FormalPara Clinician’s capsule

What is known about the topic?

Satisfaction with virtual care in Canada is high but the reasons for this satisfaction have yet to be elucidated.

What did this study ask?

Why are families choosing a virtual paediatric urgent care option in Canada and what impact is this service having?

What did this study find?

Families identified convenience, reassurance, and safety as the primary drivers of their satisfaction with the virtual option.

Why does this study matter to clinicians?

This study identifies patient values and opportunities for improvement to paediatric emergency care on an individual and policy level.

Introduction

Virtual care is defined as “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care” [1]. Virtual care has had a limited role in Canadian paediatric emergency care to-date and primarily consisted of provider-to-provider interactions via phone prior to its more widespread implementation.

In response to a 58% decrease in paediatric ED visits during the early COVID-19 pandemic [2], a virtual paediatric emergency care option was implemented at London Health Sciences Centre (LHSC). With virtual care systems now in place, studies of why families decide to utilize virtual emergency care are needed to understand the value to specific populations, and ultimately determine the role of virtual emergency paediatric care in Canada moving forward. The primary objective of this work was to identify the motivations for use and value of the paediatric emergency virtual clinic by analysing common themes identified within the responses of patients and families who have used the service.

Methods

Study design

This qualitative content analysis was designed based on the technology acceptance model [3]. Data was collected from patients and their families who attended the virtual clinic through Children’s Hospital, LHSC. This was organized as a joint initiative of administration, physicians, information technology and risk management [4]. Continuous feedback of technological and patient/provider experience challenges were incorporated. With the initiation of the provincial programme, standards set out by the province were instituted, as were data reporting requirements.

To attend the virtual clinic, parents or guardians initiate contact through the urgent care Ontario website and request an appointment to see a paediatrician. Appointments are slotted into empty time slots on a first come first served basis. Time slots are assigned at 15 min increments. The appointment included a “self-view” video feed to the physician for visual assessments as well as audio communication via WebEx, a secure virtual conferencing platform.

At the time of registration, participants consented to a follow-up survey by the triage nurse. All patients registered were sent an exit survey link regardless of completion of visit. This allowed the broadest strategy to welcome criticism or support of the visit. This study was a quality improvement initiative as determined by the Western Research QI checklist and therefore this project was exempted from ethics approval in accordance with Article 2.5 of the TCPS.

Study setting, time period and sample size

Data was collected from a prospective cohort of all patients that were offered the exit survey following their virtual care visit. The cohort attended the virtual emergency clinic at LHSC Children’s Hospital between May 2020 and May 2021. Of 2194 total visits 773 virtual clinic patients responded to the survey (Supplemental 1). A brief anonymous survey was distributed to consenting families directly following their virtual ED visit. Two open-ended questions were asked in the survey: Please tell us, in your own words, the impact this virtual visit had for you today; and Is there anything else that you would like to share about how Children’s Hospital at LHSC can support patients and their loved ones during this time? Anonymized data was extracted into excel format for subsequent software uploading.

The demographic data presented in Supplemental 2 was collected for 2194 VC patients from May 2020 to May 2021. The registration clerk consented each patient and asked for reason for choosing virtual care and contact with primary care provider prior to the appointment. Reason for visit, outcome, postal codes and age were obtained from the electronic health record.

Data analysis

Participant responses were analysed using conventional content analysis and the step model of inductive category development [5]. Survey responses were uploaded into Dedoose (Version 7.0.23) [6]. Respondent comments were independently coded by two reviewers (VS, BV) and analysed until thematic saturation was reached. The coding categories were then collaboratively assessed by reviewers (VS, BV, SC, RL) to ensure codes reliably and accurately captured the themes present within the patient responses. Any discrepancies or disagreements in coding were resolved through consensus. The codes were then applied to the remainder of the responses. Upon coding completion, related codes were combined and subcodes were subsumed within major coding categories to distinguish overarching, major and minor themes.

