Telemedicine for Critically Ill Children Presenting to Remote Hospitals
It is well documented that critically ill children presenting to EDs without pediatric expertise receive a lower quality of care compared with those receiving care provided in EDs with that expertise. 20,28–31 Many of these EDs are at times inadequately equipped to care for pediatric emergencies. 28,31–37 In addition, the staff working in smaller, general EDs—including physicians, nurses, pharmacists, and support staff—are often less experienced in caring for critically ill children and may do so infrequently. The combined inherent stresses of caring for a critically ill child with this lack of equipment, infrastructure, and experienced personnel can result in delayed or incorrect diagnoses, suboptimal therapies, and imperfect medical management. 17,20,38,39 As a consequence, acutely ill or injured children often receive a lower quality of care than children presenting to EDs in regionalized children's hospitals. 20,40–43 This is succinctly reflected in the aphorism that children are not just little adults.
The use of telemedicine technologies for disaster victims 44 or in remote or underserved EDs can be a means of obtaining subspecialty expert consultation. 45–51 Telemedicine has also been shown to be a feasible method of providing specialty expertise from the United States internationally, namely to augment the care of children with congenital heart disease. 52,53 The benefit of using this technology as opposed to using the telephone (the current standard of care) is that the consultant (ie, the pediatric critical care physician) has the ability to have a virtual presence at the patient's bedside. The consultant has full control of the remote camera, including movement about the room and high-resolution zoom, allowing access to high-definition video views of the patient, the treating providers, and the family, as well as monitors and other medical equipment.
Telemedicine During Transport of Critically Ill Pediatric Patients
The use of telemedicine by physicians to assist in the care of critically ill patients during transport has the potential to improve processes of care at several levels. For example, telemedicine allows physicians to be an immediate part of the monitoring, identification, and management of changes in the patient's status that occur during transport. With more immediate physician supervision using telemedicine, medical decisions, including new medication orders, have the potential to occur more rapidly and efficiently than without direct physician supervision.
At present, mobile telephone technologies are used to transmit two-way audio as well as data, including electrocardiogram data. However, to create a model of care that uses telemedicine during transport, much more robust mobile broadband telecommunications are needed. Only a few transport programs in the United States use these technologies because high-quality broadband mobile telecommunication is expensive and not always or easily available, 54 particularly if continuous video transmission or large amounts of data streaming is desired. Common methods of transmitting video include the use of high-fidelity cell phone services (sometimes combining several cell phone lines) and the use of the Internet, which can be available with citywide WiFi or satellite services. 55,56 Although satellite technologies can be used to provide mobile telemedicine connections, this technology is most often prohibitively expensive.
There have been anecdotal reports documenting the feasibility of cell phone and WiFi transmitted telemedicine consultations during transport. In one study, the outcomes of adult patients with simulated trauma were compared among scenarios that used telemedicine and scenarios that used telephone communications during transport. 57 Use of telemedicine resulted in a reduction in adverse clinical events, including fewer episodes of desaturation and hypotension and less tachycardia, compared with identical simulated patients without telemedicine use. In addition, recognition rates for key physiologic signs and the need for critical interventions were higher in the transport simulations that used telemedicine. 57 These data are encouraging and support the possibility that telemedicine can be used during patient transport. However, until more reliable and affordable mobile telecommunications are available to implement telemedicine during transport and until more research is conducted on the impact that telemedicine has during transport and on workflow, the effectiveness and benefit of this technology remain undetermined.
Critical Care Telemedicine Consultations for Hospitalized Children
Pediatric critical care services are more regionalized and less available than adult critical care services. Therefore children living in nonurban communities who may need critical care services are often transported to a pediatric ICU, exposing them to the inherent risks and costs. At times, pediatric patients who are not critically ill are overtriaged and transferred to the regional center, because there may be a need for the specialty services provided by the pediatric ICU. 58 Adding to this inefficiency, regionalized quaternary pediatric ICUs frequently run at full capacity. The transfer of some pediatric patients to a quaternary pediatric referral center is often not necessary if there is a closer hospital with adequate pediatric capabilities, such as a level II or community pediatric ICU, an intermediate or step-down pediatric care unit, or a general ICU with pediatric expertise. 59
Admitting some of the less ill children to hospitals other than regional quaternary referral centers can result in a high quality of care provided with shorter length of stays, less resource use, and lower costs. 60–62 It is therefore logical that some mildly or moderately ill children (eg, children with asthma who require continuous albuterol or children with known diabetes and mild diabetic ketoacidosis) can be cared for in level II or community pediatric ICUs or other non-children's hospital ICUs under the care of pediatric nurses and physicians with supervision from a regional children's hospital pediatric critical care team using telemedicine and remote monitoring. 63
Telemedicine can be used by pediatric critical care clinicians using a broad range of applications to assist in the care of hospitalized children in a variety of clinical scenarios. 64 Physician consultations, nurse and physician monitoring, and medical oversight can range from a simple model of intermittent, need-based consultations (reactive model) to a model that integrates continuous oversight via monitoring and proactive medical decision making (continuous model). 65 In a reactive model, a pediatric critical care physician can provide bedside telemedicine consultations to patients in remote EDs, inpatient wards, high-acuity units, or ICUs. Such consultations could prompt a variety of clinical interventions, including recommendations on diagnostic studies, medications, or other therapies. The consultation may also conclude the need to transport the patient to the regional pediatric ICU. This type of model could result in a range of interventions from a one-time consultation to multiple videoconferencing interactions during the course of the day or hospital stay. 66,67
In the continuous model, oversight by critical care physicians and nurses is provided by telemedicine in combination with comprehensive electronic remote monitoring. In such a model, a remote team of physicians and nurses is able to monitor many patient beds, often covering several ICUs. This continuous oversight model of telemedicine is more proactive with medical interventions and often involves nontelemedicine guidelines such as the implementation of evidence-based protocols. This electronic ICU is created by centralizing electronic health records, ICU monitoring technologies, and nurse/physician video oversight. Tele-ICUs can be created internally by large health systems or can be contracted out to third-party technology and physician organizations that specialize in remote ICU monitoring services.
There is a trend within pediatric critical care toward 24-hour in-house attending-level coverage, but many pediatric ICUs continue to use a system of overnight coverage by trainees at the bedside, with attending backup from home. Another novel use of telemedicine allows at-home pediatric ICU physicians to connect to the ICU at night to assist the onsite team in a reactive mode. 68 This method has been shown to be feasible, although it has not been rigorously assessed with regard to quality. The reactive telemedicine model has also been reported by other pediatric specialists to provide inpatient consultations, including cardiology consultations and ethics consultations. 69,70