Telemedicine




 

Telemedicine service helps lower mortality rate in paediatric pilot program

Ricardo Muñoz, MD and Alejandro López, MD report on a Paediatric Cardiac Critical Care Pilot Program at Children’s Hospital of Pittsburgh at University of Pittsburgh Medical Center (UPMC) which demonstrates the potential of telemedicine to improve care for patients around the world.

Paediatric cardiac critical care is a field in which decisions requiring a high degree of clinical expertise must be made in a timely fashion. But physicians with specialist training in paediatric cardiac intensive care are in demand worldwide. In some countries, other resource challenges exacerbate the difficulty of providing adequate care for a growing population of surviving children with complex congenital heart defects. Results from a 10-month pilot international telemedicine initiative involving paediatric cardiac intensive care units (CICUs) in the United States and Colombia demonstrate the potential of telemedicine to improve medical care for paediatric cardiac patients around the world, as reported in the March 2012 issue of “Telemedicine and eHealth”.

Background

The Fundación Valle del Lili in Cali, Colombia, is a 368-bed tertiary care teaching hospital with a 10-bed paediatric intensive care unit (PICU), a six-bed cardiac intensive care unit (CICU), and two full-time paediatric cardiac intensive care specialists. Children’s Hospital of Pittsburgh of UPMC in Pittsburgh, Pennsylvania, has a 36-bed PICU, a 12-bed CICU, two fulltime cardiac intensive care specialists, and one full-time paediatric intensive care specialist with vast experience in cardiac critical care.

Collaboration between the paediatric CICUs at the two institutions began in 2008 with the initiation of a telephonebased system to provide as-needed medical consultations. Although this system was useful, it had the obvious limitation that the specialists in Pittsburgh were unable to see the patients in Cali, evaluate their general appearance, and review diagnostic images. The exchange of information was based solely on the subjective interpretation of the local intensive care specialist.

In February 2010, a telemedicine system was implemented at both CICUs. The system consists of two identical mobile carts, each equipped with a videoconferencing unit, a 22-inch monitor, a wireless Internet connection, and a portable power supply that enables the cart to run for up to two hours without being connected to an electrical outlet. One cart was located in the office of Ricardo Muñoz, MD, chief of the Paediatric Cardiac Intensive Care Unit at Children’s Hospital. The other cart was located in the CICU at Valle del Lili.

Study methods

A study was conducted of telemedicine consultations for 53 paediatric patients admitted to the CICU at Valle del Lili between March 1 and Dec. 31, 2010. All consultations were carried out between Dr Muñoz and one of the two on-call cardiac intensive care specialists at Valle del Lili, María Motoa, MD, and Gabriel Santiago, MD. Whenever the specialists in Cali felt they needed advice to manage a patient, they contacted Dr Muñoz by e-mail, which was converted to and immediately delivered as a page. Consultations were usually limited to more complex and sicker patients.

Upon receiving a page from the specialist in Cali, Dr Muñoz placed a phone call through the videoconferencing system to begin a consultation. The patient’s case was presented to Dr Muñoz via videoconference. The mobile cart at Valle del Lili was moved within the CICU as needed to provide Dr Muñoz with any visual information he needed about the case. Data such as vital signs, pressure values, electrocardiograms, relevant laboratory test results, and diagnostic imaging studies were presented for Dr Muñoz’s review.

Following the presentation of the clinical case, Dr Muñoz offered recommendations for further evaluation, treatment, or both. These recommendations most often related to surgery, management of arrhythmias, and cardiac catheterization studies. Once the videoconference ended, the specialist at Valle del Lili decided how best to follow Dr Munoz’s recommendations in managing their patient.

Results

Approximately two to three telemedicine contacts per week occurred during the study period. A total of 71 recommendations were given for 53 patients, of whom 70% were male and 72% were surgical cases. The patients’ average age was 10 months, ranging from 7 days to 20 years.

The length of the telemedicine consultations ranged from 10 minutes to 45 minutes, with an average of 20 minutes. In addition to the on-call videoconferences for consultations on specific patients, the medical staff of the two CICUs participated in scheduled monthly multidisciplinary videoconferences to review other cases and engage in medical education.

At the end of the 10-month study period, a survey was conducted to gauge the Valle del Lili participants’ satisfaction with the telemedicine service. Nine people – the two cardiac intensive care specialists, the cardiac surgeon, the chief of nursing, and five intensive care fellows rotating in the CICU – were sent an electronic link to a 12-question Internet-based survey that could be completed and submitted anonymously. Eight of the nine recipients (89%) responded to the survey.

Six respondents said they used the telemedicine system one or more times per week; two said they used it two to three times per month. All respondents agreed to continue using the system and said they would recommend it to other paediatric intensive care specialists. All reported being satisfied or very satisfied with both the technical and medical aspects of the system (see table).



Four survey respondents said they always followed the recommendations offered in the telemedicine consultation, three said they did so regularly, and one did so half the time. Although an objective method was not used to quantify clinical outcomes in cases in which telemedicine recommendations were given, six respondents attributed improvements in the patients’ clinical condition to the telemedicine recommendations. Eighty-four percent of respondents said that at least 50% of the time the telemedicine recommendations had led them to make a change in their plans for the patient’s medical care. All respondents agreed that the scheduled monthly multidisciplinary videoconferences were useful.

