Telemedicine in Pediatrics Assessment of Critical Care Patients

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 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 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 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 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 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 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

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 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