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Telehealth can promote a cost reduction and allocate resources to improve the quality of patient care&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a></p><p id="para0015" class="elsevierStylePara elsevierViewall">Pediatric remote care offers the unique opportunity and additional benefit of seeing children where they live&#46; Through the use of telemedicine&#44; doctors can safely observe young individuals in a calm and comfortable environment while assessing their clinical condition without the influence of additional stressors&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0016" class="elsevierStylePara elsevierViewall">Studies have shown that around 80&#37; of telemedicine consultations between doctors and patients are being conducted properly without the need for in-person visits to the emergency department&#46; Further&#44; they have reported good user satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0017" class="elsevierStylePara elsevierViewall">Despite its recognized value and availability&#44; telemedicine is not universally used&#44; suggesting that some barriers prevent its adoption and acceptance within the community&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> Some barriers to the use of telemedicine include technological challenges&#44; workflow integration&#44; perceived usefulness&#44; regulatory issues and costs for the hospital services with equipment&#44; personal and dedicated connection&#44; and for the users&#44; which require a minimum internet band and a computer&#44; tablet or smartphone to be able to use this service&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> So&#44; the inclusion of this tool in public services involves even greater challenges&#46;</p><p id="para0018" class="elsevierStylePara elsevierViewall">The Brazilian government and Ministry of Health&#44; motivated by the current COVID-19 pandemic&#44; have recently allowed the use of telemedicine services&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> The Institute is a tertiary university center&#44; a reference for the care of pediatric patients with chronic health conditions&#46; Although COVID-19 is not associated with severe respiratory manifestations in children&#44;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> most patients in The Institute have comorbidities&#44; thus being considered a risk population for COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> In the pandemic scenario&#44; telemedicine could contribute to avoiding unnecessary visits to the emergency department and for the rational use of health services&#46; In response to the pandemic&#44; The Hospital Telemedicine Emergency Care Program &#40;PATMHO- &#8220;Pronto Atendimento em Telemedicina Hospitalar&#8221;&#44; in Portuguese&#41; was developed in the pediatric emergency department of this tertiary pediatric public hospital&#46;</p><p id="para0019" class="elsevierStylePara elsevierViewall">Using a severity screening score for teleconsultation can be challenging&#46; Some screening tools have been developed to assess the severity in pediatric telecare and have demonstrated satisfactory results&#44; reinforcing that telemedicine can be used to safely assess patients remotely&#46; However&#44; the majority of studies have focused on the use of screening tools for doctor-to-doctor telecare in an intensive care environment&#46;<a class="elsevierStyleCrossRefs" href="#bib0011"><span class="elsevierStyleSup">11&#8211;13</span></a> Due to the scarcity of specific scores for pediatric teleconsultation&#44; the authors developed a severity score specifically for this study&#46;</p><p id="para0020" class="elsevierStylePara elsevierViewall">In this article&#44; the authors describe the challenges and process for implementing a telemedicine program for pediatric emergencies&#46; The authors also present the severity score developed for the PATMHO implementation&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">Additionally&#44; preliminary results on care during the COVID-19 pandemic are discussed&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Materials and methods</span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Study design</span><p id="para0022" class="elsevierStylePara elsevierViewall">The retrospective descriptive study reporting on the first three months &#40;April to June 2020&#41; of the authors&#8217; experience implementing a telemedicine emergency care program in a public tertiary hospital&#46; The study shows preliminary data&#44; mainly on user satisfaction&#46;</p><p id="para0023" class="elsevierStylePara elsevierViewall">The study was submitted and approved by the Ethics and Research Committee of the Hospital&#46; The guardians of the patients provided oral consent before the start of the teleconsultation and were informed about the limitations associated with this form of care&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Platform and security</span><p id="para0024" class="elsevierStylePara elsevierViewall">The teleconsultations were carried out through Google Hangouts&#44; a free software program with adequate safety certifications&#44; in compliance with the Brazilian Health Insurance Portability and Responsibility Law &#40;Lei de Portabilidade e Responsabilidade de Seguros de Sa&#250;de - HIPAA&#41;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> and the Brazilian general data protection law&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0025" class="elsevierStylePara elsevierViewall">The authors use HIPAA-compliant Google Hangouts configuration&#46; All video calls are encrypted in transit between the customer and Google and no images were recorded during the calls&#44; ensuring privacy&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a></p><p id="para0026" class="elsevierStylePara elsevierViewall">The teleconsultation was documented in the patient&#39;s digital medical record&#44; the same that is already used in the hospital for in-person consultations&#46; It guarantees the safety of patient data due to the study&#39;s system has all certifications in compliance with Brazilian laws&#46; All teleconsultations are digitally signed by the attending physician&#46;</p><p id="para0027" class="elsevierStylePara elsevierViewall">The teleconsultation room had a DELL ALL IN ONE Computer&#44; Intel Core i5-8265 U Processor 8GB &#40;1&#160;&#215;&#160;8GB&#41;&#44; DDR4&#44; 2400&#160;MHz HD 1&#160;TB built-in webcam&#44; and microphone&#44; with Windows 10 Pro Single Language&#44; 64 bits&#44; associated to a 22-inch monitor&#44; and an Epson Perfection V19 SCANNER&#46; All of the infrastructures for the study was already available at the hospital and were relocated for use in telemedicine&#46; Users could use any of the Google Hangouts-compatible devices &#40;e&#46;g&#46;&#44; cell phone&#44; tablet&#44; or computer&#41; with a camera&#44; microphone and internet access&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">The teleconsultation</span><p id="para0028" class="elsevierStylePara elsevierViewall">Consultations were carried out via video conference in real-time by a doctor from the pediatric emergency team&#44; accompanied by a pediatric resident&#46; The entire medical team in the emergency department&#44; including residents&#44; was trained and prepared for the teleconsultation&#46;</p><p id="para0029" class="elsevierStylePara elsevierViewall">The step-by-step instructions on how to access the telemedicine emergency care were advertised to the parents&#47;guardians by email and through social networks&#46;</p><p id="para0030" class="elsevierStylePara elsevierViewall">After the teleconsultation&#44; an email was sent to the guardians&#44; including general recommendations&#44; medication prescriptions &#40;if necessary&#41;&#44; and the satisfaction questionnaire &#40;Appendix 1&#41;&#46; Teleconsultations were carried as indicated in <a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0031" class="elsevierStylePara elsevierViewall">Patients who were referred for reassessment through telemedicine &#40;after being discharged from the in-person consultation&#41; received a folder with step-by-step instructions for participating in PATMHO &#40;Appendix 2&#41;&#46; The parent&#47;guardian&#96;s mobile number was recorded&#44; and the teleconsultation was scheduled&#46; On the day of the consultation&#44; the guardian contacted the hospital