Chapter 13: Pediatric Emergency and Critical Care Telehealth

A 7-year-old boy is found unresponsive at the bottom of a swimming pool. Cardiopulmonary resuscitation is initiated by first responders, and the child is rushed to the closest hospital. The internal medicine physician covering the emergency department (ED) at this critical access hospital has limited experience with critically ill children. Upon arrival, the staff continues resuscitation and immediately activates a pediatric tele-emergency consultation. Within a minute, a pediatric emergency medicine physician from the regional pediatric quaternary care center is connected to the bedside with telemedicine, with high-quality audiovisual communications, ready to assist the team. With the expert guidance and teamwork, the resuscitation is successful, and the child is transported to the regional pediatric hospital for definitive care.

A 4-year-old girl with a history of asthma presents to a community hospital ED in respiratory distress. The physician administers IV steroids and initiates breathing treatments, but it becomes clear that the patient needs hospital admission and close observation. Previously, a child on continuous albuterol would need to be transported several hours to the closest pediatric intensive care unit (ICU), but with a remote monitoring program in place, the child is admitted to the local community hospital with 24/7 monitoring by a pediatric critical care physician. With this collaborative treatment between the bedside team of respiratory therapists, nurses and physicians, and the telemedicine team, the child improves and after 3 days is able to go home. An expensive, risky interfacility transfer was avoided, and the patient received high-quality pediatric care in her home town, which provided good outcomes and patient-and family-centered care.

A 6-month-old with a diffuse rash presents to a small rural ED. The general emergency medicine physician has seen many rashes, but never one like this. The child is otherwise well appearing, but the physician does not feel comfortable making a diagnosis. Previously, he would have transferred the child 4 hours to the closest pediatric referral center, but with their telemedicine program, she is able to activate a consultation with a pediatric emergency medicine physician. The remote physician takes a full history and performs a physical exam and is able to efficiently diagnose and treat the child without the patient ever leaving their hometown.

Each of these scenarios illustrates how the use of telemedicine by pediatric emergency and critical care clinicians can address disparities in timely access to care, improve clinical outcomes, and reduce health care costs, all while improving the quality of care delivered to children.

According to the 2010 Census, rural areas of the United States are home to nearly 20% of the population. As a result, many children face significant access barriers to important pediatric health services. ^1,2 These barriers include geographic challenges for families living in rural communities, a relative shortage and maldistribution of general pediatricians and pediatric subspecialists, and social and economic barriers that make it difficult to travel to locations where pediatric health services are provided. Primary care pediatricians working in rural communities also report greater barriers in accessing subspecialty care compared to other providers. ³ These barriers and differential access to pediatric care are at least partly to blame for disparities in health outcomes, particularly for children with special health care needs living in underserved, rural communities. ⁴ Children with suboptimal access to care have been shown to more frequently forgo visits to pediatric subspecialists and to rely more heavily on the ED for care. ^5,6

For critically ill children where access to expertise is urgent, these health care disparities can mean the difference between life and death. The care provided in the ICU is increasingly complex and requires state-of-the-art facilities, the most modern technologies, and a comprehensive team of specially trained multidisciplinary providers and ancillary personnel. As a result, care of ICU patients has become more complicated, and patients are increasingly exposed to failures in the care delivery that result in mistakes, complications, and even death. In fact, it is estimated that on average, every patient admitted to an average U.S. ICU experiences 1.7 potentially life-threatening errors each day, and each year some 50,000 patients die from preventable deaths. ⁷

In the past two decades, two major health system factors have been identified that maximize the chances of high-quality care and minimize risks of mistakes and complications in the ICU. The first factor is the regionalization of specialty ICU services. ICU regionalization is a means of concentrating medical expertise and increasing patient volumes at designated referral and tertiary care hospitals. Higher patient volumes often result in increased care efficiency and improved patient outcomes. Well-known examples include the regionalization of trauma, specialty surgical procedures, adult critical care, and neonatal and pediatric intensive care. ^8–14

The second factor shown to improve outcomes and quality of care in the ICU is to ensure that all patients are actively cared for by critical care physicians. In both adult and pediatric ICUs, research demonstrates that critically ill patients have a lower risk of death, shorter ICU and hospital length of stay, and receive higher-quality care when critical care physicians are involved in their management. ^15–18 In fact, researchers estimate that ICU mortality is reduced by some 10% to 25% when critical care physicians direct patient care compared to ICUs, where critical care physicians have little to no involvement in patient care. ^15,18

Unfortunately, not all critically ill patients are cared for in regionalized ICUs, nor are they uniformly treated by critical care physicians. Although regionalization improves patient care, by its design it also creates disparities in access. For example, Figure 13-1 shows a map of the United States with the geographical region surrounding the children's hospitals registered with the Children's Hospital Association; those living in the shaded area are within a one-hour drive of a regionalized children's hospital, and those living outside the shaded area live more than one hour from a regionalized children's hospital. Using census data from 2016 and an estimated total U.S. population of 322,431,073, the total pediatric population (age less than 18 years) that live within the shaded area is 57,244,788, or 77.3% of the total pediatric population, and the total pediatric population living outside the shaded area (and residing more than 60 minutes from a children's hospital) is 16,810,409, or 22.7% of the total pediatric population.