Results

The exit survey reached a 35.2% response rate (Supplemental 1), encompassing the full range of paediatric ages with a skew toward younger patients, a variety of clinical presentations, and both urban and rural patients from across the entire Southwestern Ontario catchment area and beyond. Demographic details, as well as reason for visit, presenting complaint and visit outcome are outlined in Supplemental 2. Qualitative content analysis and coding successfully identified commonalities among patient experiences. As demonstrated schematically in Fig. 1, the predominant theme was satisfaction. Major themes included reassurance, convenience, avoiding hospital environment and sustainability of programme further details outlined in Fig. 1 and Supplemental 3.

Fig. 1
figure 1

Schematic representation of breakdown of overarching, major and minor themes of satisfaction identified through qualitative analysis of responses from patients and families attending paediatric emergency virtual clinic

Full size image

The primary overarching theme of satisfaction with the virtual clinic dominated the patient narrative in this analysis with over 400 comments. Sub-themes of satisfaction included: usefulness of virtual care as a concept, thankful for this service during the pandemic included alleviating the stress of having an ill or susceptible family member, hesitancies of attending the hospital and obtaining guidance on pandemic related rules and restrictions from the virtual care team, as well as satisfaction with the physicians and staff. Over 200 responses were coded with comments relating to their desire to have this service as an option in the future post-pandemic.

There were 80 comments coded with a negative experience or recommendations: 28 complaints (12 technology related, 8 associated with in-person care after virtual visit) and 64 recommendations (17 for expanded hours/expand to adults, 12 recommendations for the in-person ED/LHSC). Further details on sub-themes are described in Supplemental 3. Importantly, there were 4 comments regarding inclusivity, including: ensuring the use of inclusive language, providing an interpreter for deaf individuals, and improving access for blind parents.

Discussion

Interpretation of findings

This study builds upon literature of virtual care in Canada by conducting a qualitative thematic analysis of the value and impact of paediatric virtual emergency services in the Canadian context. It provides new insight into the attractive features of a virtual care option for paediatric emergency patients. Those families who responded to the exit survey were satisfied by the convenience, reassurance, and ability to avoid the hospital environment.

Comparison to previous studies

The high level of satisfaction expressed by families represented in this study is mirrored in previous research, with 91% satisfaction rates in Canadian virtual care settings [7, 8]. On the other hand, drawbacks of virtual care have been well established in the literature including privacy concerns, lack of tactile physical examination, technical challenges, lack of access and treatment outcomes [9, 10; of which, only technical challenges were represented in the present study.

Strengths and limitations

The strengths of this research lie in the emphasis on family-centred care, as well as the qualitative methodological approach to analysis. This study is limited geographically to the LHSC Children’s virtual clinic and did not investigate impacts on in-person ED care. Additionally, these findings are specific to the COVID-19 time period,. There was a low response rate of 35% which limits the generalizability of these findings. Due to the self-selection for survey completion, there are likely important distinctions between respondents and non-respondents and it is possible non-respondents did not value the virtual care pathway. This study may have failed to capture individuals who were unable to access the virtual clinic. The survey was only available in English and thus language is a potential barrier to completion. This study did not aim to assess patient visit outcomes, quality of care or cost efficacy; however, these will be addressed in future studies.

Clinical implications

Virtual urgent care for paediatric populations is available in other geographic regions and based on patient satisfaction seems to be a logical next step in optimizing family-centred healthcare for this population, particularly in a geographically dispersed region like Canada.

Research implications

This study concludes that those who attended the virtual clinic and responded to the exit survey value the service and outlines why they chose it. There remain key gaps in knowledge relating to digital healthcare access, performance characteristics, health outcomes and economic evaluation in this setting. This study emphasizes the value of patient engagement and input to guide improvements to virtual care offerings.

Conclusion

Using qualitative content analysis of patient and caregiver experiences written in their own words, this study provides a picture of why families chose the virtual urgent care option. The primary finding of this paper is that virtual care in the paediatric setting helped many caregivers to navigate the healthcare system and avoid the hospital environment with a convenient option for care that left them feeling reassured and satisfied.