using Google Hangouts or the pediatric resident contacted them directly by phone or WhatsApp to remind them and helping with any access difficulties&#46;</p><p id="para0032" class="elsevierStylePara elsevierViewall">A follow-up could be carried out through a new teleconsultation&#44; depending on the physician&#39;s medical judgment&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Population of study</span><p id="para0033" class="elsevierStylePara elsevierViewall">All patients were between the ages of 0 and 18 years of age&#44; currently treated at inpatient or outpatient services of the study&#39;s hospital&#44; were eligible to use PATMHO&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">The patients who participated were divided into two groups&#58; those that spontaneously sought the PATMHO services&#44; and patients that sought in-person care and were then referred for re-evaluation through telemedicine within 48&#160;h&#46; They were also divided into suspected or confirmed cases of COVID-19 or other pathologies&#46;</p></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Evaluation of satisfaction</span><p id="para0035" class="elsevierStylePara elsevierViewall">The email that was sent at the end of the teleconsultation included a satisfaction survey to be answered anonymously by the guardians &#40;Appendix 1&#41;&#46; The Telemedicine Satisfaction Questionnaire &#40;TSQ&#41; was adapted for the use of this study&#46; The TSQ was developed in 2003 and has demonstrated a high level of reliability&#44; validity&#44; and consistency&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> Questions regarding the guardians&#44; such as degree of relationship with the patient&#44; age&#44; and education level were included&#46;</p></span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Development of a severity score for teleconsultation</span><p id="para0036" class="elsevierStylePara elsevierViewall">The study&#39;s PATMHO screening score &#40;Appendix 3&#41; was developed based on early warning scores and the recognition of physiological changes such as the Pediatric Observation Priority Score&#44;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> the Pediatric Assessment Triangle&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> the Pediatric Early Warning Score&#44;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> and the screening score used in the Institute Emergency Department&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> This score was developed in the context of the COVID-19 pandemic&#44; requiring future modifications&#46;</p><p id="para0037" class="elsevierStylePara elsevierViewall">In the study&#39;s score&#44; the authors included comorbidities considered as a risk factor for developing severe forms of COVID-19&#44;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> exposure to COVID-19&#44; assessment of the level of consciousness&#44; circulatory and respiratory assessment&#44; and the last assessment item called potential risk of urgency&#46;</p><p id="para0038" class="elsevierStylePara elsevierViewall">Only considering a patient&#39;s vital signs does not seem to be the most appropriate way to identify critically ill patients in emergency departments&#46;<a class="elsevierStyleCrossRefs" href="#bib0019"><span class="elsevierStyleSup">19&#8211;22</span></a> Assessing vital signs&#44; such as heart rate&#44; through teleconsultation is very difficult&#46; Interestingly&#44; some screening systems include the overall impression of the doctor in their classification despite the clinical diagnosis&#46; For this last assessment item&#44; a physician&#39;s knowledge and experience are necessary&#44; but not sufficient&#46; An important factor in this context is the doctor&#39;s gut instinct or sixth sense&#46;<a class="elsevierStyleCrossRefs" href="#bib0019"><span class="elsevierStyleSup">19&#8211;22</span></a></p><p id="para0039" class="elsevierStylePara elsevierViewall">The severity score varies from 0 to 35 points&#46; A value greater than or equal to 5 is considered a baseline value for an emergency pediatrician to encourage the attendance of in-person emergency service&#46; This value was determined through the consensus of specialists in pediatric emergency aiming to be more sensitive than specific&#46; The cut point validation and evaluation of the severity score will be carried out in a future study&#46;</p></span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Statistical analysis</span><p id="para0040" class="elsevierStylePara elsevierViewall">Continuous variables were described as means and standard deviations or as medians &#40;variation&#41;&#44; according to the Shapiro&#8211;Wilk test&#46; Categorical variables were described in percentage terms&#46; Means or medians were compared using either Student&#39;s <span class="elsevierStyleItalic">t</span>-test or the Mann&#8211;Whitney U test&#44; as applicable&#46; Categorical variables were compared using Fisher&#39;s exact test&#46;</p><p id="para0041" class="elsevierStylePara elsevierViewall">For all statistical tests&#44; the significance level was set at 5&#37; &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;05&#41;&#46; Statistical analyses were performed using SPSS software&#44; version 22 &#40;IBM Corporation&#44; Armonk&#44; NY&#44; USA&#41;&#46;</p></span></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0016">Results</span><p id="para0042" class="elsevierStylePara elsevierViewall">From April to June 2020&#44; 255 teleconsultations were carried out with 140 different patients&#44; 122 &#40;87&#46;1&#37;&#41; of which had some form of chronic disease&#46;</p><p id="para0043" class="elsevierStylePara elsevierViewall">Of the total consultations&#44; 182 were from 99 patients who underwent RT-PCR exam for SARS-Cov-2 at some point or had direct contact with a person known to be positive for COVID-19&#46; The mean age of these patients was 7&#46;1 &#40;&#177; 5&#46;7&#41; years&#44; ranging from 0&#46;3 to 18 years and the female&#47;male ratio was 1&#44;14&#58;1&#46; 87 &#40;88&#37;&#41; of the patients had a chronic disease&#46;</p><p id="para0044" class="elsevierStylePara elsevierViewall">The mean number of teleconsultations for patients tested positive for SARS-Cov-2&#44; or in close contact with a person who received a positive RT-PCR test&#44; was 1&#46;7 &#40;&#177; 1&#46;0&#41; per patient&#44; ranging from 1 to 6&#46; 48 patients were seen through teleconsultation for one session&#44; 32 patients received two teleconsultations&#44; and 21 patients underwent three or more teleconsultations&#46; Of the 182 teleconsultations&#44; only 20 &#40;11&#37;&#41; were spontaneously sought out by the patients&#44; with the remaining being follow-up consultations after in-person consultation or hospitalization&#46;</p><p id="para0045" class="elsevierStylePara elsevierViewall">A higher median teleconsultation severity score was found in the teleconsultations of patients who tested positive or were in direct contact with a person with a confirmed diagnosis of COVID-19 compared to those who tested negative for SARS-Cov-2&#58; 3 &#40;1&#8211;7&#41; vs 2 &#40;0&#8211;8&#41;&#44; <span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;001&#46;</p><p id="para0046" class="elsevierStylePara elsevierViewall">Of the 182 teleconsultations&#44; 26 &#40;14&#37;&#41; were resolved with a doctor referring the patient to the emergency department for in-person care&#46; Fifteen patients &#40;58&#37;&#41; were referred in the first teleconsultation&#44; five patients &#40;20&#37;&#41; were referred in the second&#44; three patients &#40;11&#37;&#41; were referred in the third&#44; and three patients &#40;11&#37;&#41; in the fourth teleconsultation&#46;</p><p id="para0047" class="elsevierStylePara elsevierViewall">Of the patients referred for in-person consultation in the emergency department&#44; 20 &#40;77&#37;&#41; tested negative for SARS-Cov-2 and six &#40;23&#37;&#41; tested positive or had direct contact with a person with confirmed COVID-19 &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;03&#41;&#46; In 14 &#40;54&#37;&#41; of the 26 teleconsultations in which patients were referred to the emergency department&#44; the individuals had a severity score greater than or equal to 5 &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; Twelve individuals had a score less than 5 referred due to the physician&#39;s opinion or for clinical laboratory