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Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
Microsoft PowerPoint - 02_Heath_Pediatric.Telehealth.9.16 ...
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  • 1. 2008 Pediatric Telehealth Colloquium Update on Rural Pediatric Critical Care Telemedicine Barry Heath MD, Amelia Hopkins MD, Richard Salerno MD MS Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Vermont College of Medicine Pediatric Intensive Care Unit, Vermont Children’s Hospital at Fletcher Allen Health CareAllen Health Care The authors have no financial disclosures.
  • 2. Introduction A disparity in access to health care exists between ruralp y and urban areas • 21% of children in the United States live in rural areas • 3% of board certified pediatric intensivists practice in rural areas
  • 3. Introduction • Outcomes for critically ill pediatric patients are bettery p p when they are cared for by pediatric intensivists, in tertiary care pediatric intensive care units, and Level 1 trauma centerstrauma centers
  • 4. Introduction • Vermont Children’s Hospital is the tertiary referralp y center for Vermont and northern up-state New York • Level 1 trauma center • The referral area includes 19 rural counties with a population of ~1,000,000 • Pediatric Intensivists n=3Pediatric Intensivists n=3 • Pediatric Emergency Medicine specialists n=0
  • 5. Cambridge VT Cambridge MA
  • 6. Introduction • In an attempt to address the issue of local rural access top sub-specialty pediatric critical care, we implemented a program to perform and evaluate pediatric critical care telemedicine consultations in rural emergencytelemedicine consultations in rural emergency departments
  • 7. Methods • 10 rural emergency departments in a referral area with ag y p population of 1,000,000 in 19 rural counties in VT and upstate NY • Ground distance to the PICU averages 62 miles (rangeGround distance to the PICU averages 62 miles (range 30-117 miles) • One-way ground transport averages 104 minutes (range 35 195 minutes)35-195 minutes)
  • 8. Massena St. AlbansMalone Plattsburgh Burlington Morrisville Canton-Potsdam Saranac Elizabethtown Middlebury Ticonderoga Rutland 20 miles
  • 9. Massena St. Albans 30 miles 35 minutes 113 miles 180 minutes Malone 80 miles 135 minutes Plattsburgh 30 il Burlington Morrisville 45 miles 60 minutes Canton-Potsdam 117 miles 195 minutes 30 miles 75 minutes Saranac 50 miles 100 minutes Elizabethtown 66 miles Middlebury 35 miles 60 i t 66 miles 120 minutes 60 minutes Ticonderoga 52 miles 90 minutes Rutland 65 miles 105 minutes20 miles
  • 10. Methods • ISDN telephone lines and hardware-based dedicatedp videoconferencing systems were installed in the emergency departments, the PICU office, and the homes of the three pediatric intensivistshomes of the three pediatric intensivists • Telemedicine contact was initiated by the attending pediatric intensivist following a request for consultation or transport on a 24 hour-a-day, 7-day-a-week basis • Post-consultation questionnaires using a 5 point Likert scales and “fill in the blanks” were given to consultingscales and “fill in the blanks” were given to consulting intensivists and referring providers
  • 11. Results Total of 73 consultations were performed from 10 sitesp • Average of 7.3 consultations per referring emergency departments • Range 3 to 21 consultations
  • 12. Massena St. Albans 6 5 Malone 6 Plattsburgh 21 Burlington Morrisville 6Canton-Potsdam 3 21 Saranac 4 Middlebury 12 Ticonderoga 5 Rutland 3 20 miles
  • 13. Results • Patients ranged in age from 2 days to 17 years (mean 50g g y y ( months, median 17 months). • 69/73 patients were transported to the tertiary care h i lhospital. • 3 patients were kept at the referring facility • 1 patient died in the outside ED1 patient died in the outside ED
  • 14. Respiratory distress/failure Bronchiolitis (7) 36 Bronchiolitis (7) Status asthmaticus (6) Seizures/status epilepticus 12 Infections 6Infections Septic shock (2) 6 Ingestion/overdose 6 Altered mental status 3 Cardiopulmonary arrest 3 Diabetic ketoacidosis 2Diabetic ketoacidosis 2 Angioedema 1 GI bleed 1 Hemorrhagic shock (hepatic tumor) 1 Hemoptysis (Fontan) 1 T 1Trauma 1
  • 15. Results • Consulting intensivists made a total of specific 261g p recommendations (mean 3.6 per consult) • Transport team was supervised by telemedicine in 31 cases • In 3 cases, the patients were triaged to the pediatric ward • In 3 cases, transport was not required after consultation
  • 16. Results 22 Equipment issues were reportedq p p • 18 times the unit in the referring ED was initially off • 3 times audio feedback was reported • 1 time the consultant had a difficult time “zooming in”
  • 17. Results Recommendations n Transport 69 Medications Antibiotics 55 11Antibiotics Nebulized respiratory treatment Anticonvulsant therapy Sedation/Pain Intubation 11 12 11 8 5Intubation IVF Resuscitation medications IV bronchodilators I / 5 4 4 4 3Inotrope/vasopressor 3 Administer crystalloid 43 Obt i l b i i d t 28Obtain lab or imaging data 28
