First, health care costs are crippling the U.S. economy, and hospitals are regarded as the most expensive component.1 Secondly, the impending shortage of health care professionals will result in a U.S. physician deficiency of 125,000 by 2025.2 Third, there has been an increase in the volume of people with chronic diseases, who are the most frequent users of health care in the U.S.3
The rise of consumerism is another force for transformation. Consumerism is an orientation to new delivery models that encourage and enable greater patient responsibility through the intelligent use of information technology. Hospitals compete for both paying customers and tax-funded health services. Tax-funded health services desire hospital services to be responsive to quality measures and measures of patient satisfaction. Patient experience affects not only consumer perception, but also clinical efficiency. The Beryl Institute Report, The State of the Patient Experience 2013, looked at what American hospitals are actually doing to improve the patient experience.4 Approximately 70% of respondents felt their hospitals were making improvements toward better patient experiences.
Another force behind this transformation is health care reform and the subsequent use of electronic medical records and connectivity, as well as the need for transparency.5 In the near future, anyone will be able to compare multiple metrics on any hospital or physician simply by going online. A final driving force centers on the errors occurring in hospitals. One-third of all hospitalized patients experience adverse events, and approximately 7% are harmed permanently or die as a result.6
Newborn Intensive Care Unit (NICU)
It is estimated that 8% to 12% of all U.S. births (approximately 500,000 infants per year) will need some type of care in one of the 1,100 newborn intensive care unit (NICU) settings currently available.7 More than 7% of infants stayed in the hospital for 6 or more days, with the average infant admitted to a U.S. NICU hospitalized 20 days. This results in 6 to 10,000,000 NICU patient-days per year.
NICU is a Stressful Place
Having an infant in the NICU, especially if he or she is very small or very sick, is stressful for parents, as most parents generally do not anticipate having to admit their child. Upon admission, parents often have simultaneous feelings of disappointment, and anger and/or guilt, and they experience a loss of control in their lives.
Barriers to parent visitation can often arise in the NICU. Restrictions due to distance, maternal illness, visitor restrictions, responsibilities to family or work, and financial constraints all play a role.
Utah Valley Regional Medical Center NICU
The Utah Valley Regional Medical Center NICU is a 55-bed regional referral center located in Provo, Utah, that averages more than 800 admissions per year. Since the NICU was first established in 1979, approximately 26,000 babies have received treatment there.
The NICU began an aggressive redesign/quality improvement effort in 1990. More than 100 projects covering all aspects of clinical care have been undertaken by multidisciplinary committees.
In reviewing the health care environment of the NICU, it became obvious that our care processes were designed for health care deliverers and not for families and babies. Insufficient family/patient empowerment was a significant problem, as was communication between family members and health care providers.
Redesign/ Parent-Focus Meeting
A 3-day redesign/parent-focus meeting was held at a local hotel with 70 parents, 16 nurses, two neonatologists and four respiratory therapists
At the end of the meeting, the participating parents reminded us of the following points:
- Permission for “our care of their baby” comes from them.
- Parents often miss many milestones like the first bath, first feeding, and first time the eyelids open, usually for staff convenience.
- Parents are told when they can be in the NICU and what they can do while there.
- Someone else decides everything for them.
- Many felt that they weren’t fully informed.
- Some felt like it was not their baby being treated, but rather one who belonged to someone else.
- Many were afraid to bond and/or get close to their child.
- Many parents experienced struggle to assume their parental roles while in the NICU.
After our redesign/parent-focus meeting, we conducted multiple parental interviews during and after the hospitalization of NICU babies. Parental responses about their needs included: accurate, real-time information; inclusion in decision-making and care; respect; empowerment; contact, both tactile and visual; individualized care; a relationship with the nursing staff; and for the staff to be vigilant and protect their baby.
Parent-to-Parent Support Group
A parent-to-parent support group was created with NICU graduate parents. This group and one of the authors of this paper further clarified NICU parents’ feelings about their role in the NICU, which included: nurturer, responsible provider, protector, the one constant, legal responsibility, advocate, should be at the center of the care.
NICU is Home
As a result of this work with the parents, it became obvious we could modify, redesign, and improve what we were doing in the NICU repeatedly and still not achieve what the parents needed. We needed a new model to truly empower parents; thus, the “NICU is Home” was born.
For this project, we elected to make a shift in our focus — not to focus on what patient/families think, but on how they think. Patient satisfaction mostly occurs subconsciously.8 This creates an emotion that influences their attitude and, ultimately, their behavior. Only 5% of parents’ decisions are based on conscious, rational thought.
It was determined that, when possible, everything our NICU did should be couched to meet the family/patient subconscious needs. These include:
- Being respected.
- Being informed.
