'We’re concerned about the kids that we’re not seeing': CHEO launches virtual emergency department

Faced with a decline in emergency department visits during the COVID-19 pandemic, the children's hospital in Ottawa decided to go virtual.

CHEO, the pediatric hospital and research centre whose catchment area includes eastern Ontario, Western Quebec, northern Ontario and Nunavut, launched a "virtual emergency department" on Monday — and according to the institution, became the first children's hospital in Canada to do so.

Some of Ontario's other major children's hospitals include the Hospital for Sick Children in Toronto, Children’s Hospital at the London Health Sciences Centre and McMaster Children's Hospital in Hamilton. At least one of them is also exploring the possibility of setting up a virtual emergency department.

"We’re concerned about the kids that we’re not seeing," said Dr. Sarah Reid, a pediatric emergency physician who was one of the people at CHEO involved in launching this new care model.

Reid said what CHEO experienced since the COVID-19 outbreak in Ontario was similar to what emergency departments across the world were seeing.

"Within a couple of weeks of the lockdown, we really noticed a very significant drop-off in our visits, down to below 50 per cent of what we would normally see at this time of year," she said. Reid acknowledged that due to physical distancing and the closure of schools and daycares, children were likely not getting the viruses or injuries that they normally would, but said the decrease was still significant.

"So that got us thinking: do we need to reach out in some other way to our families in our region to offer care at this time in case they’re not coming because they’re worried or concerned about coming into a hospital at this time?" she said of why CHEO decided to launch the project. "One of our concerns is that it’s actually anxiety and fear around coming into the hospital that’s preventing some of the visits that we would normally be seeing."

The hospital has been working on its "virtual emergency department" for the past three or four weeks and had a full morning of patients on Monday, Reid told QP Briefing in the afternoon.

To start, CHEO will offer 24 virtual appointments each day through a secure video platform. Because this program is meant for patients with "urgent problems," the hospital is only booking appointments for the day or the day after a patient registers.

"One thing to really stress is this is not meant to replace primary care," said Reid, noting that many family physicians are offering virtual care right now. She said that even pre-pandemic, emergency departments often struggled with people going to the hospital when a visit to their family doctor would suffice.

"We really are trying to stress that in our messaging...that this service that we're offering is for patients who may not have access to primary care or patients after hours who aren’t able to access primary care, but it’s not for somebody who has a family physician who they’re able to get in touch with," she said.

While a regular emergency department visit would involve hospital staff triaging the patient, this is a little different in that the families are, in a way, triaging themselves, Reid noted. CHEO's website takes families through a list of symptoms and conditions; if a patient has them, the hospital recommends an in-person visit. This includes if a baby who is less than three months old has a fever.

"They need to be seen in the emergency department because they actually need investigations done and they definitely need a full physical exam," Reid said, adding that another example would be a child who has a major head injury and experiences a change in behaviour or is vomiting repeatedly.

If a patient answers 'no' to the symptoms listed, virtual care could be an option for them with the patient then being asked to to fill out a registration form online. Registration clerks in the emergency department would then contact the family to book the next available appointment.

Reid said examples of when a virtual emergency department visit could be used is if a child was vomiting and had diarrhea and the parents were concerned about dehydration.

"That’s a child who could be assessed over virtual care using a really good history from the physician and some easy physical examination maneuvers," Reid said.

Another example is if a child has an ankle injury. The physician could assess virtually whether or not an x-ray is needed.

Reid said there will likely be two groups of patients they see through this virtual care program. The first will be those with a problem that can be managed virtually from start to finish.

"And then there’s the second group of patients where we’re going to hear about the story, assess the patient and then say this is really something that needs more done and we would really recommend that you come into the emergency department today," she said. "For that second group of patients, we can actually reassure the family that coming to the emergency department is a safe place, we’re practicing our physical distancing and (using) personal protective equipment."

Reid said they're hearing of stories of patients going into the hospital "a bit later than they normally would," so there are some that are seemingly sicker than they typically would be when they show up at an emergency department.

"It’s the hidden problems that maybe the parent would seek care for in a non-pandemic environment; it’s also the problem that might have been minor and now is a little bit more serious and so the hesitancy to present to the emergency department may lead to things being a little bit more serious," she said.

In recent weeks there have been increased efforts from hospitals and medical practitioners to reassure the public that they should visit a hospital if they need to.

London Health Sciences Centre (LHSC) released a public service announcement last week noting that "essential hospital services including the emergency departments remain open." The head of the teaching facility also looked to local media to get the word out.

"Physical distancing does not mean avoiding the hospital if you have a serious health concern," wrote Neil Johnson, LHSC's interim president, and St. Joseph’s Health Care London's Dr. Gillian Kernaghan in a column in the London Free Press. "Please know that patients with a suspected case of COVID-19 are separated from other patients, and a number of protocols are followed to protect the health and safety of our staff, physicians and patients."

In April, LHSC's children's hospital had 996 patients register in the emergency department. That's down from the 3,307 registrations the department saw in the same month last year, according to LHSC.

Similar to CHEO, the emergency department at SickKids is seeing around 50 per cent of the number of patients it would expect to at this time of year, a hospital spokesperson noted.

While one of the reasons is fewer illnesses and injuries, the hospital is also aware that “many families may be avoiding or delaying a visit to their local emergency department due to fears of COVID-19,” the spokesperson said, adding that infection prevention measures are in place and families should “not hesitate” to visit the hospital.

Reid said that while the CHEO tends to bring in patients from certain regions, it's not unusual for them to see out-of-province or out-of-country patients in their emergency department.

"We're not restricting to anyone at this point," she said of the virtual emergency appointments, adding that she's interested to find out who accesses this service. The hospital will keep track of that, along with whether families like the service, the rate at which it's used, the hospital's capacity to continue to offer it and what is or isn't working.

"I think it will be really interesting over the next few weeks and months to see if this becomes one of the ways we do business," Reid said.

She said there are several other pediatric hospitals in Canada that have "similar programs that are in the works that are just not yet launched." In fact, she said the group at CHEO received an email from another pediatric hospital in Ontario on Monday morning that is also looking to launch a virtual emergency department and wanted to discuss "lessons learned."

"I think that there’s going to be a lot of collaboration to develop this innovative sort of program at other sites," she said.

QP Briefing did confirm that at least one other children's hospital in Ontario is looking to launch a similar program. However, the hospital requested it not be named until details are finalized.

-Photo of Dr. Sarah Reid courtesy of CHEO