Telemedicine in Pediatrics:Telemedicine in Pediatrics:Assessment of Critical Care PatientsAssessment 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

BackgroundEvidence and Best Practice:Evidence and Best Practice: Intensivists improve ICU patient outcomes1

Leapfrog Group2: 5 min response 8 hr/day; ideally 24/7 LUMC Initiative: > PGY4 immediately available in ICU

Pediatric Critical Care Unit at RMCHPediatric 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 2002;288:2151-2162

2 http://www.leapfroggroup.org/media/file/Fact_Sheet_IPS_080327.pdf Confidential: For Quality Improvement Purposes Only

Admissions to PCCU

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

Solid line: intensivist may not be in house

Dotted line: +/- intensivist in house

3 Odetola et al, Pediatr Crit Care Med 2008;9:20-25

All Admissions

Confidential: For Quality Improvement Purposes Only

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

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 1998;102;58 http://www.pediatrics.org/cgi/content/full/102/5/e58

5 Marcin Pediatr Crit Care Med 2004;5:251-256Confidential: For Quality Improvement Purposes Only

Patient Evaluation by Intensivist Within 1 Hour of Admission

Patients Less Than 12 months Old Patients Transferred From 4Peds

in person

telemedicine

Confidential: For Quality Improvement Purposes Only

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 (6.7%of PICU admits,

1.3% of 4Peds admits)

Transfer mortality 1.5% 6.8%

Confidential: For Quality Improvement Purposes Only

Pediatric Critical Care Telemedicine Use

Num

ber

of e

valu

atio

ns

Confidential: For Quality Improvement Purposes Only

ConclusionsUse 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

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