reassessment&#46; The reasons for referring patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0048" class="elsevierStylePara elsevierViewall">Out of the 20 patients who were referred to the emergency department and tested negative&#44; 14 patients were evaluated and discharged promptly&#46; Although one of the patients did not attend&#44; he was re-evaluated through telemedicine two days later and showed clinical improvement after measures taken by his mother at home&#46; Another four patients &#40;21&#37;&#41; were admitted&#44; three in the pediatric ward and one in PICU&#46; No deaths&#44; adverse events&#44; or delayed diagnosis were recorded&#46;</p><p id="para0049" class="elsevierStylePara elsevierViewall">Of the six patients tested who were positive or in direct contact with a person diagnosed with COVID-19&#44; four referrals were of different patients with one patient being referred twice&#46; Of these five individuals&#44; only two patients &#40;33&#37;&#41; were hospitalized after evaluation&#44; both in the pediatric ward&#46;</p></span><span id="sec0011" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0017">PATHMO satisfaction</span><p id="para0050" class="elsevierStylePara elsevierViewall">Of the 255 teleconsultations during April and June 2020&#44; 50 guardians &#40;19&#46;6&#37;&#41; answered the satisfaction questionnaire &#40;Appendix 1&#41;&#46; 72&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;36&#41; answered that it took less than 30&#160;min to speak to the doctor&#44; with another 16&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;8&#41; waiting up to 1&#160;hour for the teleconsultation&#46; The demographic data of those who answered the questionnaire are described in <a class="elsevierStyleCrossRef" href="#fig0002">Figure 2</a>&#46; <a class="elsevierStyleCrossRef" href="#fig0003">Figure 3</a> shows the results of the satisfaction questionnaire on a Likert scale&#46;</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia><elsevierMultimedia ident="fig0003"></elsevierMultimedia><p id="para0051" class="elsevierStylePara elsevierViewall">Although most participants did not have any difficulties&#44; 18&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;9&#41; had reported problems with connection and 12&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;6&#41; reported difficulty with the use of the application &#40;Google Hangouts&#41;&#46;</p></span><span id="sec0012" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0018">Discussion</span><p id="para0052" class="elsevierStylePara elsevierViewall">Telemedicine is becoming part of medical services as the result of the growth in technology and communication&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> Although regulation surrounding telemedicine in Brazil is still restricted to the timeframe of the pandemic&#44;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> there is a strong movement from the medical population to extend this regulation&#46;</p><p id="para0053" class="elsevierStylePara elsevierViewall">The implementation of telemedicine has greatly contributed to providing services during the COVID-19 pandemic&#46; In this period&#44; the study&#39;s service had 1041 in-person consultations&#44; and about 24&#37; &#40;255 out of 1041&#41; of the total consultations were carried out by video call&#46; This represents a reduction in the circulation of populations at risk while allowing many patients to continue to be seen&#46;</p><p id="para0054" class="elsevierStylePara elsevierViewall">The leave of numerous health professionals due to the COVID-19 pandemic was a recurring problem in several health systems&#46; Thus&#44; the implementation of telemedicine services contributed to a reduction in the spread of the new coronavirus among the medical teams and allowed professionals in high-risk groups to work with greater security while in quarantine&#46;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a></p><p id="para0055" class="elsevierStylePara elsevierViewall">In addition to a decrease in exposure and a reduction in the circulation of individuals during the pandemic&#44;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a> teleconsultations allowed for the ability to save in regard to patient expenses for the public health system&#46; North American data has indicated that 76&#37; of consultations in the emergency department could be avoided with savings of up to &#36;733 per visit&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a> Considering the study population as overly complex&#44; this savings may be even greater since transport often requires advanced resources such as ambulance and oxygen transport&#46;</p><p id="para0056" class="elsevierStylePara elsevierViewall">The use of already available software&#44; some of which was free &#40;e&#46;g&#46;&#44; Google Hangouts and WhatsApp&#41;&#44; and others which were already being used in the hospital &#40;e&#46;g&#46;&#44; the electronic medical record where the teleconsultation was recorded&#41;&#44; allowed for a fast&#44; efficient&#44; and low-cost implementation of PATMHO&#46; Moreover&#44; the training of the team was facilitated via software that was already part of their daily lives and was increasingly used during the pandemic&#46;</p><p id="para0057" class="elsevierStylePara elsevierViewall">The present study is one of the first to propose a severity score developed specifically for pediatric care through direct doctor-patient teleconsultation&#46; The preliminary assessment of the study&#39;s severity score showed that patients were referred for in-person care in teleconsultations in which the score was higher&#44; even with some patients remaining hospitalized&#46; In the current context of COVID-19&#44; the score related to the disease was included in the score&#44; increasing the score rating in these patients&#46;</p><p id="para0058" class="elsevierStylePara elsevierViewall">However&#44; from what was observed within the preliminary results&#44; the resulting score on the question for the presence of COVID-19 does not seem to be associated with the referral of patients as most of the in-person consultations were with patients who were negative for SARS-Cov-2 or did not have direct contact with someone who had been exposed to SARS-Cov-2&#46; The study&#39;s score will be validated in terms of the decision-making process in a future study to assess patient safety&#46;</p><p id="para0059" class="elsevierStylePara elsevierViewall">Comparing the present study&#39;s results of referrals for in-person care with those obtained by Haimi et al&#46; &#40;2020 evaluated 339 children attended by an Israeli pediatric screening service by a phone call between 2014 and 2017&#44; the referral rate was lower &#40;14&#37; vs 28&#46;3&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0026"><span class="elsevierStyleSup">26</span></a> suggesting that teleconsultation may be more advantageous than consultation by telephone when it comes to assessing the need for referral of in-person emergency consultations&#46;</p><p id="para0060" class="elsevierStylePara elsevierViewall">Teleconsultation service was evaluated by users as practical&#44; fast&#44; and efficient&#44; with a good resolution of questions and an understanding of the recommendations&#46; A high degree of end-user satisfaction was observed in this preliminary phase of the present study&#46; A retrospective cohort study conducted in New York during the pandemic also showed a high degree of patient satisfaction in medical service through the use of video&#44;<a class="elsevierStyleCrossRef" href="#bib0027"><span class="elsevierStyleSup">27</span></a> which reinforces the importance of PATMHO now that there is a global concern on exposure to COVID-19&#46; Connection difficulties were the greatest challenge faced by end-users&#44; exposing the need for investment in technology and greater digital inclusion of the Brazilian population&#46;<a class="elsevierStyleCrossRef" href="#bib0028"><span class="elsevierStyleSup">28</span></a></p><p id="para0061" class="elsevierStylePara elsevierViewall">The limitations of the study in this preliminary phase include a small population sample and complex health needs&#46; Most of the teleconsultations were a follow-up meeting involving a reassessment&#46; As it is a new service&#44; there was a low investment in advertising&#44; with spontaneous demand being low&#46; However&#44; the aim is for