A picture is worth a thousand words: critical care consultations to emergency departments using telemedicine

Telehealth in pediatric emergency medicine

Modern technologies and contemporary clinical practice have set the stage for the integration of telehealth into existing models of healthcare. These models of telehealth care offer novel opportunities for advancing pediatric emergency care. In this manuscript, we introduce applications of telehealth in pediatric emergency medicine (PEM) with the pediatric emergency department (ED) both as originating site and distant site. We present barriers to adoption, implementation, and sustaining PEM telehealth programs, as well as strategies to overcome those. We discuss cost and finances as well as policy considerations and implications. Lastly, we review strategies for evaluation to assess program impact and ensure sustainability.

Essentials of Pediatric Emergency Medicine Fellowship: Part 3: Clinical Education and Experience

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.

Preventable transfers in pediatric trauma: A 10-year experience at a level I pediatric trauma center

BACKGROUND

Injured children are often treated at one facility then transferred to another that specializes in pediatric trauma care. The purpose of this study was to identify and characterize potentially preventable transfers (PT) to a freestanding level-I pediatric trauma center.

METHODS

Children with traumatic injuries transferred between 2003 and 2013 were retrospectively analyzed. A PT was defined as a child who was discharged within 36hours of arrival without surgical intervention or advanced imaging studies.

RESULTS

During this period, 6380 children were transferred, with head injury being the most common injury. 61% had CT imaging performed before transfer. The mean age was 6.9years, mean injury severity score (ISS) 10.4, and median transfer distance 37miles. 27% of these transfers were classified as PT. Air transport was used in 15% at mean charge of $18,574. 29% were discharged from the emergency department. When compared, PTs were younger (6.0 vs. 7.2years, p<0.001), with lower median ISS (5 vs. 9, p<0.001), shorter median LOS (15 vs. 43.6hours, p<0.001), and less PICU admissions (6% vs. 34%, p<0.001).

CONCLUSION

A significant number of pediatric trauma transfers can be classified as preventable. Reducing preventable transfers could offer opportunities for improving value in a trauma care system.

The role of telemedicine in pediatric critical care

Telemedicine technologies involve real-time, live, interactive video and audio communication and allow pediatric critical care physicians to have a virtual presence at the bedsides of critically ill children. Telemedicine use is increasing and will be a common in remote emergency departments, inpatient wards, and intensive care units for pediatric care. Hospitals and physicians that use telemedicine technologies provide higher quality of care, are more efficient in resource use with improved cost-effectiveness, and have higher satisfaction among patients, parents, and remote providers. More research will result in improved access to pediatric critical care expertise.

Patient Outcomes of an International Telepediatric Cardiac Critical Care Program

BACKGROUND

An optimal model for telemedicine use in the international care setting has not been established. Our objective was to describe variables associated with patient outcome during the implementation of an international pediatric cardiac critical care (PCCC) telemedicine program.

MATERIALS AND METHODS

A retrospective review was performed of clinical records and a telemedicine database of patients admitted to the cardiac intensive care unit (CICU) at the Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, during the initial 10 months of our program, compared with patients admitted during a previous period. Information collected included demographic data, cardiac diagnosis and associated factors, Risk Adjustment for Congenital Heart Surgery (RACHS)-1 classification, and perioperative events. Primary outcome was composed of CICU and hospital mortality. Secondary outcomes were CICU and hospital length of stay (LOS).

RESULTS

Of the 553 patients who were included, teleconsultation was done for 71 (12.4%), with a total of 156 encounters, including 19 for patients on extracorporeal membrane oxygenation. Three hundred twenty-one recommendations were given, and 42 real-time interventions were documented. RACHS-1 distribution was similar between study periods (p=0.427). Teleconsulted patients were significantly younger (44 versus 24 months; p=0.03) and had higher surgical complexity than nonteleconsulted patients (p=0.01). RACHS-1 adjusted hospital survival was similar between study periods. CICU and hospital LOS intervals were significantly shorter in the telemedicine period (10 versus 17 days [p=0.02] and 22 versus 28 days [p<0.001]). In surgical cases, preoperative CICU LOS was significantly shorter (3 versus 6 days; p<0.001). Variables associated with hospital mortality were higher RACHS-1 categories, lower weight, bypass time longer than 150 min, and use of circulatory arrest, as well as the presence of sepsis or necrotizing enterocolitis. Those associated with increased LOS were lower weight, extracorporeal membrane oxygenation, and cross-clamp time longer than 60 min.

CONCLUSIONS

An international telemedicine service in PCCC was associated with lower CICU and hospital LOS. Prospective telemedicine interventions aimed to decrease mortality and LOS should focus on patients with higher RACHS-1 categories, lower-weight infants, and those with prolonged operative time and selective perioperative complications.

