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Remote video neonatal consultation: A system to improve neonatal quality, safety and efficiency

2013; Elsevier BV; Volume: 85; Issue: 2 Linguagem: Inglês

10.1016/j.resuscitation.2013.11.003

1873-1570

Christopher E. Colby, Jennifer L. Fang, William A. Carey,

Context-Aware Activity Recognition Systems

Perinatal care networks often resemble a spoke-and-hub model in which one regional perinatal center partners with several community hospitals to provide consultative and emergency transport services to expectant mothers with high-risk pregnancies and critically ill neonates. Despite a network's best efforts, neonatal emergencies occur in settings potentially unequipped to respond immediately and expertly. One unintended and untoward consequence of this construct is that neonates are at higher risk of morbidity and mortality if they are born in hospitals with lower-level neonatal intensive care units (NICUs).1Cifuentes J. Bronstein J. Phibbs C.S. Phibbs R.H. Schmitt S.K. Carlo W.A. Mortality in low birth weight infants according to level of neonatal care at hospital of birth.Pediatrics. 2002; 109: 745-751Crossref PubMed Scopus (211) Google Scholar, 2Phibbs C.S. Baker L.C. Caughey A.B. Danielsen B. Schmitt S.K. Phibbs R.H. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.N Engl J Med. 2007; 356: 2165-2175Crossref PubMed Scopus (382) Google Scholar, 3Lorch S.A. Baiocchi M. Ahlberg C.E. Small D.S. The differential impact of delivery hospital on the outcomes of premature infants.Pediatrics. 2012; 130: 270-278Crossref PubMed Scopus (139) Google Scholar While the cause of this outcomes disparity is multifactorial, the timeliness and effectiveness of those providing resuscitative efforts at birth may be contributing factors. Another limitation of the spoke-and-hub model is the manner in which a neonatologist may assist local providers with their resuscitative efforts. In the current state, local providers must first conduct their initial resuscitation before leaving the bedside to request the dispatch of a transport team and discuss further interventions with a neonatologist. In this model, the neonatologist becomes involved only after critical first steps have already been taken. Furthermore, this model requires the neonatologist to rely on a brief verbal report from the local provider in order to formulate a plan for next steps. It is only hours later, following transport, that a neonatologist becomes directly involved in the patient's care. Because the majority of births in the United States occur in hospitals without a level IV NICU, new strategies to improve outcomes for newborns irrespective of birth hospital must be identified. Communications technology is readily available to address many of these issues and may be a means by which to narrow the outcomes disparity between low- and high-volume delivery hospitals. Adult intensive care units already utilize telemedicine for consultative services.4Lilly C.M. Cody S. Zhao H. et al.Hospital mortality, length of stay, and preventable complication among critically ill patients before and after tele-ICU reengineering of critical care processes.JAMA. 2011; 305: 2175-2183Crossref PubMed Scopus (317) Google Scholar, 5Young L.B. Chan P.S. Lu X. Nallamothu B.K. Sasson C. Cram P.M. Impact of telemedicine intensive care unit coverage on patient outcomes. A systematic review and meta-analysis.Arch Intern Med. 2011; 171: 498-506Crossref PubMed Scopus (168) Google Scholar Thus, these systems could easily be reengineered to make neonatologists immediately available for remote video consultation, essentially diffusing neonatal expertise throughout a perinatal care network. At our institution, we have begun a pilot program that allows our neonatologists to partner with providers in our health system to facilitate neonatal resuscitation and optimize outcomes. Examples of various cases are listed in Table 1.Table 1Examples of pilot cases, including a description and how remote video consultation was used to improve outcomes and minimize risks.Case numberCase descriptionOutcomes optimized and risks mitigated1Mother with no prenatal care delivered an infant thought to be at the limit of viability.Gestational age was assessed, resuscitation was recommended, and guidance was offered.The local provider was uncertain if resuscitation was indicated.The infant was ultimately discharged home without long-term morbidities.2A late preterm infant developed worsening respiratory distress.A diagnosis of respiratory distress syndrome was made based on patient assessment and review of radiographs.The local provider was unsure of the diagnosis and if transportation was indicated.The infant was intubated, given surfactant, and transferred to the regional NICU.3A two-day-old newborn was noted to be jittery.After review of the history and video evaluation of the patient, it was determined that maternal medications were the likely source of the infant's symptoms.The local provider requested transfer for possible seizures.He remained with his mother at the local hospital.4A full term infant was noted to have hemihypertrophy and a large hemangioma.A remote consultation was performed between the local hospital and a neonatologist and dermatologist.The local providers were unsure of the diagnosis and need for transfer for further evaluation.The diagnosis was made, and the infant was managed locally with close dermatology follow-up.5A mother precipitously delivered a 25 week gestational age infant at home, who was then brought to the local hospital.The providers were guided through the resuscitation, which included airway management and decompression of a tension pneumothorax.Local providers requested assistance with the resuscitation.Ultimately, the nuances of offering palliative care were offered remotely. Open table in a new tab These cases demonstrate the feasibility of using remote video consultation to partner with local providers in a network to improve patient safety and quality of care, while reducing cost by avoiding unnecessary neonatal transports. A deidentified survey was sent to local providers participating in the pilot study (physicians and nurses n = 14) and response to this technology has been positive. Ninety-three percent of respondents agreed that this would improve neonatal outcomes. Moreover, they agreed there is a need for remote video consultation and that it strengthens relationships to support local providers. Considerable hypothesis-driven testing is needed to determine whether remote video consultation can be a true breakthrough in improving newborn outcomes. The results from the pilot phase of this project suggest that it is a feasible concept worthy of investigation. None of the authors of this manuscript have a conflict of interest. We would like to thank the neonatologists at Mayo Clinic for participating in this pilot program: Garth Asay MD, Douglas Derleth MD, Tara Lang MD, and Robert V Johnson MD. As well as our colleagues within the Mayo Clinic Health System who partnered with us: Jeff Green MD, Marie Morris MD, Shabbir Khambaty MD, Padma Yarrapureddy MD, Behzad Goharfar MD, and Jennifer Vanberkum RN, and to our administrative fellow: Keon Jones.