Wednesday, October 24, 2012

PICU Study Finds Telemedicine Feasible for Remotely Managing Care

Chief of Pediatric Critical Care Medicine Natan Noviski, MD, and critical care physician Phoebe Yager, MD, on the portable videoconferencing unit.

In a recent study, the Pediatric Intensive Care Unit (PICU) at MassGeneral Hospital for Children (MGHfC) found that nighttime telemedicine linking staff intensivists on overnight home-call with PICU bedside care providers, patients and their families is technologically feasible and beneficial for remotely managing critically ill patients. Published in the Critical Care Medicine June 2012 issue, the study reviewed 56 telemedicine encounters with patients between the ages of 0 and 19 who were seen between May 2010 and July 2011. In these encounters, PICU attending physicians used video conferencing technology from their homes to evaluate patients, communicate with the bedside team and reassure families.

Critical care physician Phoebe Yager, MD, recalls one high-risk case that prevented a potentially lethal intervention in a 2-year-old patient. The boy was having trouble breathing at night after having airway surgery, and the bedside team called Dr. Yager at home using the “Bot,” the PICU staff’s nickname for the portable videoconferencing station. The team was prepared to re-intubate the boy, an invasive procedure that eases airway distress but can have serious consequences in a patient with a fresh airway reconstruction. Using the video remote controls, Dr. Yager examined the patient closely, reassured the team that the patient had demonstrated similar breathing earlier in the day, and recommended non-invasive therapies to avert re-intubation.  

“A traditional phone conversation is limited by the fact that you can’t see the patient and are only hearing input from one member of the bedside team,” says Dr. Yager, director of telemedicine at MGHfC. “Telemedicine enables multiple members of the bedside care team to participate in a discussion and helps to ensure clear communication.

Currently, all seven PICU attending physicians have videoconferencing units in their home offices. When they are on-call at night, they have the ability to telecommute to the bedside of each PICU patient for immediate videoconference consultations with on-site residents and fellows. Prior to videoconferencing technology, a single member of the on-site team would make a telephone call, and the attending physician would have to make recommendations and decide whether to travel back to the hospital based on limited, second-hand information. Specialists still may choose to travel to the hospital after a video-call, but Dr. Yager says the ability to see a patient on camera, hear all perspectives from the team in real time and make therapeutic recommendations before returning to the hospital is vital to optimizing care. “One look is worth a thousand words,” says Dr. Yager. The technology is also used to help stabilize critically ill pediatric patients in outlying community hospitals. 

“Telemedicine offers a new paradigm in the delivery of care,” says Natan Noviski, MD, Chief of Pediatric Critical Care Medicine. “Parents can be reassured that the attending physician who saw their child during the day will also be there at night. It establishes credibility and trust.”

While videoconferencing can be more effective than a telephone call, physicians can sometimes face a learning curve when training to use the video system. PICU staff should not be deterred though, Dr. Yager says, as comfort levels only improve with practice. The PICU staff are instructed on proper use of the software, and periodic refresher training is offered to maintain skills and disseminate best practices.

The origins of telemedicine reach back to the 1960’s, but it was not until the past decade that the technology became widespread due to advances in telecommunications. Telemedicine at MGH had its beginnings in 1967, when it connected with Logan International Airport as a way for MGH physicians to evaluate airport employees and travelers who were ill. Since then, telemedicine services were established between the PICU and the pediatric emergency room at North Shore Children’s Hospital in 1997 to help stabilize critically ill patients before they were transported. The MGHfC PICU continues to be only one of a handful of PICUs in the United States with a telemedicine program, according to the American Telemedicine Association. The pediatric telemedicine team is currently expanding its services to include neonatal consults with faculty from the MGHfC Neonatal Intensive Care Unit as well as outpatient consults with various pediatric subspecialists. 

“We need our most senior clinicians to take care of our sickest patients,” says J. Perren Cobb, MD, Director of the Massachusetts General Hospital Critical Care Center. “Patients can come in at any time, sometimes in the middle of the night. Telemedicine facilitates the MGH mission: we serve everybody, everywhere.”

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