Stabilisation and Transport of the Critically Ill Child

Since the Department of Health Report ‘Paediatric Intensive Care: A framework for the future’ in 1997, paediatric intensive care services have been centralised and 24-hour retrieval services developed. However, all hospitals admitting critically ill children must be able to resuscitate and stabilise prior to retrieval, and occasionally undertake the ‘time-critical’ transfers themselves. This article reviews the clinical and organisational skills involved in the retrieval process, and also suggests ways in which knowledge and skills can be maintained.

The impact of telemedicine intensivist support and a pediatric hospitalist program on a community hospital

BACKGROUND

Because of centralization of care, pediatric patients often require transfer for subspecialty care. We evaluated the impact of telemedicine critical care consultation and a pediatric hospitalist program on enabling patients to remain at a community hospital.

PATIENTS AND METHODS

This is a retrospective chart review of pediatric patients at a community hospital receiving critical care consultation from a tertiary children's hospital from January 2006 to October 2009. Patient cohorts differed by modality of intensivist consultation (telephone versus telemedicine) and modality of inpatient ward care at the community hospital (primary care physician versus hospitalist). Patients were compared for differences in transfer rate and rate of diversion from the pediatric intensive care unit to the tertiary ward.

RESULTS

One hundred fifty-three charts were analyzed: 41 from prior to hospitalist and telemedicine implementation (Cohort 1), 56 from post-implementation of telemedicine but pre-hospitalist program (Cohort 2), and 56 after implementation of both the telemedicine and hospitalist programs (Cohort 3). Baseline data did not differ among cohorts. Transfer rates after intensivist consultation were lower after implementation of telemedicine consultation (100%, 85.7%, and 87.5% in Cohorts 1-3, respectively; p=0.04). The proportion of transferred patients who were diverted to the tertiary ward decreased over time (19.5%, 14.5%, and 6.1% in Cohorts 1-3, respectively; p=0.003).

CONCLUSIONS

Telemedicine consultation between pediatric intensivists and community hospital physicians combined with a pediatric hospitalist program at the community hospital has the potential to improve triage of pediatric patients and reduce the need to transfer patients.

Telemedicine in the pediatric intensive care unit

Telemedicine technologies involve real-time, live, interactive video and audio communication and allow pediatric critical care physicians to have a virtual presence at the bedside of any critically ill child. Telemedicine use is increasing and will be a common technology in remote emergency departments, inpatient wards, and pediatric intensive care units. There is mounting data that demonstrate that the use of telemedicine technologies can result in higher quality of care, more efficient resource use and improved cost-effectiveness, and higher satisfaction among patients, parents, and remote providers compared to current models of care.

The Role of Telemedicine in Treating the Critically Ill

Telemedicine use has been increasing exponentially and is expected to become a common tool in remote emergency departments, inpatient wards, and ICUs for acute care. Telemedicine involves real-time, live interactive high-definition video and audio communication that allows critical care physicians to have a virtual presence at the bedside of any critically ill patient. There is increasing data to support new care models that incorporate telemedicine in caring for the critically ill, resulting in higher care quality; more efficient resource use with improved cost-effectiveness; and higher patient, family, and remote provider satisfaction. As further research is conducted, the best use of telemedicine will be better defined and will result in increased access to critical care expertise to a larger population of patients requiring ICU services.

Telemedicine in pediatric cardiac critical care

OBJECTIVE

To describe our international telemedicine experience in pediatric cardiac critical care.

MATERIALS AND METHODS

This is a case series of pediatric patients teleassisted from the Cardiac Intensive Care Unit (CICU) at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, to the CICU at Hospital Valle del Lili, Cali, Valle, Colombia, between March and December 2010. An attending intensivist from the CICU in Pittsburgh reviewed cases, monitored real-time vital signs, and gave formal medical advice as requested by the attending physician in Cali. The network connection is a Cisco (San Jose, CA)-based Secure Sockets Layer virtual private network via the Internet that allows access to the web-based interface of the Dräger(®) (Lübeck, Germany) physiological monitor system. The videoconferencing equipment consists of a standard component on a custom-made mobile cart that uses an APC(®) (West Kingston, RI) uninterruptible power supply for portable power and 3Com(®) (Hewlett-Packard, Palo Alto, CA) for wireless connectivity. A post-intervention survey regarding satisfaction with the telemedicine service was conducted.

RESULTS

Seventy-one recommendations were given regarding 53 patients. Median age and weight were 10 months and 7.1 kg, respectively. Ventricular septal defect, transposition of the great vessels, and single ventricle accounted for most cases. The most frequent recommendations were related to surgical conduct, management of arrhythmias, and performance of cardiac catheterization studies. No technical difficulties were experienced during the monitoring of the patients. Satisfaction rates were equally high for technical and medical aspects of telemedicine service.

CONCLUSIONS

Telemedicine is a feasible option for pediatric intensivists seeking experienced assistance in the management of complex cardiac patients. Real-time remote assistance may improve the medical care of pediatric cardiac patients treated in developing countries.