You can visit the ER without leaving the couch
‘It’s quite amazing how much you can do by video,’ says MD about virtual emergency room
An elderly man who had fallen and badly injured his wrist. A young child with a high fever, his parents worried about a possible infection. A man with an alarmingly red and swollen eye. A woman who had recently suffered a miscarriage and was in mental distress.
Dr. Justin Hall saw each of these patients during a recent shift at Sunnybrook
Health Sciences Centre. But instead of conducting in-person examinations at the bedside, the emergency physician was logged into the hospital’s new virtual emergency department and cared for these patients by Zoom.
“It’s quite amazing how much you can do by video,” said Hall, the program’s physician lead.
“Being able to see the patient in their own environment tells us a lot about how well they are — or how unwell they might be.”
The first hospital in Greater Toronto to launch a virtual emergency department, Sunnybrook opened its online portal to patients on Dec. 1.
The six-month pilot project, funded by the Ministry of Health, allows for same-day appointments for patients with urgent but not life-threatening conditions who are unable to see a family doctor. Sunnybrook is one of 14 Ontario hospitals — and one of seven in the GTA — that has received provincial funding to launch a virtual emergency department.
Hall said the goal of Sunnybrook’s virtual program is to see patients who might not otherwise come to the ER.
That might be because of traditional barriers to hospital care, such as a lack of transit, or, more recently, due to fears of COVID-19.
“During the pandemic, we’ve recognized that some patients are not coming into the emergency department because they are afraid,” he said. “Or they are delaying their care such that when they do arrive, they are much sicker or more unwell.”
Seeing some ER patients virtually also helps reduce crowding in the hospital’s waiting areas, creating a better patient experience and reducing the risk of being in close quarters with someone with COVID-19, said Hall. Sunnybrook’s virtual ER sees patients on weekdays between 2 and 9 p.m., typically the emergency department’s busiest times.
While video visits may seem like an unexpected way to do emergency medicine, Hall said he’s encouraged by Sunnybrook’s early experience. From the virtual platform, physicians can send prescriptions to pharmacies, book next-day appointments for ultrasounds or other imaging services, connect patients quickly with specialists, such as ophthalmologists, and even loop in social supports, when needed.
Since Dec. 1, about 400 patients have logged in to the hospital’s virtual ER, with 70 per cent saying they would have gone to wait at the hospital without the service and 96 per cent saying they would recommend it to a friend or family member.
So far, about one-quarter of patients seen virtually were advised to go directly to a physical emergency department for immediate care, with some admitted to hospital. Hall said talking to worried patients by video helps assure them the hospital is safe, and the virtual platform alerts staff in the physical ER of a patient’s arrival.
During his most recent shift in the virtual ER, Hall said he saw a patient by Zoom who was clearly unwell due to an undetected infection and who needed to go to hospital right away. The patient was admitted to Sunnybrook’s general medicine unit that same day.
“It’s important to recognize that not everything can be resolved virtually with our patients, but there is a lot we can do.”
Monda Rosenberg booked an appointment with Sunnybrook’s virtual emergency department in mid-December, one week after being prescribed antibiotics to treat an infection in her toe.
It was a Friday, and Rosenberg, unable to see her own family physician over the weekend, was worrying the infection that had caused her toe to balloon “like Rudolph’s red nose” needed additional care.
“It was still quite red and sore and I wasn’t sure what to do,” said Rosenberg, who lives with her husband, both self-described seniors, a short drive from Sunnybrook. “I was concerned about going to the hospital because we stay home all the time because of the pandemic. And this way (a virtual appointment) I was able to stay home with my slippers on.”
Once online with an emergency physician, Rosenberg held her toe up to the camera on her computer screen. After asking some additional questions, the physician said she could wait until Monday to see her family physician for followup.
“I had this sense that I had done all I could and that gives you peace of mind.”