Discussion

The results of this study show that telemedicine is a feasible tool for paediatric cardiac intensive care specialists around the world who seek medical advice from an experienced international centre. Use of the Internet to transmit data made the telemedicine system highly versatile, easy to access, low in cost, user friendly, and secure. Issues relating to poor connectivity or poor quality of the audio or video signal were seen in fewer than 5% of all calls made through the videoconferencing system.

According to the two intensive care specialists at Valle del Lili, two of the most important changes that have taken place in that paediatric CICU since the inception of the telemedicine program are more opportune surgical decisions and increased use of cardiac catheterization studies. An extracorporeal membrane oxygenation (ECMO) program – an advanced form of life support for patients whose heart and lungs are failing – began at Valle del Lili after the telemedicine program went into operation; however, recommendations related to ECMO were infrequent, possibly due to the few patients treated with ECMO at Valle del Lili during the study period.

Total mortality in the paediatric CICU at Valle del Lili during the period of the telemedicine study was 4%, compared with 9.3% in the previous year. The study design precludes attributing this decline in mortality to the telemedicine program. It is the authors’ opinion, however, that prospective studies that address mortality as a specific outcome will confirm this observation.

Expansion of the telemedicine initiative

During the period of this study the paediatric CICU at Children’s Hospital did not have an intensive care specialist providing telemedicine consultations full time. In July 2011, Alejandro López, MD, joined the medical staff of the CICU in the role of full-time telemedicine specialist. A native of Mexico, Dr López trained in paediatric cardiology at Massachusetts General Hospital and Children’s Hospital of Boston and served as chief of the Echocardiography Laboratory at the Instituto Nacional de Pediatria in Mexico City for three years before joining Children’s Hospital.

Since Dr López’s appointment as fulltime telemedicine specialist, the telemedicine initiative has expanded to encompass four paediatric CICUs in Latin America: three in Colombia and one in Mexico. In addition to Valle di Lili, the participating paediatric CICUs in Colombia are the Fundación Cardiovascular de Colombia in Bucaramanga and the Clinica Cardiovascular Congregación Mariana in Medellín.

In January 2013 technical tests were initiated for a telemedicine collaboration between Children’s Hospital and the Hospital Infantil de México Federico Gomez in Mexico City, the oldest dedicated paediatric hospital in Latin America, which is a tertiary referral centre for all paediatric subspecialties and a national referral centre for complex paediatric cardiac surgery. Once fully operational, this program will encompass both consultations for postoperative or medically complex paediatric cardiac patients and participation in weekly surgical rounds.

Since his appointment in July 2011, Dr López has participated in more than 900 telemedicine consultations. He conducts tele-assisted medical rounds in paediatric patients with complex or critical heart disease, providing consultations daily on weekdays and as needed on weekends and holidays. He interacts directly with the remote physicians and evaluates each clinical situation based on the patient’s history, laboratory findings, and the results of diagnostic imaging studies, using this information to provide recommendations to the remote team relating to further diagnostic testing and medical, interventional, or surgical treatment.

Many consultations involve reading cardiac ultrasounds in “real-time”; occasionally Dr López assists in real time with additional diagnostic testing or medical interventions such as electrophysiology tests and treatment, adjustments of mechanical ventilation, and ECMO tests or adjustments. In one case, he assisted in real-time with a cardiopulmonary resuscitation.

The authors are now working with their Latin American counterparts to design a prospective, randomized study with the aim of quantifying the results of telemedicine consultations for paediatric cardiac intensive care patients treated at the centres in Colombia and Mexico. Study outcomes will be presented in terms of mortality, frequency of complications, length of stay in the CICU, and costs.

In conclusion, this pilot initiative demonstrates that telemedicine is a feasible option for paediatric intensive care specialists who seek experienced assistance in the management of complex paediatric cardiac patients. Real-time remote assistance, provided by means of relatively simple, easily installed technology, may improve medical care for paediatric cardiac patients in developing countries.

The Authors

Ricardo Muñoz, MD, FAAP, FCCM, FACC, is chief of the Cardiac Intensive Care Division and director of the Cardiac Recovery Program for Children’s Hospital of Pittsburgh of UPMC. He is also Children’s Medical Director for Global Business and Telemedicine. Dr Munoz attended medical school at the Universidad del Norte, Barranquilla, Colombia and completed his residency in paediatrics at the Hospital Militar Central, Bogota, Colombia, Massachusetts General Hospital, and Children’s Hospital Boston. He also completed fellowships in paediatric critical care medicine at Massachusetts General Hospital and in paediatric cardiology at Children’s Hospital in Boston. Email: munorx@upmc.edu

Alejandro López, MD, is clinical assistant professor of Telemedicine at Children’s Hospital of Pittsburgh of UPMC. He is trained in paediatric cardiology at Massachusetts General Hospital and Children’s Hospital of Boston and served as chief of the Echocardiography Laboratory at the Instituto Nacional de Pediatria in Mexico City for three years before joining Children’s Hospital of Pittsburgh. Email:
lopezmagallonaj@upmc.edu

 Date of upload: 20th May 2013

 

                                  
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