Telemedicine in Rural Pediatric Critical Care in Vermont (T5A4)

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Telemedicine in Rural Pediatric Critical Care in Vermont (T5A4)

  1. 1. Pediatric Critical Care Telemedicine in a Rural Underserved Area Barry Heath, MD; 1 Richard Salerno, MD, MS; 1 Jeremy Hertzig, MD; 2 Michael Caputo, MS 3 . 1 Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Vermont College of Medicine, 2 Department of Pediatrics, University of Vermont College of Medicine, 3 Central Information Technology Services, Washington University at St. Louis School of Medicine. The authors have no financial disclosures.
  2. 2. Introduction <ul><ul><li>A disparity in access to health care exists between rural and urban areas. </li></ul></ul><ul><ul><ul><li>21% of children in the United States live in rural areas. </li></ul></ul></ul><ul><ul><ul><li>3% of board certified pediatric intensivists practice in rural areas. </li></ul></ul></ul><ul><ul><li>Outcomes for critically ill pediatric patients are better when they are cared for by pediatric intensivists, in tertiary care pediatric intensive care units, and Level 1 trauma centers. </li></ul></ul>
  3. 3. Introduction <ul><ul><li>Vermont Children’s Hospital is the tertiary referral center for Vermont and northern up-state New York. </li></ul></ul><ul><ul><li>The referral area includes 19 rural counties with a population of 750,000. </li></ul></ul><ul><ul><li>Pediatric Intensivists n= 2. </li></ul></ul><ul><ul><li>Pediatric Emergency Medicine specialists n = 0. </li></ul></ul>
  4. 4. Introduction <ul><ul><li>In an attempt to address the issue of local rural access to sub-specialty pediatric critical care, we implemented a pilot program to examine the feasibility and effectiveness of pediatric critical care telemedicine consultations in rural emergency departments. </li></ul></ul>
  5. 5. Methods <ul><ul><li>Approval was obtained from the University of Vermont Institutional Review Board for a prospective study of pediatric critical care consultations in rural emergency departments March through October 2006. </li></ul></ul><ul><ul><li>10 rural emergency departments in a referral area with a population of 750,000 in 19 rural counties in VT and upstate NY. </li></ul></ul><ul><ul><li>Ground distance to the PICU averaged 75 miles (median 61, range 26-143 miles). </li></ul></ul><ul><ul><li>Clear-weather round-trip ground transport times ranged from 70 to 360 minutes (mean 204, median 215 minutes). </li></ul></ul>
  6. 6. ■ Massena (1) ■ Malone (2) ■ Saranac Lake (3) Ticonderoga (2) ■ ■ St. Albans (0) ■ Morrisville (3) ■ Middlebury (4) ■ Rutland (1) ■ Burlington Plattsburgh (9) ■ ■ Canton (1) 50 miles
  7. 7. Methods <ul><ul><li>ISDN telephone lines and hardware-based dedicated videoconferencing systems were installed in the emergency departments, the PICU office, and the homes of the two pediatric intensivists. </li></ul></ul><ul><ul><li>Telemedicine contact was initiated by the attending pediatric intensivist following a request for transport or consultation, on a 24 hour-a-day, 7-day-a-week basis. </li></ul></ul><ul><ul><li>Post-consultation questionnaires using a 5 point Likert scale were given to consulting intensivists and referring providers. </li></ul></ul>
  8. 8. Results <ul><ul><li>Total of 26 consultations were performed from 9 of 10 sites. </li></ul></ul><ul><ul><ul><li>Average of 2.6 consultations per referring emergency department (median 2, range 0 to 9 consultations). </li></ul></ul></ul><ul><ul><li>Patients ranged in age from 2 days to 16 years (mean 61, median 34.5 months). </li></ul></ul><ul><ul><li>All patients were transported to the tertiary care hospital. </li></ul></ul><ul><ul><ul><li>20 by the tertiary care hospital’s transport team. </li></ul></ul></ul><ul><ul><ul><li>5 by local emergency medical services. </li></ul></ul></ul><ul><ul><ul><li>1 by air. </li></ul></ul></ul>
  9. 9. 1 Subarachnoid hemorrhage 1 Respiratory failure 1 Pulmonary hemorrhage 1 Oomphalitis 1 Neck abscess 1 GI bleed 1 Blunt abdominal trauma 1 Angioedema 2 Status asthmaticus 2 Septic shock 2 Diabetic ketoacidosis 3 Respiratory distress 3 Drug overdose 6 Status epilepticus Number Primary Diagnosis