- Participating in the team care for their baby.
- Our staff having genuine care about their baby.
- Believing that their child is getting the best care.
- Having trust in us as their health care providers.
Parents were divided into teams and asked to design a NICU of the future based on the six subconscious needs established previously. It became immediately obvious about which areas they were concerned. Parents wanted to be able to see their babies 24 hours a day from wherever they were located. They wanted to be able to see and talk to their physician any time. They wanted immediate access to critical information. They wanted to never lose being a parent. Almost everything was about access and communication. We were obviously going to need to use not only a new mind set, but also new tools for communication.
Telemedicine has been used increasingly in both adult and pediatric in-patient and out-patient settings for many years.9–14 Historically, telemedicine has focused on the traditional physician-to-patient and physician-to-physician interactions enhanced by two-way video and audio capability. This usually occurs on demand. In the case of newborns, it has primarily been used to do staff and parent education,15,16 subspecialty and neonatology consultation,13–17 and to provide specific subspecialty diagnostic interpretations like echocardiography18–22 on radiographic interpretations.23 Many of these efforts have been associated with improved quality of care, reduced health care costs, and reduced length of hospitalization. Garingo et al24 used a mobile robotic telemedicine technology to provide a neonatologist off-site visual and auditory information for a patient and to directly interact with NICU staff and parents.
NICU Web Cam Technical Solution
Web cams and other video apparatuses have been used in a number of NICUs across the country. Programs such as Angel Eye in Arkansas, the East Carolina University NICU program, the CHLA project’s use of robots, and Tri-City program with UC San Diego have all explored a number of technical solutions and features that make use of video-enabled telecommunications equipment in the NICU setting. A single camera either above the baby’s bed or on a rolling cart provides a short live-video feed to a home computer or smart phone. Most have no audio.
This concept of an NICU web cam was presented to multiple groups of parents. They immediately loved the idea and felt every parent in the NICU should have the ability to see his or her baby and feel connected at any time. They felt it would allow mothers to get more rest in the comfort of their homes and allow siblings to bond with their hospitalized sibling in the NICU without being there. The parents also felt it would help improve the feelings of parenting and control issues.
Our equipment requirements included high-resolution cameras, full high-definition video recording, autofocus, audio microphones, automatic noise reduction, and automatic low-light correction. Our conferencing software needed to be able to accommodate multiple users and have multiple-picture capabilities, low band width, and be relatively inexpensive.
It was recognized that a single video camera feed was insufficient to adequately capture the desired amount of information. With traditional technology, a remote user can have access to several camera feeds but can only view one feed at a time. In most of the traditional solutions examined, the remote user was dependent on a user on the opposite end to toggle between the camera feeds. This was insufficient since we desired to use our system for remote referral hospital team support during emergencies like resuscitations.
A decision was made to pursue a solution to support a multi-camera feed allowing multiple simultaneous video feeds from a single bed. This approach has a number of benefits for parents, such as being able to see their baby as well as the nurse or physician while they are talking to them without the need for toggling (Figures 1a–d). In clinical care, the consultant can view several angles of the patient at the same time.
(A) Newborn intensive care unit (NICU) webcam in radiant warmer. (B) NICU webcam inside closed isolette under covering blanket. (C) Mother remotely viewing baby in NICU. (D) Remote view of baby in radiant warmer.
Images courtesy of Stephen Minton, MD.
Parent Communication Bedside Monitor
Verbal communication between parents and their babies’ principal care providers is critical. Several studies25,26 have reported low physician availability and low frequency/quantity of physician communication is a major cause of parent dissatisfaction.
When a parent is not present for a direct discussion with the physician after daily assessments of the baby, the physician usually updates the mother or father by phone. Parents felt a telephone discussion with the physician was acceptable, but limiting due to lack of visual contact, inability to repeat the message, limited time, and inability to ask questions.
Parents loved the idea of expanding the remote NICU web cam virtual visualization of their baby to a two-way parent communication bedside monitor. This enabled them to see who was giving the report, gave them a feeling of being shown respect, and enabled them to feel as though they were present in the NICU. Using this method, parents reported that they felt as though they received more information and had the ability to record the discussion for review on their own or with relatives. Overall, parents reported feeling as though adding this technology improved communication with physicians and nurses and enhanced their feelings of participation.
Doctors at Utah Valley Regional Medical Center have a mobile desk, which utilizes a wi-fi physician computer with an attached camera to send the video/audio reports to their patients’ families (Figure 2). This allows messages to be sent to any remote parent location, but also viewed or reviewed in the NICU on a bedside monitor with a camera attached to the isollette/overhead radiant warmer.
NICU mobile physician desk.