Hall said the team was mindful of creating a virtual ER with few barriers, particularly for older generations; it has one short form to fill out, can be used on a smartphone, tablet or computer, and a staff member can help with any problems.
Family and caregivers can join the video consult, including those who live in different households, a feature Hall has found helpful, especially when a language barrier arises.
St. Michael’s Hospital, a part of Unity Health, launched its virtual emergency department on Dec. 8, offering weekday appointments between 2 and 9 p.m. — when the physical ER waiting room is typically at its busiest — using Zoom for video calls.
Emergency physician Dr. Shaun Mehta said the team worked hard to design a virtual ER that would best fit the hospital’s primary patient populations.
“As an inner-city, urban hospital, we have a lot of marginalized patients that we treat,” said Mehta, the program’s colead. “We see a lot of people experiencing homelessness. We treat recent immigrants and refugees. We treat patients with substance and addiction problems ... and we know many of these patients don’t have the infrastructure — a phone or tablet — to engage with this service.”
As part of the six-month pilot project, the team has alerted local shelters and community service agencies. They’ve also donated a computer, monitor, webcam and microphone to a nearby shelter specifically for St. Mike’s virtual ER.
And while a video consult works best, Mehta said physicians can speak by phone if that’s what’s available.
Since many patients from marginalized populations don’t have good access to primary care, Mehta said many rely on their local ER for concerns such as medication refills or an assessment for a rash. For those types of problems the platform works “perfectly.”
Dr. Kyle Vojdani, chief and medical director of the emergency department at Toronto’s Michael Garron Hospital, remains worried about the patients too scared to go to an ER for care.
During the first pandemic wave, a Star analysis showed emergency room volumes in Ontario dropped by 49 per cent between March 11 and April 30.
“We’re continuing to see a decrease in (emergency department) volumes across the system, particularly in the GTA, of about 25 to 30 per cent,” he said.
Like most hospitals, Michael Garron has tried to get out the message that its emergency room is safe. In the fall, the hospital created an online booking system for patients with musculoskeletal injuries who need urgent but not immediate care, such as for fractures or sprains.
The next step, Vojdani said, is to add a virtual emergency department to help ensure patients who are fearful of ERs or who, because of COVID-19 restrictions, find it hard to come to the building, can still get care for non-life-threatening conditions.
Set to launch March 1, Michael Garron’s virtual ED is not part of the Ministry of Health’s pilot project and will use Maple, a private medical app company, for its video platform. Vojdani said the hospital will cover the cost of the platform; patients will not have to pay for the service.
Though some details still need to be worked out, Vojdani said they want to offer virtual emergency care in the evenings, going as late as possible, when few other care options are available.
At University Health Network, emergency physician Dr. Sameer Masood has noted the initial success of its virtual emergency department and is making plans for how to improve on the pilot project.
Launched on Dec. 14, UHN’s virtual platform has seen almost 250 patients, three-quarters of whom did not have to be sent to the ER.
“We were able to mitigate or avoid these unnecessary ER visits,” said Masood, UHN’s virtual ED lead, noting the pilot project will be evaluated at its conclusion. “Now it’s a matter of finding additional wins and efficiencies.”
In early March, a nurse practitioner will join the program to help triage patients before they’re seen by a physician. Masood said the team will collect data with the goal of one day augmenting the virtual platform with artificial intelligence to automate some decisionmaking.
Masood sees a time when a virtual ER will incorporate a patient’s health data, such as a heart rate or blood pressure, gleaned from their smartphone. In the meantime, he and other UHN emergency physicians will focus on helping patients get virtual care during the pandemic. In the past two months, they have seen many patients needing such a service, including a recent patient with a wrist injury who didn’t have a family doctor and couldn’t take time off from their minimumwage job.
“We were able to arrange followup care for him to see a specialist, and I could prescribe medications and offer advice on splinting. And this could all be done while he was actually at work, in a quiet space, not having to lose a day’s work and wages or being potentially exposed to an infectious illness in the ER.”