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Telemedicine in Pediatrics: Assessment of Critical Care Patients Project Team: Kathleen Webster MD, Jenny Telemedicine in Pediatrics: Assessment of Critical Care Patients Project Team: Kathleen Webster MD, Jenny Wang MD, Dina Calamur MD, Cindi La. Porte RN, Sandra Swanson RN, MSOD Confidential: For Quality Improvement Purposes Only

Background Evidence and Best Practice: n Intensivists improve ICU patient outcomes 1 n Leapfrog Background Evidence and Best Practice: n Intensivists improve ICU patient outcomes 1 n Leapfrog Group 2: 5 min response 8 hr/day; ideally 24/7 n LUMC Initiative: > PGY 4 immediately available in ICU Pediatric Critical Care Unit at RMCH n 800 admissions/yr: 57% between 5 pm and 8 am n 3 pediatric intensivists q In House at least 8 -12 hrs Apr-May, 12 -15 hrs Jan-Mar q PGY 2 or 3 in house, no fellows 1 Pronovost 2 JAMA 2002; 288: 2151 -2162 http: //www. leapfroggroup. org/media/file/Fact_Sheet_IPS_080327. pdf Confidential: For Quality Improvement Purposes Only

Admissions to PCCU All Admissions Vulnerable Populations n Infants (under 1 year) q q Admissions to PCCU All Admissions Vulnerable Populations n Infants (under 1 year) q q n 21% of all admissions 72% occur at night Transfers from 4 Peds q q q 9% of all admissions 63% occur at night High risk group n Solid line: intensivist may not be in house Dotted line: +/- intensivist in house Previous studies show 2 fold increase in mortality for transfer pts vs admit from ED 3 3 Odetola et al, Pediatr Crit Care Med 2008; 9: 20 -25 Confidential: For Quality Improvement Purposes Only

Project Aim n Opportunity q q n Increase intensivist presence through use of telemedicine Project Aim n Opportunity q q n Increase intensivist presence through use of telemedicine Target vulnerable populations Goal q 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 n Two way audio visual connection q q n n Proven Solutions: Telemedicine Connection n Two way audio visual connection q q n n Proven to be accurate 4 and useful 5 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 4 Kofos 5 Allows patient assessment, including stethoscope and dialogue with team Intensivist can connect from anywhere Pediatrics 1998; 102; 58 http: //www. pediatrics. org/cgi/content/full/102/5/e 58 Marcin Pediatr Crit Care Med 2004; 5: 251 -256 Confidential: For Quality Improvement Purposes Only

Patient Evaluation by Intensivist Within 1 Hour of Admission in person telemedicine Patients Less Patient Evaluation by Intensivist Within 1 Hour of Admission in person telemedicine Patients Less Than 12 months Old Patients Transferred From 4 Peds Confidential: For Quality Improvement Purposes Only

Impact on Mortality Pre-Telemedicine (Apr 06 -Mar 07) Post-Telemedicine (Apr 07 -Mar 08) PCCU Impact on Mortality Pre-Telemedicine (Apr 06 -Mar 07) 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 4 Peds admits) Transfer mortality 1. 5% 59 (6. 7%of PICU admits, 1. 3% of 4 Peds admits) 6. 8% Confidential: For Quality Improvement Purposes Only

Number of evaluations Pediatric Critical Care Telemedicine Use Confidential: For Quality Improvement Purposes Only Number of evaluations Pediatric Critical Care Telemedicine Use Confidential: For Quality Improvement Purposes Only

Conclusions Use of telemedicine technology is effective in reaching goals for intensivist evaluation of Conclusions Use of telemedicine technology is effective in reaching goals for intensivist evaluation of pediatric critical care patients in target populations n Infant Evaluation q q q n Transfer Patient Evaluation q q q n 100% target reached 33% of evaluations are by telemedicine Decreased mortality seen 100% target reached, 59% by telemedicine Fewer transfers Higher mortality “Other” Uses q q q Deteriorating inpatient Ward/IMC pt evaluated but transfer averted Code Supervision Confidential: For Quality Improvement Purposes Only

Next Steps n n n Continue to monitor goals Evaluate “other” uses Evaluate at Next Steps n n n Continue to monitor goals Evaluate “other” uses Evaluate at risk patients through use of Tele-Rapid Response Team q n Monitor mortality of transfer patients Tele-link with ED to facilitate early intervention and triage Confidential: For Quality Improvement Purposes Only