Madan Dharmar, MBBS, is Assistant Research Professor, University of California-Davis Department of Pediatrics; and UC-Davis Center for Health and Technology. Anthony C. Smith, PhD, MEd, BN, is Deputy Director and Senior Research Fellow, Centre for Online Health, The University of Queensland, Brisbane, Australia; Queensland Children’s Medical Research Institute, Royal Children’s Hospital, Brisbane. Nigel R. Armfield, MSc, is Senior Research Assistant, Centre for Online Health, The University of Queensland, Brisbane, Australia; Queensland Children’s Medical Research Institute, Royal Children’s Hospital, Brisbane. Juan Trujano is Information Technology Supervisor, UC-Davis Department of Pediatrics. Candace Sadorra, BS, is Program Manager, UC-Davis Department of Pediatrics; and UC-Davis Center for Health and Technology. James P. Marcin, MD, MPH, is Professor, Pediatric Critical Care Medicine, UC-Davis Department of Pediatrics; and Director, Pediatric Telemedicine, UC-Davis Center for Health and Technology.
Dr. Dharmar; Dr. Smith; Mr. Armfield; Mr. Trujano; Ms. Sadorra; and Dr. Marcin have disclosed no relevant financial relationships.
Address correspondence to: James P. Marcin, MD, MPH, Professor, Pediatric Critical Care Medicine, and Director, Pediatric Telemedicine, Center for Health and Technology, UC Davis Children’s Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817; fax 916-456-2235; e-mail: firstname.lastname@example.org.
Because children in rural and underserved communities live a greater distance from regional specialty centers than children living in suburban and urban areas,1 they are faced with an inherent geographic barrier in access to care. Telemedicine provides a solution to this access barrier and has been used to deliver specialty consultations to children living in rural and underserved communities for more than 10 years.
Most commonly, telemedicine has been used in the outpatient setting, delivering subspecialty health services to children in rural communities, with a focus on children with special healthcare needs.2,3 Common outpatient specialties that have used telemedicine include psychiatry and behavior health,4 endocrinology,5 and dermatology.6 Increasingly other specialties such as cardiology,7,8 otolaryngology,9 and neurology10 have taken advantage of the many advantages inherent in telemedicine use.
The access barrier that is created as a result of regionalized services is particularly significant for children who are in need of emergency and critical care. These subspecialties are often more regionalized than outpatient services, and the delivery of care often occurs in an urgent and sometimes lifesaving manner. Because disparities in access to emergency and critical care specialists may lead to delays in care, particularly among infants and children who are acutely ill and injured,11,12 the use of telemedicine for consultation in emergency departments13 and intensive care units14,15 is increasing.
This article focuses on the how telemedicine (particularly live, interactive or “real-time” telemedicine) is being used to reach out and help infants and children in need of neonatal and pediatric intensive care. The applications described in this article tend to be clinically focused, but without question, educational and administrative benefits are derived for everyone involved.
Medical researchers have demonstrated that critically ill neonates, children, and adolescents with access to neonatal and pediatric intensive care services and specialists experience improved clinical outcomes and lower mortality.12,16–18 Newborns or hospitalized children who become critically ill do not always have access to neonatal or pediatric critical care specialists. Common examples abound. An expectedly well newborn delivered at a nursery without a neonatal ICU can develop a critical medical condition. Similarly, a child admitted to a hospital without a pediatric ICU can unexpectedly decompensate and become acutely ill. In similar fashion, a child admitted to an adult or other non-pediatric ICU, which is managed by a general pediatrician, an adult critical care physician, or a surgical specialist, can take an unanticipated turn for the worse.
Although such neonates, infants, and children on average are “less critically ill” than those in a neonatal or pediatric ICU, they are often still in need of intensive care services and subspecialty physician consultations. The use of telemedicine to conduct consultations with pediatric critical care specialists could give nearly immediate access to expert advice in such situations, whether or not the infant or child is ultimately transported to a higher level of care.
Telemedicine in the Neonatal ICU
The use of telemedicine has a long history in neonatal care. Possibly the earliest documented use of real-time, video-based telemedicine in the subspecialty occurred in 1980,19 when closed-circuit television was used for consultations between neonatologists at a large teaching hospital and nursing staff at an inner-city community hospital. Over a two-and-a-half-year period, the television link was used to provide neonatal assessments and to give management advice. In a pre-post comparison, the study found that for infants assessed to have high prenatal risk, the transfer rate to the teaching hospital was significantly higher for those assessed by television than for those not assessed (8.7% versus 4.6%). For low-risk infants, no difference was detected. We believe this to be the first reported study to show the potential for telemedicine in the assessment of neonates. Since this early work, there have been a number of applications of telemedicine in neonatal care, including cardiology,7,20 ophthalmology,21,22 radiology,23 clinical education and assessment,24–26 and family support and education.27,28
A number of established programs deliver neonatal care by telemedicine. The potential of the modality for newborns has been well demonstrated. Despite this success, telemedicine usage in neonatology has not been great. In order to convince physicians as a whole, large, well-designed studies are needed to provide definitive evidence relating to which areas of neonatal care can be safely and effectively provided by telemedicine. This need is not restricted to neonatal telemedicine. Researchers in telemedicine have done many studies, but few have produced convincing evidence that telemedicine results in improved objective outcomes. Where such studies have been done, the evidence supports telemedicine’s intuitive advantages.