The parent’s home system or the NICU bedside system provides the capability for parents to communicate a response or ask a new question of either the bedside nurse or attending physician. In addition, new daily attending physicians can review previous physician-family communication.
Approximately 10% of newborns require some assistance to begin breathing at birth.27 Fewer than 1% of these newborns require extensive resuscitation measures, but it is a sizable number (40,000 annually in the U.S.) Neonatal resuscitation can be a stressful and sometimes life-changing experience for rural hospitals and for those who perform the task infrequently.
To mitigate the possibility of a newborn being born at an institution that does not have adequately trained personnel, the American Academy of Pediatrics has developed and promoted a Neonatal Resuscitation Program (NRP) that aims at having one to two certified NRP graduates present at every delivery.28 NRP training includes simulation programs, didactic lectures, and tests; however, despite receiving NRP training, it is difficult to remain proficient in something that may only occur once every few years. Furthermore, in many small or rural hospitals, all of the physicians present could potentially be in their offices at the time that an emergency resuscitation occurs.
Videotaping Neonatal Resuscitation
Videotaping of neonatal resuscitation as an educational tool to be reviewed post-resuscitation was pioneered by Finer et al. at the University in San Diego.29,30 Since 1999, this group has used video to compare their resuscitation practices with the standards set in NRP. They have reported deviations in more than half of resuscitations performed in the university setting. Deviations have been shown to occur more frequently the more complex the resuscitation.
Teleneonatology: Remote Neonatal Resuscitation
At our two largest referral hospitals, neonatologists currently do telephone consultations for all resuscitations that are not going well. We presented the concept of shared assessment and participation in neonatal resuscitation using our remote neonatal resuscitation bed to the newborn executive team (comprising pediatricians, nurses, respiratory therapists, administrators, and referral neonatologists, and corporate representatives) from those hospitals. The physicians immediately recognized the value of this service, stating that to not use it would be unethical. They believed this would enhance the service to their patients and felt it would also be a great teaching tool for them. Overall, the executive team felt it would reduce liability.
Remote Neonatal Resuscitation Bed
The remote neonatal resuscitation bed consists of an overhead radiant warmer (ORW) equipped with a resuscitator. Attached to both the posterior post of the ORW and to the warmer’s lateral side rail are two high-definition cameras (Figures 3a–3b). A 12” touch-screen monitor is attached to the posterior post of the ORW, providing both video from the neonatologist (Figures 3b–4) and audio. Beside the resuscitation bed is a computer screen (Figures 5a–5b), which can be used to teach the resuscitating team during the resuscitation. Each hospital will have two remote neonatal resuscitation bed, with one kept in the Special Care Nursery, and the other kept mobile for use in the delivery room or emergency room.
(A) Lateral rail camera. (B) Posterior radiant warmer camera and monitor.
Remote resuscitation bed with cameras and monitor.
(A) Remote resuscitation bedside computer and monitor. (B) Remote resuscitation bed computer and monitor.
At the referring hospital’s NICU, the neonatologist can use their parent communication bedside monitor NICU Mobile desk, capable of seeing two camera views and audio from the resuscitation bed (Figures 6a–6b). This system will allow the neonatologist to see everything going on in the resuscitation bed. The lateral high-definition camera then allows the neonatologist to determine the effectiveness of hand ventilation since chest excursion is easily seen. Mask ventilation and intubation head-positioning are easily determined. With the video application that we are use, up to four camera feeds can be sent simultaneously. At the referring hospital, the neonatologist can use the computer screen by the resuscitation bedside to point out and teach anyone at the resuscitation bed, with the bidirectional audio making communication easy.
(A) Neonatologist at referral hospital viewing camera views and audio. (B) Views on referral hospital monitors.
Following the resuscitation, the neonatologist can dictate a resuscitation note, and there is a neonatology consultation charge. The referring physician and neonatologist both have the ability to talk with patients’ parents. In the future, the resuscitations will be recorded and used for audits and teaching.
- National Health Expenditures 2011 Highlights. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Accessed January 23, 2014.
- Association of American Medical Colleges. Recent Studies and Reports on Physician Shortages in the US. Center for Workforce Studies, Association of American Medical Colleges. Available at: https://www.aamc.org/download/100598/data. Accessed January 23, 2014.
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- The Beryl Institute, Catalyst Healthcare Research. The State of Patient Experience – 2013 Findings, Improving the Patient Experience. Available at: http://www.theberylinstitute.org. Accessed January 23, 2014.
- Silow-Carroll S, Edwards JN, Rodin D. Using electronic health records to improve quality and efficiency: the experiences of leading hospitals. Issue Brief (Commonw Fund). 2012;17:1–40.
- Classen DC, Resar R, Griffin F, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581–589. doi:10.1377/hlthaff.2011.0190 [CrossRef]
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