  10. 10. Results <ul><ul><li>Consulting intensivists made a total of 100 specific recommendations (mean 2.6, range 1 to 10 recommendations per consultation). </li></ul></ul><ul><ul><li>6 children underwent tracheal intubation and mechanical ventilation initiated at the referring hospital. </li></ul></ul><ul><ul><ul><li>1 for bronchiolitis, 1 for pneumonia and septic shock, 2 for respiratory failure due to drug overdose, and 2 for respiratory failure due to status epilepticus. </li></ul></ul></ul><ul><ul><ul><li>2 of the intubations were supervised in real time on telemedicine. </li></ul></ul></ul><ul><ul><li>Transport team was supervised by telemedicine in 9 cases. </li></ul></ul>
  11. 11. 1 Vent gastrostomy tube 1 Pain control 1 Move endotracheal tube (right main intubation) 1 Local EMS cleared for transport 1 Inotrope/vasopressor therapy 1 Do not intubate 2 Intubation drugs and equipment 2 Intubate 2 Insulin therapy 3 Antibiotic therapy 4 Obtain vascular access 4 Changes in intravenous fluid therapy 5 Medical management of wheezing 6 Sedation for mechanical ventilation 6 Initiation and stabilization on mechanical ventilation 6 Medical management of seizures 7 Obtain further laboratory data 9 Care reviewed with transport team 12 Give crystalloid 26 Transport patient Number Recommendations (n=100)
  12. 12. Results <ul><ul><li>Technical problems were encountered in 2 consultations. </li></ul></ul><ul><ul><li>In both circumstances, the television units at the referral emergency departments had been inadvertently turned off. </li></ul></ul><ul><ul><ul><li>The consultant could see and hear while the referring providers had audio capability only. </li></ul></ul></ul>
  13. 13. Results <ul><ul><li>Questionnaires were returned for 26/26 (100%) consultations by intensivists and 19/26 (73%) consultations by referring providers. </li></ul></ul>
  14. 14. Results 92% 100% Provider-to-Provider communications (good/very good) 96% 100% Quality of audio (good/very good) 85% 90% Quality of video (good/very good) 92% 89% Ease of equipment use (good/very good) 85% 78% Improved the quality of patient's care (agree/strongly agree) Consultant Referring MD
  15. 15. Results <ul><li>“ This consult could have been performed as well by telephone” </li></ul><ul><ul><li>Intensivists </li></ul></ul><ul><ul><ul><li>Disagree, Strongly Disagree 96% </li></ul></ul></ul><ul><ul><li>Referring providers </li></ul></ul><ul><ul><ul><li>Disagree, Strongly Disagree 42% </li></ul></ul></ul><ul><ul><ul><li>Agree, Strongly Agree 37% </li></ul></ul></ul><ul><ul><li>Despite this difference, provider-to-provider communications were rated superior by referring providers. </li></ul></ul>
  16. 16. Discussion <ul><ul><li>The vast amount of audiovisual information (vs telephone consultation) concerning the patient made available to the consultant by telemedicine may not be clearly appreciated by referring providers. </li></ul></ul><ul><ul><li>The value of early examination and management of a patient long before arrival at the tertiary center may also be underappreciated from the perspective of the referring provider. </li></ul></ul><ul><ul><li>The perceived difference may lie in the benefit of triage and planning accrued to the receiving intensivist. </li></ul></ul>
  17. 17. Discussion <ul><ul><li>Telemedicine was also used to communicate with the transport team at referring hospitals during stabilization prior to ground transports of patients. </li></ul></ul><ul><ul><li>This application of telemedicine has been described only in a feasibility study. </li></ul></ul>
  18. 18. Conclusions <ul><ul><li>It is feasible to provide urgent subspecialty critical care for children in underserved rural emergency departments with a high degree of provider satisfaction. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  19. 19. Funding <ul><ul><li>Funded by a grant by the U.S. Department of Transportation </li></ul></ul><ul><ul><li>US DOT FAST STAR: Linking Telemedicine to the Moving Ambulance CONTINUATION/Project #2 of Telemedicine and Rural Specialty Care: A Pilot Study. </li></ul></ul>
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