  • 18. Results Recommendations n Technical recommendations Bagging technique/ventilator management Respiratory therapy I b i 19 12 5 3Intubation Decompress the stomach Foley placement 3 2 1 Obtain vascular access 17Obtain vascular access 17 Do NOT intubate 14 Intubate 10 Transfuse PRBCs 2 Stop resuscitation 1 D n t t n p t 3Do not transport 3
  • 19. Results Recommendations n Technical recommendations Bagging technique/ventilator management Respiratory therapy I b i 19 12 5 3Intubation Decompress the stomach Foley placement 3 2 1 Obtain vascular access 17Obtain vascular access 17 Do NOT intubate 14 Intubate 10 Transfuse PRBCs 2 Stop resuscitation 1 D n t t n p t 3Do not transport 3
  • 20. Results Intubate or not? • 7 patients were already intubated • 10 patients were intubated after the recommendation was made via telemedicine • Recommendations NOT to intubate were made in 14 patients in whom intubation was considered at thepatients in whom intubation was considered at the referring ED • 1 recommendation NOT to extubate and re-intubate for hypercarbia
  • 21. Results • Questionnaires were returned for 73/73 (100%) consultations by consulting intensivists Q i i d f 46/73 (63%)• Questionnaires returned for 46/73 (63%) consultations by referring providers
  • 22. This consult improved the quality of this patient’s h l hhealth care. Agree, Strongly Agreeg , g y g • Consulting Intensivists 80% • Referring Providers 82% 50 60 30 40 50 Consulting intensivists Referring 0 10 20 Referring providers SD D N A SA
  • 23. The ease of use of the telemedicine equipment wasq p Good, Very Good, y • Consulting Intensivists 89% • Referring Providers 86% 80 40 50 60 70 Consulting intensivists 10 20 30 Referring providers 0 VP P A G VG
  • 24. The quality of the video wasq y Good, Very Good, y • Consulting Intensivists 92% • Referring Providers 91% 60 30 40 50 Consulting intensivists 10 20 30 intensivists Referring providers 0 VP P A G VG
  • 25. The quality of the audio wasq y Good, Very Good, y • Consulting Intensivists 88% • Referring Providers 100% 70 80 40 50 60 70 Consulting intensivists 10 20 30 Referring providers 0 VP P A G VG
  • 26. Provider-to-provider communications during the isession was Good, Very Good, y • Consulting Intensivists 90% • Referring Providers 98% 80 90 100 40 50 60 70 80 Consulting intensivists R f rrin 0 10 20 30 40 Referring providers 0 VP P A G VG
  • 27. This consult could have been performed as well by l htelephone Disagree, Strongly Disagreeg , g y g • Consulting Intensivists 89% • Referring Providers 56% 50 60 30 40 Consulting intensivists Referring 0 10 20 g providers SD D N A SA
  • 28. This consult could have been performed as well by l htelephone Agree, Strongly Agreeg , g y g • Consulting Intensivists 7% • Referring Providers 26% 50 60 30 40 Consulting intensivists Referring 0 10 20 g providers SD D N A SA
  • 29. Discussion Telephone versus telemedicinep Were the consultants wrong? • Bias • Caught up in cool new technology
  • 30. Discussion What does the intensivist want from telemedicine? • To make the best recommendations possible • To triage appropriately • To improve outcome providing the earliest definitive critical care management • T p r i th tr n p rt t m• To supervise the transport team
  • 31. Discussion What does the referring physician want from telemedicine?g p y • Recommendations • Transport facilitated
  • 32. Discussion • The audiovisual information (vs telephone consultation)( p ) made available by telemedicine may not be clearly appreciated by referring providers V l f l i i d l• Value of early examination and management may also be underappreciated by the referring provider • The benefit of triage and planning benefits theg p g consultant more than the referring physician
  • 33. Telephone v. Telemedicinep d • Poor chest rise - bag-mask technique • Desaturation and bradycardia not noticed – stop laryngoscopy • Asymmetrical chest rise post-intubation - check depth ofy p p the endotracheal tube and re-position it out of the right mainstem • Poor chest rise and desaturation with bag-endotrachealg tube - disable pressure pop-off on a self-inflating bag • Abdominal distention after intubation - place a nasogastric tube • Poor skin perfusion after bolus - repeat crystalloid • Ventilator-patient dys-synchrony - repeat sedatives Rx • Do not intubate x 14Do not intubate x 14
  • 34. Conclusions • It is feasible to provide urgent subspecialty critical carep g p y for children in underserved rural emergency departments that improves patient care and provides a high degree of provider satisfactionhigh degree of provider satisfaction. • The application of pediatric critical care telemedicine technology may help to address the disparities in the access to medical care between rural and urban areas. • The addition of telemedicine to the armamentarium of the pediatric intensivist may change the practicethe pediatric intensivist may change the practice patterns of pediatric critical care in rural areas.
  • 35. Fundingg Funded by a grant by the U.S. Department ofy g y p Transportation (March 2006-March 2008) US DOT FAST STAR: Linking Telemedicine to the Moving Ambulance CONTINUATION/Project #2 of Telemedicine and Rural Specialty Care: A Pilot Study.p y y

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