Telemedicine in Pediatrics: Assessment of Critical Care Patients

1
Telemedicine in PediatricsAssessment of
Critical Care Patients
Project Team Kathleen Webster MD, Jenny Wang MD,
Dina Calamur MD, Cindi LaPorte RN, Sandra Swanson
RN,MSOD
Confidential For Quality Improvement Purposes
Only
2
Background

• Evidence and Best Practice
• Intensivists improve ICU patient outcomes1
• Leapfrog Group2 5 min response 8 hr/day ideally
  24/7
• LUMC Initiative gt PGY4 immediately available in
  ICU
• Pediatric Critical Care Unit at RMCH
• 800 admissions/yr 57 between 5pm and 8am
• 3 pediatric intensivists
• In House at least 8-12 hrs Apr-May, 12-15 hrs
  Jan-Mar
• PGY2 or 3 in house, no fellows

1Pronovost JAMA 20022882151-2162 2
http//www.leapfroggroup.org/media/file/Fact_Sheet
_IPS_080327.pdf Confidential For Quality
Improvement Purposes Only
3
Admissions to PCCU

• All Admissions

• Vulnerable Populations
• Infants (under 1 year)
• 21 of all admissions
• 72 occur at night
• Transfers from 4Peds
• 9 of all admissions
• 63 occur at night
• High risk group
• Previous studies show 2 fold increase in
  mortality for transfer pts vs admit from ED3

3 Odetola et al, Pediatr Crit Care Med
2008920-25
Solid line intensivist may not be in
house Dotted line /- intensivist in house
Confidential For Quality Improvement Purposes
Only
4
Project Aim

• Opportunity
• Increase intensivist presence through use of
  telemedicine
• Target vulnerable populations
• Goal
• 100 of patients in target populations will have
  evaluation by pediatric intensivist and creation
  of treatment plan within 1 hour of admission

Confidential For Quality Improvement Purposes
Only
5
Solutions Telemedicine Connection

• Two way audio visual connection
• Allows patient assessment, including stethoscope
  and dialogue with team
• Intensivist can connect from anywhere
• Proven to be accurate4 and useful5 for real time
  assessments
• Guidelines for use were created
• Nightly test calls conducted to increase
  familiarity
• Monthly chart review of target populations to
  assess compliance

4Kofos Pediatrics 199810258 http//www.pediatric
s.org/cgi/content/full/102/5/e58 5 Marcin Pediatr
Crit Care Med 20045251-256
Confidential For Quality Improvement Purposes
Only
6
Patient Evaluation by Intensivist Within 1 Hour
of Admission
in person
telemedicine
Patients Less Than 12 months Old
Patients Transferred From 4Peds
Confidential For Quality Improvement Purposes
Only
7
Impact on Mortality
Pre-Telemedicine (Apr 06-Mar07) Post-Telemedicine (Apr 07-Mar 08)
PCCU admissions 764 872
PCCU mortality 1.4 1.7

Infant admissions 163 (21) 202 (23)
Infant mortality 2.5 0.5

Transfer admissions 66 (8.6 of PICU admits 1.6 of 4Peds admits) 59 (6.7of PICU admits, 1.3 of 4Peds admits)
Transfer mortality 1.5 6.8
Confidential For Quality Improvement Purposes
Only
8
Pediatric Critical Care Telemedicine Use
Number of evaluations
Confidential For Quality Improvement Purposes
Only
9
Conclusions

• Use of telemedicine technology is effective in
  reaching goals for intensivist evaluation of
  pediatric critical care patients in target
  populations
• Infant Evaluation
• 100 target reached
• 33 of evaluations are by telemedicine
• Decreased mortality seen
• Transfer Patient Evaluation
• 100 target reached, 59 by telemedicine
• Fewer transfers
• Higher mortality
• Other Uses
• Deteriorating inpatient
• Ward/IMC pt evaluated but transfer averted
• Code Supervision

Confidential For Quality Improvement Purposes
Only
10
Next Steps

• Continue to monitor goals
• Evaluate other uses
• Evaluate at risk patients through use of
• Tele-Rapid Response Team
• Monitor mortality of transfer patients
• Tele-link with ED to facilitate early
  intervention and triage

Confidential For Quality Improvement Purposes
Only