely and securely, to those who are ill during a time of crisis.”

Marc-André Reid, Chief Nursing Informatics Officer, also notes that during the crisis, “nurses have intensified their enthusiasm and creativity.

“They have embraced the concept of virtual visits and combined it with their nursing expertise to make an enormous difference in the lives of users and their families. Leadership by nurses was crucial in deploying this new medium of care.”

Vital signs monitored remotely

While a good deal of telenursing creates a link by phone or Zoom, other forms of remote contact are also being introduced. Most notably, plans are under way at the JGH this fall to test a wearable monitoring device (similar to either a wristwatch or patch) that allows patients’ vital signs to be checked at a distance.

Erin Cook, Co-Director of Operations at the Segal Cancer Centre.

Erin Cook, Co-Director of Operations at the Segal Cancer Centre.

As a first step, device for testing has been given to each of about 100 oncology and cardiovascular patients who are being treated in the hospital, explains Erin Cook, Co‑Director of Operations at Segal Cancer Centre, and Clinical Administrative Coordinator of Oncology and Cardiovascular Services.

This enables clinicians to confirm that the devices—which transmit data about temperature, blood pressure, respiration rate, heart rate, oxygen level, heart rhythm, and more—are properly calibrated and accurately match the measurements taken by standard hospital equipment.

At the same time, Ms. Cook says, the inpatients will provide feedback about the devices’ comfort and user-friendliness.

A wristwatch-style telehealth device is used to remotely monitor patients’ vital signs.

A wristwatch-style telehealth device is used to remotely monitor patients’ vital signs.

If everything checks out, the devices will then be taken home by outpatients for a field test. The expectation is that if a patient is not feeling well, the nurses who monitor the readouts will be able to determine more quickly how serious the problem is.

As well, they can base their treatment decisions on physiological data, in addition to the patients’ subjective descriptions of what they are experiencing.

Under normal circumstances, Ms. Cook says, if a patient without a monitoring device is feeling unwell at home, he or she might choose to wait and see whether their situation improves. If it doesn’t, they then might go for care to the hospital, most likely to the Emergency Department.

“But with this device, we can review the information quickly, contact the patient at an early stage, and say, ‘You’re looking a little less well today. How are you feeling?’ If support is needed, we can offer it right away, which might help to prevent an Emergency visit or hospitalization.”

In the longer term, Ms. Cook adds, the wristwatch and patch might even enable certain patients to be discharged from the hospital earlier than usual. Since their vital signs would continue to be monitored on a regular basis, nurses would quickly become aware of any significant change in their condition at home.

Feedback from a survey

Despite the many benefits of creating a connection using digital technology, some obstacles do exist. Ms. Cook cites a survey that was conducted at the JGH in mid‑spring, in which some cancer patients said their lack of access to a cell phone or a computer prevented them from participating in a Zoom meeting or from downloading written information.

Nurse Clinician Mandy Collins in the Segal Cancer Centre.

Nurse Clinician Mandy Collins in the Segal Cancer Centre.

This could be an aspect of the patients’ socio-economic status, which is why Ms. Cook and her colleagues are sharing the results of their survey with Quebec’s Ministry of Health, in the hope of improving access to care for those patients.

On the other hand, the survey also found that the availability of telehealth pleased many immuno-compromised patients, who appreciated not having to come to the hospital, where their risk of exposure to COVID-19 is higher.

Of the nurses surveyed, many said that Zoom helped them more effectively decrease patients’ anxiety, since the visual link was the next best thing to in-person contact.

In addition, the screen enabled nurses to strengthen their personal bond with both patients and caregivers, and to better understand their patients’ general situation by being able to take a look at their home environment.

A source of psychological and emotional relief

Kimberly Gartshore, Head Nurse of the Oncology Clinic at the Segal Cancer Centre.

Kimberly Gartshore, Head Nurse of the Oncology Clinic at the Segal Cancer Centre.

For certain patients in Head and Neck Oncology, telehealth has also been a source of psychological and emotional relief. Ms. Cook explains that almost all of these patients have had some degree of disfigurement to their face, mouth or throat, where cancerous tissues were surgically removed.

As a result, they often struggle with their self-image and they may feel self-conscious about making a trip to the hospital for follow-up care. Zoom enables them to avoid most of these potentially uncomfortable visits, while sharply decreasing their possible exposure to COVID‑19.

Gabrielle Chartier, who maintains contact with many Head and Neck Oncology patients, says that before the crisis began, plans were already under way to begin introducing some elements of telehealth. When the pandemic struck, the rate of implementation was simply accelerated.

Using a visual platform added a significant, new dimension. For example, Ms. Chartier explains, when a patient has to be informed about making a transition in care—for example, the need to begin palliative care—the information can be delivered on Zoom while the patient is in the supportive company of a spouse or other relatives.

Esther Laforest, a Nurse Clinician in the Heart Failure Clinic.

Esther Laforest, a Nurse Clinician in the Heart Failure Clinic.

Her comments are echoed by colleagues in other fields. In the Heart Failure Clinic, Nurse Clinician Esther Laforest works with an interdisciplinary team that, in pre-COVID days, regularly held in-person meetings to ascertain the condition of more than 700 patients who are living with various stages of heart failure.

Since most of these patients are unable to visit the JGH during the pandemic, telehealth has become essential in delivering the visual element, she says. “You can’t underestimate the importance of what a person’s face can tell you. If things are not going well, or if the patient has considerable fluid overload or congestion, the face alone will tell a story.

“You can see accessory muscle use and panting, and you can monitor respiratory symptoms. You can get a sense of the patient’s status from their colour or any swelling in the face or legs.”

Ms. Laforest acknowledges that in some instances, the range of the visuals can be limited—for instance, if they come from a patient whose webcam is fixed to the screen of their desktop computer. “But even in that kind of situation, the visual dimension can add a great deal to the evaluation.”

Similarly, in the Division of Pulmonary Medicine, Yujie Hu says the ability to visually detect shortness of breath is vitally important in helping patients with chronic obstructive pulmonary disease.

As a Care Counsellor Nurse, Ms. Hu used to provide almost all of her pre-pandemic support over the phone to patients who needed immediate assistance. Now, she says, Zoom’s visuals have become much more common, not only in using a patient’s appearance to help determine their condition, but in seeing whether patients are using their inhalers properly to receive the optimal dose of medication.

For all of these reasons, Erin Cook is convinced that telehealth has taken a major stride in becoming integral to certain aspects of nursing. “These initiatives give us increased access to our patients, so that we can reach them in a more timely manner,” she says.

“Over all, it’s a better way of engaging patients in their own health. To help them do that, telenursing has become an extra tool in our kit. We’re only just beginning to tap the potential of what it can do.”

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