growth in all remote medical services post-pandemic&#44; which most likely will also happen with emergency-related care&#46;</p><p id="para0062" class="elsevierStylePara elsevierViewall">Moreover&#44; the implementation of telemedicine services within medical residency creates a teaching environment&#44; enabling the introduction of telemedicine as part of the medical residency program in pediatrics&#44; pediatric emergencies&#44; or even as part of undergraduate education&#46; Two systematic reviews on telemedicine education and training&#44; one from 2016<a class="elsevierStyleCrossRef" href="#bib0029"><span class="elsevierStyleSup">29</span></a> and another from 2020&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">30</span></a> demonstrate that the literature on this subject is limited and requires greater exploration&#46;</p></span><span id="sec0013" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0019">Conclusion</span><p id="para0063" class="elsevierStylePara elsevierViewall">This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service&#46; The program developed was low cost&#44; generated great satisfaction in guardians&#44; and increased patient safety&#46; In this way&#44; PATMHO may serve as a reference for other public services in Brazil and other developing countries&#46;</p><p id="para0064" class="elsevierStylePara elsevierViewall">The present study&#39;s preliminary results are encouraging and demonstrate the potential of the program&#46; Further studies are needed to demonstrate the benefits in populations with different health needs&#44; the impact of telemedicine health services over a longer period of time&#44; and the use of this service outside of the COVID-19 pandemic&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objective</span><p id="spara005" class="elsevierStyleSimplePara elsevierViewall">In Brazil&#44; telemedicine was allowed as an exception during the coronavirus disease &#40;COVID-19&#41; pandemic&#46; Despite its recognized value and availability&#44; telemedicine is not universally used&#44; suggesting that some barriers prevent its adoption and acceptance within the community&#46; This study aims to describe the implementation of a low-cost telemedicine service in a pediatric hospital in Brazil&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Method</span><p id="spara006" class="elsevierStyleSimplePara elsevierViewall">Retrospective descriptive study reporting the first three months &#40;April to June 2020&#41; of the experience of implementing a low-cost telemedicine emergency care program in a public tertiary hospital&#46; The service was available to patients up to 18 years of age enrolled in this hospital&#46; A tool for assessing the severity of the patient was developed&#44; the aim of standardizing the procedure&#44; while maintaining quality and safety&#46; Guardian&#39;s satisfaction was assessed with a questionnaire sent after teleconsultations&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara007" class="elsevierStyleSimplePara elsevierViewall">255 teleconsultations were carried out with 140 different patients&#46; Of the total consultations&#44; 182 were from 99 patients that had performed the Real-Time Polymerase Chain Reaction &#40;RT-PCR&#41; test for the new coronavirus &#40;SARS-Cov-2&#41; or had direct contact with a person known to be positive for COVID-19&#46; Only 26 &#40;14&#37;&#41; were referred to an in-person consultation&#46; No deaths&#44; adverse events or delayed diagnosis were recorded&#46; 86&#37; of the patients who answered the satisfaction questionnaire were satisfied and 92&#37; would use telemedicine again&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusion</span><p id="spara008" class="elsevierStyleSimplePara elsevierViewall">This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service&#44; serving as a reference for future implementation in other public services in Brazil and developing countries&#46;</p></span>"
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                      "titulo" => "Telemedicine for general pediatrics"
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                          "autores" => array:2 [
                            0 => "L&#46; Taylor"
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                      "titulo" => "Use of telemedicine to screen patients in the emergency department&#58; matched Cohort study evaluating efficiency and patient safety of telemedicine"
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                          "etal" => true
                          "autores" => array:6 [
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                            3 => "G&#46; Kelen"
                            4 => "J&#46;W&#46; Fan"
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                    0 => array:1 [
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                      "titulo" => "Implementation of a pediatric emergency telemedicine program"
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                            0 => "J&#46;W&#46; Kim"
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                            3 => "B&#46; Hafeez"
                            4 => "D&#46; Listman"
                            5 => "M&#46; Lame"
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                      "titulo" => "Pediatric telemedicine use in united states emergency departments"
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                            2 => "K&#46;S&#46; Zachrison"
                            3 => "R&#46;D&#46; Freid"
                            4 => "A&#46;F&#46; Sullivan"
                            5 => "J&#46;A&#46; Espinola"
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                    0 => array:2 [
                      "doi" => "10.1111/acem.13629"
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                        "fecha" => "2018"
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                            4 => "W&#46;F&#46; Gattaz"
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                      "Revista" => array:4 [
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                      "titulo" => "Antibiotic prescribing during pediatric direct-to-consumer telemedicine visits"
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                            0 => "K&#46;N&#46; Ray"
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                        "tituloSerie" => "Pediatrics"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Barriers and enablers to implementing a virtual tertiary-regional Telemedicine Rounding and Consultation &#40;TRAC&#41; model of inpatient pediatric care using the Theoretical Domains Framework &#40;TDF&#41; approach&#58; a study protocol"
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                  "referenciaCompleta" => "Resposta E&#46;&#44; Of&#237;cio M&#46;E&#46; OF&#205;CIO CFM No 1756&#47;2020 &#8211; COJUR &#91;Internet&#93;&#46; Org&#46;br&#46; &#91;cited 2021 May 10&#93;&#46; Available from&#58;<a target="_blank" href="https://portal.cfm.org.br/images/PDF/2020_oficio_telemedicina.pdf">https&#58;&#47;&#47;portal&#46;cfm&#46;org&#46;br&#47;images&#47;PDF&#47;2020&#95;oficio&#95;telemedicina&#46;pdf</a>"
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                    0 => array:2 [
                      "titulo" => "Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome"
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                        0 => array:2 [
                          "etal" => true
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                            0 => "M&#46;F&#46; Pereira"
                            1 => "N&#46; Litvinov"
                            2 => "S&#46;C&#46; Farhat"
                            3 => "A&#46;P&#46; Eisencraft"
                            4 => "M&#46;A&#46; Gibelli"
                            5 => "W&#46;B&#46; Carvalho"
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                    0 => array:2 [
                      "doi" => "10.6061/clinics/2020/e2209"
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Original article
Fast, cheap and feasible: Implementation of pediatric telemedicine in a public hospital during the Covid-19 pandemic
Rafael da Silva Giannasi Severinia,b,
Corresponding author
rafaelgiannasi@gmail.com

Corresponding author.