Work under way in the United States and around the world is systematically addressing the lack of evidence in the areas of remote advice and infant referral. Early results of a method comparison study conducted in Queensland, Australia,29 and a multicenter trial30 are positive from both clinical and cost perspectives. These studies are also examining challenges to the acceptance of the technology. Although there are a limited number of published studies, acceptance seems to be more likely in remote nurseries where the clinical support is most required. In the tertiary referral neonatal ICU, telemedicine may be seen as an onerous task and unnecessary for specialist decisions.
Telemedicine in the Pediatric ICU
The use of telemedicine to deliver care to children in emergency situations and in remote ICUs has previously been described in the medical literature as well.14,15,31,32 Studies have demonstrated that a regional pediatric ICU can provide live interactive consultations to hospitals without a pediatric ICU and successfully provide supportive care for select critically ill children. Data demonstrate that severity-adjusted pediatric mortality rates for those admitted to remote hospitals and cared for with telemedicine and critical care specialists had lower than expected mortality, even when compared with similar children admitted to regional Pediatric ICUs.14,15 This model of care provides a significant solution for the consequences of regionalization, in that efficiency and volume can be maintained at pediatric referral centers, while the expertise can be projected to any remote hospital to assist children in need of urgent consultation. This model of care delivery can result in higher quality of care for children admitted to rural and underserved hospitals, and can result in the avoidance of sometimes lengthy, risky and expensive patient (and family) transports.14,15,31
The number of pediatric ICU-based telemedicine programs is increasing and will likely continue to increase as the use of telemedicine continues to become integrated in the healthcare system. This model of care is also becoming part of the evolving “virtual PICU” that is currently networking many pediatric ICUs across the country.33 In fact, adult ICUs have been using telemedicine incorporated in more comprehensive monitoring and smart-technologies to provide “continuous presence” ICUs, or so-called e-ICUs. These remotely monitored ICUs have experienced a reduction in patient complications, severity-adjusted length of stay, severity-adjusted mortality, and overall healthcare costs.34,35
Models of Care
A range of possible telemedicine models can be implemented to deliver remote intensive care. Perhaps the simplest model is an intermittent “consultative model,” in which a remote newborn nursery, hospital, or ICU is able to call upon an intensive care specialist to conduct a consultation using videoconferencing and other peripheral equipment, if needed. A full history and physical examination can be conducted including complete physiologic, laboratory, and radiographic reviews. This model could incorporate online and/or electronic health records (EHRs) for case review and documentation. This approach could be most appropriate when a child is “less” critically ill and may not require transport to an actual pediatric ICU. An open policy for any remote provider (nurse, therapist, resident and/or attending physician) to call any time for a consultation has proved most effective in the authors’ opinions.
More comprehensive and proactive models could be delivered by increasing the specialists’ presence through telemedicine and e-health technologies. For example, some centers conduct intermittent or scheduled ICU rounds in combination with consultations on demand. In this model, the rounds can be multidisciplinary involving nurses, therapists, dieticians and social services. Again, such a model could incorporate EHRs, other online health information, and peripheral telemedicine devices.
The most comprehensive models of care are those that incorporate telemedicine technologies into a comprehensive ICU monitoring system, in which multiple patients (or ICUs) are monitored on a round-the-clock basis by a remote healthcare team of physicians and nurses. In this model of care, the remote team may not act solely as consultants responsible for continuous monitoring of patients but may also actively participate in the medical management of patients, including addition and titration of therapies, ensuring compliance with best practices and active communication with other members of the healthcare team.36,37 Although there are clear advantages to this continuous presence model, the model selected is depending on the needs of the remote hospital, the experience of the remote hospitals’ healthcare team, and the number of patients requiring ICU support.
Remote Monitoring and Discharge Planning
Telemedicine can be used to promote collaboration between tertiary (specialist) centers and regional hospitals. For example, when patients are transferred for specialist care, communication, and collaboration between the referral (remote) site and specialist site may be very limited or non-existent. Without telemedicine, the referring clinicians depend heavily on telephone calls and patient summaries, which are posted back to the regional hospital, sometimes up to several months later. This may hinder continuity of care, especially when patients are ready for return transfer back to the regional hospital.