Acutely ill patients living in nonurban areas are by necessity treated and cared for in hospitals that lack full pediatric ICU (PICU) services and critical care expertise, ¹⁹ resulting in risk of both delays in care and inappropriate care. ^20,21 Magnifying this problem is the continued shortages of critical care physicians for both adult and PICUs, which is expected to worsen in future years. ^22,23

Telemedicine is defined as the provision of health care over a distance using telecommunications technologies. It can be used to supplement efforts to both maintain the regionalization of ICU services and help specially trained critical care physicians participate in the care of critically ill patients in other locations. Telemedicine technologies can be used to more efficiently increase access to specialty care services, including critical care physicians, to patients living in underserved and remote communities and in community hospitals where the full spectrum of ICU and critical care services are not available. ^24,25 By importing specialty expertise using telemedicine, EDs, inpatient wards, and intensive care units are given the means to increase their capacity to provide a higher quality of care to critically ill patients. Critical care physicians can also increase their efficiency with these technologies so that their expertise can be shared with more patients at more than one ICU or hospital at a time. In addition, telemedicine use can potentially reduce patient transfers of less severely ill and injured children to referral centers, thus reserving limited ICU beds to those most in need of care at a regionalized center. ^26,27 For these reasons, use of telemedicine in pediatric emergency and critical care is increasing and is expected to become a technology that most centers will use in future practice.

Although telemedicine can be part of the solution to disparities in access to critical care physicians and specialized care, it is not meant to obviate the transfer of critically ill patients in need of services at a regional ICU, nor is it meant to replace an onsite critical care physician. Instead, as numerous clinical programs across the country have demonstrated, critical care providers can use telemedicine and remote monitoring technologies to immediately share their expertise in a variety of clinical scenarios.

In this chapter, we review how telemedicine can be used by pediatric emergency and critical care physicians. Specifically, we review how telemedicine can be used in remote hospital EDs during the transport of critically ill children, in hospital inpatient wards, and in remote ICUs where pediatric critical care specialists are not immediately available.

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

Telemedicine ICU consultations involve real-time, interactive, high-definition video and audio communication between the specialist at the regional children's hospital and health care provider at the remote hospital. Therefore, in developing a telemedicine program that originates from a children's hospital, there are many technical challenges to address, considering the goal is to provide 24/7 immediate assistance to critically ill infants and children. It is a requirement to have on-call systems for both clinicians and the technical personnel at both the remote and regional ED and ICU.

Telecommunication lines need to be reliable and have adequate bandwidth to maintain quality of service. In the past, this required the use of dedicated telecommunication lines, such as complete or fractionated T1 lines, Integrated Services Digital Network (ISDN), or some other private networking telecommunication systems. Currently, however, the Internet is more often used, as the connection speeds and audio-video quality have become more reliable. Further, modifications to allow encryption need to be made so that the communications are compliant with the Health Insurance Portability and Accountability Act (HIPAA). A common solution to this is built-in videoconferencing unit encryption, the use of private networks, and/or establishing a virtual private network (VPN) tunnel. Careful consideration of the telemedicine imaging equipment is also needed. Remotely controlled videoconferencing devices offer a range of quality and can be ceiling mounted, wall mounted, pole mounted, or even mounted on mobile robotic platforms. Peripheral devices, such as high-resolution exam cameras, stethoscopes, otoscopes, and ophthalmoscopes, are available; however, it may be easier to have the remote physician or nurse describe physical findings, such as pupillary responses, than to have a remote operator use the camera. In the continuous oversight telemedicine models, the connections for live cardiorespiratory and pressure monitors are needed, as well as the option for live monitoring of ventilators or other devices. In some cases where these monitoring systems are not used, as in the consultative model, a remotely controlled video camera can be directed for close-up, real-time monitor visualization and other equipment with interpretations similar to physical bedside interpretations.

