Telemedicine in Rural Pediatric Critical Care in Vermont (T5A4)

Pediatric Critical Care Telemedicine in a Rural Underserved Area

Barry Heath, MD;1 Richard Salerno, MD, MS;1 Jeremy Hertzig, MD;2 Michael Caputo, MS3.

1Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Vermont College of Medicine, 2Department of Pediatrics, University of Vermont College of Medicine, 3Central Information Technology Services, Washington University at St. Louis School of Medicine.

The authors have no financial disclosures.

Introduction

• A disparity in access to health care exists between rural and urban areas.

• 21% of children in the United States live in rural areas.

• 3% of board certified pediatric intensivists practice in rural areas.

• 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.

Introduction

• Vermont Children’s Hospital is the tertiary referral center for Vermont and northern up-state New York.

• The referral area includes 19 rural counties with a population of 750,000.

• Pediatric Intensivists n= 2.• Pediatric Emergency Medicine specialists n = 0.

Introduction

• 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.

Methods• 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.

• 10 rural emergency departments in a referral area with a population of 750,000 in 19 rural counties in VT and upstate NY.

• Ground distance to the PICU averaged 75 miles (median 61, range 26-143 miles).

• Clear-weather round-trip ground transport times ranged from 70 to 360 minutes (mean 204, median 215 minutes).

■ 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

Methods

• 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.

• 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.

• Post-consultation questionnaires using a 5 point Likert scale were given to consulting intensivists and referring providers.

Results

• Total of 26 consultations were performed from 9 of 10 sites.

• Average of 2.6 consultations per referring emergency department (median 2, range 0 to 9 consultations).

• Patients ranged in age from 2 days to 16 years (mean 61, median 34.5 months).

• All patients were transported to the tertiary care hospital.

• 20 by the tertiary care hospital’s transport team. • 5 by local emergency medical services.• 1 by air.

Primary Diagnosis Number

Status epilepticus 6

Drug overdose 3

Respiratory distress 3

Diabetic ketoacidosis 2

Septic shock 2

Status asthmaticus 2

Angioedema 1

Blunt abdominal trauma 1

GI bleed 1

Neck abscess 1

Oomphalitis 1

Pulmonary hemorrhage 1

Respiratory failure 1

Subarachnoid hemorrhage 1

Results

• Consulting intensivists made a total of 100 specific recommendations (mean 2.6, range 1 to 10 recommendations per consultation).

• 6 children underwent tracheal intubation and mechanical ventilation initiated at the referring hospital.

• 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.

• 2 of the intubations were supervised in real time on telemedicine.

• Transport team was supervised by telemedicine in 9 cases.

Recommendations (n=100) Number

Transport patient 26

Give crystalloid 12

Care reviewed with transport team 9

Obtain further laboratory data 7

Medical management of seizures 6

Initiation and stabilization on mechanical ventilation 6

Sedation for mechanical ventilation 6

Medical management of wheezing 5

Changes in intravenous fluid therapy 4

Obtain vascular access 4

Antibiotic therapy 3

Insulin therapy 2

Intubate 2

Intubation drugs and equipment 2

Do not intubate 1

Inotrope/vasopressor therapy 1

Local EMS cleared for transport 1

Move endotracheal tube (right main intubation) 1

Pain control 1

Vent gastrostomy tube 1

Results

• Technical problems were encountered in 2 consultations.

• In both circumstances, the television units at the referral emergency departments had been inadvertently turned off.

• The consultant could see and hear while the referring providers had audio capability only.

Results

• Questionnaires were returned for 26/26 (100%) consultations by intensivists and 19/26 (73%) consultations by referring providers.

Results

Referring MD

Consultant

Improved the quality of patient's care (agree/strongly agree) 78% 85%

Ease of equipment use (good/very good) 89% 92%

Quality of video (good/very good) 90% 85%

Quality of audio (good/very good) 100% 96%

Provider-to-Provider communications (good/very good) 100% 92%

Results

“This consult could have been performed as well by telephone”Intensivists

• Disagree, Strongly Disagree 96%Referring providers

• Disagree, Strongly Disagree 42%• Agree, Strongly Agree 37%

Despite this difference, provider-to-provider communications were rated superior by referring providers.

Discussion

• 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.

• 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.

• The perceived difference may lie in the benefit of triage and planning accrued to the receiving intensivist.

Discussion

• Telemedicine was also used to communicate with the transport team at referring hospitals during stabilization prior to ground transports of patients.

• This application of telemedicine has been described only in a feasibility study.

Conclusions

• It is feasible to provide urgent subspecialty critical care for children in underserved rural emergency departments with a high 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.

Funding

• Funded by a grant by the U.S. Department of Transportation

• US DOT FAST STAR: Linking Telemedicine to the Moving Ambulance CONTINUATION/Project #2 of Telemedicine and Rural Specialty Care: A Pilot Study.

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