In several states and in other countries internationally, programs have implemented innovative methods of delivering telemedicine services to regional hospitals.38 The use of wireless videoconference systems has proven to be an extremely useful method for engaging clinicians, patients, and specialists. Instead of relying on fixed videoconference systems in lecture rooms or staff meeting rooms, mobile systems can either be wheeled or remotely driven to deliver care where clinical services are most likely to be needed. This is particularly important for ICU services or inpatient wards. Mobile systems have been designed to complement the needs of clinical departments, including robots in pediatric wards and transportable communication stations in intensive care environments (see Figure 1, page 563, and Figure 2, page 564).
Figure 1: Mobile Telemedicine Robot Used for Specialist Pediatric Consultations at the Bedside.
Figure 2: Telemedicine in the Neonatal ICU: Virtual Ward Rounds.
In the context of pediatric intensive care, several centers have established a method of connecting remote and tertiary hospitals’ nurses and physicians in daily or weekly rounds. When patients are transferred between facilities, clinicians at both hospitals are now able to contribute to the child’s ongoing care, monitor progress and assist with discharge planning or back transfer to the regional hospital. Additionally, families have been included in the care of their child at all stages during the admission and are able to communicate with clinicians at both the remote and tertiary hospitals. The overall benefits include improved communication and collaboration between remote hospital staff, families and specialists at tertiary hospitals, as well as valuable opportunities for professional education and support in remote areas, which traditionally are underserved. Telemedicine consultations in the pediatric ICU help to connect patients and specialists; it also plays an important role in strengthening the partnership between regional staff and specialists. The interactions serve as an opportunity to teach new ideas to a range of staff at rural locations. During telemedicine consultations and ward rounds, the natural discussions that take place not only promote multidisciplinary input from all parties involved, but also encourage networking and relationship building between the two sites. This is likely to have long-term benefits for future referrals and management of critically ill children in remote communities.
In developing a telemedicine program for an intensive care unit, there are many technical challenges to address, particularly when providing round-the-clock service to assist in the urgent care of critically ill infants and children. This includes having on-call systems for both the clinicians, as well as the technical personnel at both remote and tertiary sites. Telecommunication lines need to be reliable and have adequate bandwidth to maintain quality of service. This may mean the use of dedicated telecommunication lines, such as fractionated T1 lines, Integrated Services Digital Network (ISDN), or some other private networking telecommunication systems. Currently, this may mean avoiding the use of the public internet, unless quality of service and privacy can be assured.
Consideration as to which sophisticated telemedicine imaging equipment is needed must be thoughtfully made. Remotely controlled videoconferencing devices offer a range of quality and can be wall mounted, pole mounted, or even mounted on mobile robotic platforms.39 Peripheral devices, such as high resolution exam cameras, stethoscopes, and otoophthalmoscopes are available; however, it may be easier to have the remote physician or nurse describe physical findings, such as pupillary responses, than to have a remote operator use the camera. There is also the capability of having connections for live feeds of cardiorespiratory monitors, ventilators, or other monitoring devices. In some cases where these monitoring systems are not available, a remotely controlled video camera can be directed for close-up real time visualization of the monitors and other equipment with interpretations similar to physical bedside interpretations.
Future of Tele-ICU
The use of telemedicine technologies will increase in the delivery of neonatal and pediatric ICU services. These technologies will allow the subspecialist to extend his expertise much further than can be done using the old approach of calling a referral center and sending the patient there as quickly as possible. The advantages will be numerous. Subspecialists will be able to provide better consultations than could have been provided over the telephone. Children will receive better care due to these more accurate consultations. Only those children who need to be transported will be sent to the referral center. Referring hospitals and physicians will get to keep some of the patients who would have previously been referred, to the advantage of the patient, the patient’s family, the local physician, and the local hospital. Relationships between local and referral centers will be enhanced. Education will flow in both directions, as subspecialists provide the latest information to their local peers, and these peers will teach the subspecialist about the challenges faced in a more rural practice. We expect that these technologies will become integrated into our daily care, just as computerized physician order entry and the EHRswill soon be. Different models of care using different technologies will be used depending upon the needs of the patients and remote-tertiary hospitals. Data have been published and will continue to be published, defining telemedicine’s effect on efficiency, clinical outcomes, and cost-effectiveness to better define where, when, and on which patients the technologies can be deemed most clinically and economically effective.
- Dougherty D, Simpson LA, McCormick MC. Rural areas and children’s health care coverage, use, expenditures, and quality: policy implications. Ambul Pediatr. 2006;6(5):265–267. doi:10.1016/j.ambp.2006.06.005 [CrossRef]
- Karp WB, Grigsby RK, McSwiggan-Hardin M, et al. Use of telemedicine for children with special health care needs. Pediatrics. 2000;105(4 Pt 1):843–847. doi:10.1542/peds.105.4.843 [CrossRef]
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- Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med. 2007;356(21):2165–2175. doi:10.1056/NEJMsa065029 [CrossRef]
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