Pediatric Critical Care Telemedicine in a Rural Underserved Area

1
Pediatric Critical Care Telemedicine in a Rural
Underserved Area

• Barry Heath, MD1 Richard Salerno, MD, MS1
  Jeremy Hertzig, MD2 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.

2
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.

3
Introduction

• Vermont Childrens 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.

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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.

5
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).

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Massena (1)
Malone (2)
St. Albans (0)
Canton (1)
Morrisville (3)
Plattsburgh (9)
Burlington
Saranac Lake (3)
Middlebury (4)
Ticonderoga (2)
Rutland (1)
50 miles
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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.

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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 hospitals transport
  team.
• 5 by local emergency medical services.
• 1 by air.

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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.

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12
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.

13
Results

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

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Results
15
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.

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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.

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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.

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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.

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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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