Previous studies have shown that the use of telemedicine in the ED to deliver consultations is similar to in-person consultations in terms of diagnostic accuracy, treatment plans, and plans for disposition. ^{46,63,71–74} The use of telemedicine to urgently obtain a consultation from a neurologist in the ED to treat a patient with an acute stroke is now common practice. ^71,74–76 Similarly, telemedicine is used to provide emergency medicine consultations to critical access hospitals, which are staffed by physician assistants. ⁷⁷ Both of these examples have been shown to result in high-quality, cost-effective care. ^77–79

There is increasing evidence and acceptance that providing pediatric emergency and critical care consultations to remote EDs for critically ill children can improve the quality of care and increase provider, patient, and parent/guardian satisfaction. ^72,80 Three studies have described how pediatric critical care physicians use telemedicine to provide consultations to critically ill children presenting to several rural EDs. ^63,72,80 Heath and colleagues ⁷² at the University of Vermont concluded that use of telemedicine was associated with improved patient care and was superior to telephone consultations. ⁸¹ A study by Dharmar and colleagues ⁸² showed that patients receiving telemedicine consultations in remote EDs received higher overall care quality compared with similar patients receiving telephone consultations. ⁸⁰ Both of these programs also reported that referring ED physicians more frequently changed their diagnoses and/or therapeutic interventions than when consultations were provided by telephone. In addition, the use of telemedicine to provide critical care consultations has been shown to result in significantly higher parent/guardian satisfaction and perceived quality compared with telephone consultations. ⁸⁰

Published data from a consultative telemedicine program show excellent clinical outcomes for the reactive consultative model described earlier, including mortality and length of stay, similar to severity-adjusted benchmark data from a set of national pediatric ICUs. ^66,67 Programs have reported a high degree of satisfaction among remote providers and parents/guardians and allowed patients to remain in their local communities, thereby lessening the burden on family members. In addition, implementation of this consultative telemedicine model resulted in an overall reduction in health care costs because of more appropriate transport use and decreased use of the more costly regional pediatric ICU. ⁸³ Moreover, the use of telemedicine to assist with cardiopulmonary resuscitation has been reported. ⁸⁴

Success factors for current programs for pediatric emergency and critical care telemedicine in a recent survey included identifying spoke hospitals based on receptivity and cultivating clinical champions at the spoke facilities. ⁸⁵ Several barriers were also identified, including credentialing, workflow integration at both sites because telemedicine consults require more time compared to telephone consults, usability of the technology, lack of physician buy-in, and misaligned incentives between the sites. Uneven reimbursement was also mentioned, but was not perceived as a major issue because many programs operate independently of reimbursement.

Most of the hub sites are academic institutions that may have motivations other than reimbursement. Overall, although more research is needed, there is mounting evidence that pediatric critical care consultations to rural and underserved EDs using telemedicine can be used to help address disparities in access to specialists and, in doing so, improve the overall quality of care. It is also likely that because of better care and the reduction in unnecessary transports, telemedicine consultations to rural and underserved EDs can be provided in a cost-efficient manner that reduces the health care costs that would otherwise be incurred if telemedicine were not used. ⁸³

Pediatric telehealth, particularly in times of emergency or critical care consultation, should be held to the same standard of quality as in-person care. The necessary equipment and connections described earlier must be available, and telemedicine must operate on a sustainable infrastructure in order to provide quality care for children. It is essential that providers use all the same diagnostic tools necessary to assess and treat children. Many refer to this as an “in-person equivalent.” Even if the telehealth providers cannot physically be at the bedside to examine the child, they need to collaborate with the bedside team using appropriate equipment to virtually emulate the exam that they would perform in person.

Improvements in technology, including connection speeds, radiology image transfer, and integrated electronic medical records systems, will all be essential in improving care of children through telemedicine. Quality care should also reflect the “medical home model of quality pediatric care: care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.” ⁸⁶

In 2015, the American Academy of Pediatrics (AAP) Section on Telehealth Care published a technical report on the use of telemedicine in pediatrics. ⁸⁷ This report chronicled the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care. It also provided a report on the use of telemedicine in response to emergencies and disasters and the use of telemedicine to provide subspecialty consultations to remote and underserved populations.

The AAP Committee on Pediatric Workforce also released a policy statement in 2015 about the use of telemedicine to address access and physician workforce shortages. ⁸⁶ A key point of this guideline is that telemedicine should be used in the context of the medical home. Telemedicine should improve access to care while also preventing further fragmentation of care.

The American Telemedicine Association released a set of guidelines regarding tele-ICU care in 2014. ⁸⁸ The purpose of these guidelines was to assist administrators, practitioners, and information technology specialists in establishing safe and effective models of care using telemedicine. This document established core guidelines for tele-ICU operations, including administrative guidelines, guidelines for the clinical application for the practice of tele-ICU, and technical guidelines.

The use of telemedicine in pediatric emergency and critical care is expanding, as there is increasing evidence that it can improve access, timeliness, quality of care, and cost of care for critically ill pediatric patients. Telemedicine can help provide children with subspecialist care in their moment of need while also reducing unnecessary testing and transfers. Studies in pediatric emergency medicine and critical care telemedicine have shown promising results. By continuing to operate in a manner to support the pediatric medical home, telehealth can continue to make a positive impact on pediatric emergency and critical care.