, Pedro Carpini de Oliveiraa,b, Thomaz Bittencourt Coutoa,b, Hany Simon Juniora,b, Anarella Penha Meirelles de Andradea,b, Danilo Yamamoto Nanbua,b, Sylvia C.L. Farhata,b, Cláudio Schvartsmana,b
a Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Departamento de Emergência, Universidade de São Paulo, São Paulo, SP, Brazil
b Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, SP, Brazil
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          "en" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">PATHMO user satisfaction results on a Likert scale &#8211; Question 1&#58; 1&#40;Not satisfied&#41; to 5 &#40;Totally satisfied&#41;&#44; Question 2&#58; 1 &#40;It was very difficult to access the system&#41; to 5 &#40;It was very easy to access the system&#41;&#44; Question 3&#58; 1 &#40;I do not understand what I need to do&#41; to 5 &#40;I definitely understand what I need to do&#41;&#44; Question 4&#58; 1 &#40;None of my issues have been resolved&#41; to 5 &#40;All my issues have been resolved&#41;&#44; Question 5&#58; 1 &#40;He &#47; She was not attentive&#41; to 5 &#40;He &#47; She was very attentive&#41;&#44; Question 6&#58; 1 &#40;Not comfortable&#41; to 5 &#40;Completely comfortable&#41;&#44; Question 7&#58; 1 &#40;I would not use telemedicine again&#41; to 5 &#40;I would definitely use telemedicine again&#41;&#44; Question 8&#58; 1 &#40;I would not recommend&#41; to 5 &#40;I would definitely recommend&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Introduction</span><p id="para0013" class="elsevierStylePara elsevierViewall">Telemedicine has advantages over telephone communication&#44; such as interactions in real-time while seeing and hearing each other from the comfort of patient&#96;s homes&#46; It can result in a higher quality of clinical approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0001"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="para0014" class="elsevierStylePara elsevierViewall">Telemedicine has expanded considerably over the past two decades&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Benefits include a possibility of remote diagnosis&#44; the ability to monitor patients with chronic diseases &#91;5&#93; and provision of emergency care&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Also contributes towards reducing the number of visits to the hospital&#44; stress due to commuting to the hospital&#44; and hospital-related stress&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> In addition&#44; telemedicine reduces school and work absenteeism for patients and guardians&#46; Telehealth can promote a cost reduction and allocate resources to improve the quality of patient care&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a></p><p id="para0015" class="elsevierStylePara elsevierViewall">Pediatric remote care offers the unique opportunity and additional benefit of seeing children where they live&#46; Through the use of telemedicine&#44; doctors can safely observe young individuals in a calm and comfortable environment while assessing their clinical condition without the influence of additional stressors&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0016" class="elsevierStylePara elsevierViewall">Studies have shown that around 80&#37; of telemedicine consultations between doctors and patients are being conducted properly without the need for in-person visits to the emergency department&#46; Further&#44; they have reported good user satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0017" class="elsevierStylePara elsevierViewall">Despite its recognized value and availability&#44; telemedicine is not universally used&#44; suggesting that some barriers prevent its adoption and acceptance within the community&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> Some barriers to the use of telemedicine include technological challenges&#44; workflow integration&#44; perceived usefulness&#44; regulatory issues and costs for the hospital services with equipment&#44; personal and dedicated connection&#44; and for the users&#44; which require a minimum internet band and a computer&#44; tablet or smartphone to be able to use this service&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> So&#44; the inclusion of this tool in public services involves even greater challenges&#46;</p><p id="para0018" class="elsevierStylePara elsevierViewall">The Brazilian government and Ministry of Health&#44; motivated by the current COVID-19 pandemic&#44; have recently allowed the use of telemedicine services&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> The Institute is a tertiary university center&#44; a reference for the care of pediatric patients with chronic health conditions&#46; Although COVID-19 is not associated with severe respiratory manifestations in children&#44;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> most patients in The Institute have comorbidities&#44; thus being considered a risk population for COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> In the pandemic scenario&#44; telemedicine could contribute to avoiding unnecessary visits to the emergency department and for the rational use of health services&#46; In response to the pandemic&#44; The Hospital Telemedicine Emergency Care Program &#40;PATMHO- &#8220;Pronto Atendimento em Telemedicina Hospitalar&#8221;&#44; in Portuguese&#41; was developed in the pediatric emergency department of this tertiary pediatric public hospital&#46;</p><p id="para0019" class="elsevierStylePara elsevierViewall">Using a severity screening score for teleconsultation can be challenging&#46; Some screening tools have been developed to assess the severity in pediatric telecare and have demonstrated satisfactory results&#44; reinforcing that telemedicine can be used to safely assess patients remotely&#46; However&#44; the majority of studies have focused on the use of screening tools for doctor-to-doctor telecare in an intensive care environment&#46;<a class="elsevierStyleCrossRefs" href="#bib0011"><span class="elsevierStyleSup">11&#8211;13</span></a> Due to the scarcity of specific scores for pediatric teleconsultation&#44; the authors developed a severity score specifically for this study&#46;</p><p id="para0020" class="elsevierStylePara elsevierViewall">In this article&#44; the authors describe the challenges and process for implementing a telemedicine program for pediatric emergencies&#46; The authors also present the severity score developed for the PATMHO implementation&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">Additionally&#44; preliminary results on care during the COVID-19 pandemic are discussed&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Materials and methods</span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Study design</span><p id="para0022" class="elsevierStylePara elsevierViewall">The retrospective descriptive study reporting on the first three months &#40;April to June 2020&#41; of the authors&#8217; experience implementing a telemedicine emergency care program in a public tertiary hospital&#46; The study shows preliminary data&#44; mainly on user satisfaction&#46;</p><p id="para0023" class="elsevierStylePara elsevierViewall">The study was submitted and approved by the Ethics and Research Committee of the Hospital&#46; The guardians of the patients provided oral consent before the start of the teleconsultation and were informed about the limitations associated with this form of care&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Platform and security</span><p id="para0024" class="elsevierStylePara elsevierViewall">The teleconsultations were carried out through Google Hangouts&#44; a free software program with adequate safety certifications&#44; in compliance with the Brazilian Health Insurance Portability and Responsibility Law &#40;Lei de Portabilidade e Responsabilidade de Seguros de Sa&#250;de - HIPAA&#41;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> and the Brazilian general data protection law&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0025" class="elsevierStylePara elsevierViewall">The authors use HIPAA-compliant Google Hangouts configuration&#46; All video calls are encrypted in transit between the customer and Google and no images were recorded during the calls&#44; ensuring privacy&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a></p><p id="para0026" class="elsevierStylePara elsevierViewall">The teleconsultation was documented in the patient&#39;s digital medical record&#44; the same that is already used in the hospital for in-person consultations&#46; It guarantees the safety of patient data due to the study&#39;s system has all certifications in compliance with Brazilian laws&#46; All teleconsultations are digitally signed by the attending physician&#46;</p><p id="para0027" class="elsevierStylePara elsevierViewall">The teleconsultation room had a DELL ALL IN ONE Computer&#44; Intel Core i5-8265 U Processor 8GB &#40;1&#160;&#215;&#160;8GB&#41;&#44; DDR4&#44; 2400&#160;MHz HD 1&#160;TB built-in webcam&#44; and microphone&#44; with Windows 10 Pro Single Language&#44; 64 bits&#44; associated to a 22-inch monitor&#44; and an Epson Perfection V19 SCANNER&#46; All of the infrastructures for the study was already available at the hospital and were relocated for use in telemedicine&#46; Users could use any of the Google Hangouts-compatible devices &#40;e&#46;g&#46;&#44; cell phone&#44; tablet&#44; or computer&#41; with a camera&#44; microphone and internet access&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">The teleconsultation</span><p id="para0028" class="elsevierStylePara elsevierViewall">Consultations were carried out via video conference in real-time by a doctor from the pediatric emergency team&#44; accompanied by a pediatric resident&#46; The entire medical team in the emergency department&#44; including residents&#44; was trained and prepared for the teleconsultation&#46;</p><p id="para0029" class="elsevierStylePara elsevierViewall">The step-by-step instructions on how to access the telemedicine emergency care were advertised to the parents&#47;guardians by email and through social networks&#46;</p><p id="para0030" class="elsevierStylePara elsevierViewall">After the teleconsultation&#44; an email was sent to the guardians&#44; including general recommendations&#44; medication prescriptions &#40;if necessary&#41;&#44; and the satisfaction questionnaire &#40;Appendix 1&#41;&#46; Teleconsultations were carried as indicated in <a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0031" class="elsevierStylePara elsevierViewall">Patients who were referred for reassessment through telemedicine &#40;after being discharged from the in-person consultation&#41; received a folder with step-by-step instructions for participating in PATMHO &#40;Appendix 2&#41;&#46; The parent&#47;guardian&#96;s mobile number was recorded&#44; and the teleconsultation was scheduled&#46; On the day of the consultation&#44; the guardian contacted the hospital using Google Hangouts or the pediatric resident contacted them directly by phone or WhatsApp to remind them and helping with any access difficulties&#46;</p><p id="para0032" class="elsevierStylePara elsevierViewall">A follow-up could be carried out through a new teleconsultation&#44; depending on the physician&#39;s medical judgment&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Population of study</span><p id="para0033" class="elsevierStylePara elsevierViewall">All patients were between the ages of 0 and 18 years of age&#44; currently treated at inpatient or outpatient services of the study&#39;s hospital&#44; were eligible to use PATMHO&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">The patients who participated were divided into two groups&#58; those that spontaneously sought the PATMHO services&#44; and patients that sought in-person care and were then referred for re-evaluation through telemedicine within 48&#160;h&#46; They were also divided into suspected or confirmed cases of COVID-19 or other pathologies&#46;</p></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Evaluation of satisfaction</span><p id="para0035" class="elsevierStylePara elsevierViewall">The email that was sent at the end of the teleconsultation included a satisfaction survey to be answered anonymously by the guardians &#40;Appendix 1&#41;&#46; The Telemedicine Satisfaction Questionnaire &#40;TSQ&#41; was adapted for the use of this study&#46; The TSQ was developed in 2003 and has demonstrated a high level of reliability&#44; validity&#44; and consistency&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> Questions regarding the guardians&#44; such as degree of relationship with the patient&#44; age&#44; and education level were included&#46;</p></span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Development of a severity score for teleconsultation</span><p id="para0036" class="elsevierStylePara elsevierViewall">The study&#39;s PATMHO screening score &#40;Appendix 3&#41; was developed based on early warning scores and the recognition of physiological changes such as the Pediatric Observation Priority Score&#44;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> the Pediatric Assessment Triangle&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> the Pediatric Early Warning Score&#44;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> and the screening score used in the Institute Emergency Department&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> This score was developed in the context of the COVID-19 pandemic&#44; requiring future modifications&#46;</p><p id="para0037" class="elsevierStylePara elsevierViewall">In the study&#39;s score&#44; the authors included comorbidities considered as a risk factor for developing severe forms of COVID-19&#44;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> exposure to COVID-19&#44; assessment of the level of consciousness&#44; circulatory and respiratory assessment&#44; and the last assessment item called potential risk of urgency&#46;</p><p id="para0038" class="elsevierStylePara elsevierViewall">Only considering a patient&#39;s vital signs does not seem to be the most appropriate way to identify critically ill patients in emergency departments&#46;<a class="elsevierStyleCrossRefs" href="#bib0019"><span class="elsevierStyleSup">19&#8211;22</span></a> Assessing vital signs&#44; such as heart rate&#44; through teleconsultation is very difficult&#46; Interestingly&#44; some screening systems include the overall impression of the doctor in their classification despite the clinical diagnosis&#46; For this last assessment item&#44; a physician&#39;s knowledge and experience are necessary&#44; but not sufficient&#46; An important factor in this context is the doctor&#39;s gut instinct or sixth sense&#46;<a class="elsevierStyleCrossRefs" href="#bib0019"><span class="elsevierStyleSup">19&#8211;22</span></a></p><p id="para0039" class="elsevierStylePara elsevierViewall">The severity score varies from 0 to 35 points&#46; A value greater than or equal to 5 is considered a baseline value for an emergency pediatrician to encourage the attendance of in-person emergency service&#46; This value was determined through the consensus of specialists in pediatric emergency aiming to be more sensitive than specific&#46; The cut point validation and evaluation of the severity score will be carried out in a future study&#46;</p></span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Statistical analysis</span><p id="para0040" class="elsevierStylePara elsevierViewall">Continuous variables were described as means and standard deviations or as medians &#40;variation&#41;&#44; according to the Shapiro&#8211;Wilk test&#46; Categorical variables were described in percentage terms&#46; Means or medians were compared using either Student&#39;s <span class="elsevierStyleItalic">t</span>-test or the Mann&#8211;Whitney U test&#44; as applicable&#46; Categorical variables were compared using Fisher&#39;s exact test&#46;</p><p id="para0041" class="elsevierStylePara elsevierViewall">For all statistical tests&#44; the significance level was set at 5&#37; &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;05&#41;&#46; Statistical analyses were performed using SPSS software&#44; version 22 &#40;IBM Corporation&#44; Armonk&#44; NY&#44; USA&#41;&#46;</p></span></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0016">Results</span><p id="para0042" class="elsevierStylePara elsevierViewall">From April to June 2020&#44; 255 teleconsultations were carried out with 140 different patients&#44; 122 &#40;87&#46;1&#37;&#41; of which had some form of chronic disease&#46;</p><p id="para0043" class="elsevierStylePara elsevierViewall">Of the total consultations&#44; 182 were from 99 patients who underwent RT-PCR exam for SARS-Cov-2 at some point or had direct contact with a person known to be positive for COVID-19&#46; The mean age of these patients was 7&#46;1 &#40;&#177; 5&#46;7&#41; years&#44; ranging from 0&#46;3 to 18 years and the female&#47;male ratio was 1&#44;14&#58;1&#46; 87 &#40;88&#37;&#41; of the patients had a chronic disease&#46;</p><p id="para0044" class="elsevierStylePara elsevierViewall">The mean number of teleconsultations for patients tested positive for SARS-Cov-2&#44; or in close contact with a person who received a positive RT-PCR test&#44; was 1&#46;7 &#40;&#177; 1&#46;0&#41; per patient&#44; ranging from 1 to 6&#46; 48 patients were seen through teleconsultation for one session&#44; 32 patients received two teleconsultations&#44; and 21 patients underwent three or more teleconsultations&#46; Of the 182 teleconsultations&#44; only 20 &#40;11&#37;&#41; were spontaneously sought out by the patients&#44; with the remaining being follow-up consultations after in-person consultation or hospitalization&#46;</p><p id="para0045" class="elsevierStylePara elsevierViewall">A higher median teleconsultation severity score was found in the teleconsultations of patients who tested positive or were in direct contact with a person with a confirmed diagnosis of COVID-19 compared to those who tested negative for SARS-Cov-2&#58; 3 &#40;1&#8211;7&#41; vs 2 &#40;0&#8211;8&#41;&#44; <span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;001&#46;</p><p id="para0046" class="elsevierStylePara elsevierViewall">Of the 182 teleconsultations&#44; 26 &#40;14&#37;&#41; were resolved with a doctor referring the patient to the emergency department for in-person care&#46; Fifteen patients &#40;58&#37;&#41; were referred in the first teleconsultation&#44; five patients &#40;20&#37;&#41; were referred in the second&#44; three patients &#40;11&#37;&#41; were referred in the third&#44; and three patients &#40;11&#37;&#41; in the fourth teleconsultation&#46;</p><p id="para0047" class="elsevierStylePara elsevierViewall">Of the patients referred for in-person consultation in the emergency department&#44; 20 &#40;77&#37;&#41; tested negative for SARS-Cov-2 and six &#40;23&#37;&#41; tested positive or had direct contact with a person with confirmed COVID-19 &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;03&#41;&#46; In 14 &#40;54&#37;&#41; of the 26 teleconsultations in which patients were referred to the emergency department&#44; the individuals had a severity score greater than or equal to 5 &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; Twelve individuals had a score less than 5 referred due to the physician&#39;s opinion or for clinical laboratory reassessment&#46; The reasons for referring patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0048" class="elsevierStylePara elsevierViewall">Out of the 20 patients who were referred to the emergency department and tested negative&#44; 14 patients were evaluated and discharged promptly&#46; Although one of the patients did not attend&#44; he was re-evaluated through telemedicine two days later and showed clinical improvement after measures taken by his mother at home&#46; Another four patients &#40;21&#37;&#41; were admitted&#44; three in the pediatric ward and one in PICU&#46; No deaths&#44; adverse events&#44; or delayed diagnosis were recorded&#46;</p><p id="para0049" class="elsevierStylePara elsevierViewall">Of the six patients tested who were positive or in direct contact with a person diagnosed with COVID-19&#44; four referrals were of different patients with one patient being referred twice&#46; Of these five individuals&#44; only two patients &#40;33&#37;&#41; were hospitalized after evaluation&#44; both in the pediatric ward&#46;</p></span><span id="sec0011" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0017">PATHMO satisfaction</span><p id="para0050" class="elsevierStylePara elsevierViewall">Of the 255 teleconsultations during April and June 2020&#44; 50 guardians &#40;19&#46;6&#37;&#41; answered the satisfaction questionnaire &#40;Appendix 1&#41;&#46; 72&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;36&#41; answered that it took less than 30&#160;min to speak to the doctor&#44; with another 16&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;8&#41; waiting up to 1&#160;hour for the teleconsultation&#46; The demographic data of those who answered the questionnaire are described in <a class="elsevierStyleCrossRef" href="#fig0002">Figure 2</a>&#46; <a class="elsevierStyleCrossRef" href="#fig0003">Figure 3</a> shows the results of the satisfaction questionnaire on a Likert scale&#46;</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia><elsevierMultimedia ident="fig0003"></elsevierMultimedia><p id="para0051" class="elsevierStylePara elsevierViewall">Although most participants did not have any difficulties&#44; 18&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;9&#41; had reported problems with connection and 12&#37; &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;6&#41; reported difficulty with the use of the application &#40;Google Hangouts&#41;&#46;</p></span><span id="sec0012" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0018">Discussion</span><p id="para0052" class="elsevierStylePara elsevierViewall">Telemedicine is becoming part of medical services as the result of the growth in technology and communication&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> Although regulation surrounding telemedicine in Brazil is still restricted to the timeframe of the pandemic&#44;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> there is a strong movement from the medical population to extend this regulation&#46;</p><p id="para0053" class="elsevierStylePara elsevierViewall">The implementation of telemedicine has greatly contributed to providing services during the COVID-19 pandemic&#46; In this period&#44; the study&#39;s service had 1041 in-person consultations&#44; and about 24&#37; &#40;255 out of 1041&#41; of the total consultations were carried out by video call&#46; This represents a reduction in the circulation of populations at risk while allowing many patients to continue to be seen&#46;</p><p id="para0054" class="elsevierStylePara elsevierViewall">The leave of numerous health professionals due to the COVID-19 pandemic was a recurring problem in several health systems&#46; Thus&#44; the implementation of telemedicine services contributed to a reduction in the spread of the new coronavirus among the medical teams and allowed professionals in high-risk groups to work with greater security while in quarantine&#46;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a></p><p id="para0055" class="elsevierStylePara elsevierViewall">In addition to a decrease in exposure and a reduction in the circulation of individuals during the pandemic&#44;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a> teleconsultations allowed for the ability to save in regard to patient expenses for the public health system&#46; North American data has indicated that 76&#37; of consultations in the emergency department could be avoided with savings of up to &#36;733 per visit&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a> Considering the study population as overly complex&#44; this savings may be even greater since transport often requires advanced resources such as ambulance and oxygen transport&#46;</p><p id="para0056" class="elsevierStylePara elsevierViewall">The use of already available software&#44; some of which was free &#40;e&#46;g&#46;&#44; Google Hangouts and WhatsApp&#41;&#44; and others which were already being used in the hospital &#40;e&#46;g&#46;&#44; the electronic medical record where the teleconsultation was recorded&#41;&#44; allowed for a fast&#44; efficient&#44; and low-cost implementation of PATMHO&#46; Moreover&#44; the training of the team was facilitated via software that was already part of their daily lives and was increasingly used during the pandemic&#46;</p><p id="para0057" class="elsevierStylePara elsevierViewall">The present study is one of the first to propose a severity score developed specifically for pediatric care through direct doctor-patient teleconsultation&#46; The preliminary assessment of the study&#39;s severity score showed that patients were referred for in-person care in teleconsultations in which the score was higher&#44; even with some patients remaining hospitalized&#46; In the current context of COVID-19&#44; the score related to the disease was included in the score&#44; increasing the score rating in these patients&#46;</p><p id="para0058" class="elsevierStylePara elsevierViewall">However&#44; from what was observed within the preliminary results&#44; the resulting score on the question for the presence of COVID-19 does not seem to be associated with the referral of patients as most of the in-person consultations were with patients who were negative for SARS-Cov-2 or did not have direct contact with someone who had been exposed to SARS-Cov-2&#46; The study&#39;s score will be validated in terms of the decision-making process in a future study to assess patient safety&#46;</p><p id="para0059" class="elsevierStylePara elsevierViewall">Comparing the present study&#39;s results of referrals for in-person care with those obtained by Haimi et al&#46; &#40;2020 evaluated 339 children attended by an Israeli pediatric screening service by a phone call between 2014 and 2017&#44; the referral rate was lower &#40;14&#37; vs 28&#46;3&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0026"><span class="elsevierStyleSup">26</span></a> suggesting that teleconsultation may be more advantageous than consultation by telephone when it comes to assessing the need for referral of in-person emergency consultations&#46;</p><p id="para0060" class="elsevierStylePara elsevierViewall">Teleconsultation service was evaluated by users as practical&#44; fast&#44; and efficient&#44; with a good resolution of questions and an understanding of the recommendations&#46; A high degree of end-user satisfaction was observed in this preliminary phase of the present study&#46; A retrospective cohort study conducted in New York during the pandemic also showed a high degree of patient satisfaction in medical service through the use of video&#44;<a class="elsevierStyleCrossRef" href="#bib0027"><span class="elsevierStyleSup">27</span></a> which reinforces the importance of PATMHO now that there is a global concern on exposure to COVID-19&#46; Connection difficulties were the greatest challenge faced by end-users&#44; exposing the need for investment in technology and greater digital inclusion of the Brazilian population&#46;<a class="elsevierStyleCrossRef" href="#bib0028"><span class="elsevierStyleSup">28</span></a></p><p id="para0061" class="elsevierStylePara elsevierViewall">The limitations of the study in this preliminary phase include a small population sample and complex health needs&#46; Most of the teleconsultations were a follow-up meeting involving a reassessment&#46; As it is a new service&#44; there was a low investment in advertising&#44; with spontaneous demand being low&#46; However&#44; the aim is for growth in all remote medical services post-pandemic&#44; which most likely will also happen with emergency-related care&#46;</p><p id="para0062" class="elsevierStylePara elsevierViewall">Moreover&#44; the implementation of telemedicine services within medical residency creates a teaching environment&#44; enabling the introduction of telemedicine as part of the medical residency program in pediatrics&#44; pediatric emergencies&#44; or even as part of undergraduate education&#46; Two systematic reviews on telemedicine education and training&#44; one from 2016<a class="elsevierStyleCrossRef" href="#bib0029"><span class="elsevierStyleSup">29</span></a> and another from 2020&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">30</span></a> demonstrate that the literature on this subject is limited and requires greater exploration&#46;</p></span><span id="sec0013" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0019">Conclusion</span><p id="para0063" class="elsevierStylePara elsevierViewall">This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service&#46; The program developed was low cost&#44; generated great satisfaction in guardians&#44; and increased patient safety&#46; In this way&#44; PATMHO may serve as a reference for other public services in Brazil and other developing countries&#46;</p><p id="para0064" class="elsevierStylePara elsevierViewall">The present study&#39;s preliminary results are encouraging and demonstrate the potential of the program&#46; Further studies are needed to demonstrate the benefits in populations with different health needs&#44; the impact of telemedicine health services over a longer period of time&#44; and the use of this service outside of the COVID-19 pandemic&#46;</p></span></span>"
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        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objective</span><p id="spara005" class="elsevierStyleSimplePara elsevierViewall">In Brazil&#44; telemedicine was allowed as an exception during the coronavirus disease &#40;COVID-19&#41; pandemic&#46; Despite its recognized value and availability&#44; telemedicine is not universally used&#44; suggesting that some barriers prevent its adoption and acceptance within the community&#46; This study aims to describe the implementation of a low-cost telemedicine service in a pediatric hospital in Brazil&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Method</span><p id="spara006" class="elsevierStyleSimplePara elsevierViewall">Retrospective descriptive study reporting the first three months &#40;April to June 2020&#41; of the experience of implementing a low-cost telemedicine emergency care program in a public tertiary hospital&#46; The service was available to patients up to 18 years of age enrolled in this hospital&#46; A tool for assessing the severity of the patient was developed&#44; the aim of standardizing the procedure&#44; while maintaining quality and safety&#46; Guardian&#39;s satisfaction was assessed with a questionnaire sent after teleconsultations&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara007" class="elsevierStyleSimplePara elsevierViewall">255 teleconsultations were carried out with 140 different patients&#46; Of the total consultations&#44; 182 were from 99 patients that had performed the Real-Time Polymerase Chain Reaction &#40;RT-PCR&#41; test for the new coronavirus &#40;SARS-Cov-2&#41; or had direct contact with a person known to be positive for COVID-19&#46; Only 26 &#40;14&#37;&#41; were referred to an in-person consultation&#46; No deaths&#44; adverse events or delayed diagnosis were recorded&#46; 86&#37; of the patients who answered the satisfaction questionnaire were satisfied and 92&#37; would use telemedicine again&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusion</span><p id="spara008" class="elsevierStyleSimplePara elsevierViewall">This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service&#44; serving as a reference for future implementation in other public services in Brazil and developing countries&#46;</p></span>"
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          "en" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">PATHMO user satisfaction results on a Likert scale &#8211; Question 1&#58; 1&#40;Not satisfied&#41; to 5 &#40;Totally satisfied&#41;&#44; Question 2&#58; 1 &#40;It was very difficult to access the system&#41; to 5 &#40;It was very easy to access the system&#41;&#44; Question 3&#58; 1 &#40;I do not understand what I need to do&#41; to 5 &#40;I definitely understand what I need to do&#41;&#44; Question 4&#58; 1 &#40;None of my issues have been resolved&#41; to 5 &#40;All my issues have been resolved&#41;&#44; Question 5&#58; 1 &#40;He &#47; She was not attentive&#41; to 5 &#40;He &#47; She was very attentive&#41;&#44; Question 6&#58; 1 &#40;Not comfortable&#41; to 5 &#40;Completely comfortable&#41;&#44; Question 7&#58; 1 &#40;I would not use telemedicine again&#41; to 5 &#40;I would definitely use telemedicine again&#41;&#44; Question 8&#58; 1 &#40;I would not recommend&#41; to 5 &#40;I would definitely recommend&#41;&#46;</p>"
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                      "titulo" => "Telemedicine for general pediatrics"
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                          "autores" => array:2 [
                            0 => "L&#46; Taylor"
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                      "doi" => "10.3928/19382359-20191119-01"
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                      "titulo" => "Use of telemedicine to screen patients in the emergency department&#58; matched Cohort study evaluating efficiency and patient safety of telemedicine"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            3 => "G&#46; Kelen"
                            4 => "J&#46;W&#46; Fan"
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                    0 => array:1 [
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                      "titulo" => "Implementation of a pediatric emergency telemedicine program"
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                            0 => "J&#46;W&#46; Kim"
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                            3 => "B&#46; Hafeez"
                            4 => "D&#46; Listman"
                            5 => "M&#46; Lame"
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                      "titulo" => "Pediatric telemedicine use in united states emergency departments"
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                            2 => "K&#46;S&#46; Zachrison"
                            3 => "R&#46;D&#46; Freid"
                            4 => "A&#46;F&#46; Sullivan"
                            5 => "J&#46;A&#46; Espinola"
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                    0 => array:2 [
                      "doi" => "10.1111/acem.13629"
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                        "fecha" => "2018"
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                      "Revista" => array:4 [
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                      "titulo" => "Antibiotic prescribing during pediatric direct-to-consumer telemedicine visits"
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                            0 => "K&#46;N&#46; Ray"
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                        "tituloSerie" => "Pediatrics"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Barriers and enablers to implementing a virtual tertiary-regional Telemedicine Rounding and Consultation &#40;TRAC&#41; model of inpatient pediatric care using the Theoretical Domains Framework &#40;TDF&#41; approach&#58; a study protocol"
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                            2 => "J&#46; Curran"
                            3 => "D&#46;W&#46; Johnson"
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                            5 => "J&#46;A&#46; Bailey"
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                    0 => array:1 [
                      "Revista" => array:4 [
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                0 => array:1 [
                  "referenciaCompleta" => "Resposta E&#46;&#44; Of&#237;cio M&#46;E&#46; OF&#205;CIO CFM No 1756&#47;2020 &#8211; COJUR &#91;Internet&#93;&#46; Org&#46;br&#46; &#91;cited 2021 May 10&#93;&#46; Available from&#58;<a target="_blank" href="https://portal.cfm.org.br/images/PDF/2020_oficio_telemedicina.pdf">https&#58;&#47;&#47;portal&#46;cfm&#46;org&#46;br&#47;images&#47;PDF&#47;2020&#95;oficio&#95;telemedicina&#46;pdf</a>"
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                    0 => array:2 [
                      "titulo" => "Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;F&#46; Pereira"
                            1 => "N&#46; Litvinov"
                            2 => "S&#46;C&#46; Farhat"
                            3 => "A&#46;P&#46; Eisencraft"
                            4 => "M&#46;A&#46; Gibelli"
                            5 => "W&#46;B&#46; Carvalho"
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                      "doi" => "10.6061/clinics/2020/e2209"
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                        "tituloSerie" => "Clinics"
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Article information
ISSN: 00217557
Original language: English
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