Telemedicine in the pediatric intensive care unit

Evaluation of the use of telemedicine in pediatric intensive care units: a cluster-randomized trial

INTRODUCTION

Telemedicine has shown promising results, allowing specialists to provide rapid and effective care in remote locations. However, to our knowledge, current evidence is not robust enough to prove the effectiveness of this tool. This cluster-randomized trial (CRT) aimed to evaluate the impact of telemedicine on clinical care indicators in pediatric intensive care units (PICUs).

METHODS

An open-label CRT was conducted in 16 PICUs within the Brazilian public health system. The trial took place from August 2022 to December 2023 and compared an intervention group, which received telemedicine support, with a control group, which received usual PICU care. The primary outcome was the PICU length of stay. The main secondary outcomes were mortality rate and ventilator-free days.

RESULTS

A total of 1393 participants were included, 657 in the control group and 736 in the intervention group. The mean PICU length of stay was 10.42 (SD, 10.71) days for the control group and 11.52 (SD, 10.80) days for the intervention group. The overall mean of ventilator-free days was 6.82 (SD, 7.71) days. Regarding mortality, 7.54% of participants died in total. No significant difference was found in the outcomes between the groups.

CONCLUSION

Despite the potential benefits of telemedicine, its effective implementation in the Brazilian public health system faces considerable challenges, highlighting the continued importance of investigating and improving the role of telemedicine in pediatric critical care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT05260710 and ReBEC - RBR-7×j4wyp.

Characteristics and special challenges of neonatal emergency transports

BACKGROUND

As a rule, newborns do not require special medical care. If unexpected complications occur peripartum or postpartum, support from and transport to specialised neonatal hospitals might be needed.

METHODS

In a retrospective study, all transport protocols of a supraregional paediatric‑neonatological maximum care hospital in northwestern Germany from 01.10.2018 through 30.09.2021 were analysed. The particular focus was on transports of newborns (<7 days) and the leading symptoms that led to contact.

RESULTS

A total of 299 patients were included (average age of 15.4 h, 61.6 % males). The average complete transport time was approximately 2 h. Five leading neonatal diseases (respiratory, infectious, asphyxia, cardiac, haematological) were found to represent the causes of >80 % of transfers. Respiratory adaptation disorders are the main reason for transferring a newborn to a centre, whereas asphyxia is the most severe condition. The various symptoms differ in their time of onset, a factor which must be taken into account in practice. Differences were also found between different types of hospitals: while a large proportion of transports were carried out from maternity hospitals (80.6 %), children transported from children's hospitals were generally more severely ill.

DISCUSSION

Transfers of neonates, especially from maternity hospitals to neonatal intensive care units due to special neonatal diseases, are not rare. In times of increasingly scarce resources, the effective care of sick or at-risk neonates is essential. For low-population regions, this means professional cooperation between maximum care providers and smaller children's hospitals and maternity-only hospitals.

Queensland Telepaediatric Service: A Review of the First 15 Years of Service

In November 2000, the Queensland Telepaediatric Service (QTS) was established in Brisbane, Australia, to support the delivery of telehealth services to patients and clinicians in regional and remote locations. The QTS was built on a centralized coordination model, where telehealth services could be effectively managed by a dedicated telehealth coordinator. In doing so, telehealth referral and consultation processes were efficient and clinicians felt better supported as they adjusted to new processes for engaging with patients. We have conducted a retrospective review of activity associated with the QTS and summarized key activities which have arisen from this extensive program of work. Telehealth service records and associated publications were used to describe the evolution of the QTS over a 15-year period. From November 2000 to March 2016, 23,054 telehealth consultations were delivered for 37 pediatric clinical specialties. The most common service areas included child and youth mental health, neurology, burns care, surgery, and ear nose and throat services. A range of different telehealth service models were developed to align with different clinical service needs and location of services. Whilst most work involved video consultation between hospitals, some services involved the delivery of telehealth services into the home, schools or community health centres. Despite its longevity, the QTS was not immune to the usual challenges associated with telehealth implementation, service redesign and sustainability. Experience reported from the QTS will be useful for other health services seeking to develop comprehensive telehealth services in a rapidly changing healthcare environment.

Telemedicine in Pediatric Intensive Care Units: Perspectives From a Brazilian Experience

Purpose of Review

To present the implementation of a telemedicine project (TeleICU) in pediatric intensive care units (ICU) throughout different Brazilian regions.

Recent Findings

Although telemedicine in pediatric ICUs has shown evidence of benefit in numerous studies with potential to 18 mitigate existing disparities, in Brazil, its use is still under development. Brazil has several opportunities for implementing this resource since, according to the National Registry of Healthcare 20 Establishments (NRHE), there is a discrepancy in the density of pediatric intensive care physicians per patient and the availability 21 of pediatric ICU beds per number of inhabitants.

Summary

Health technologies are being widely used to fill gaps in the healthcare system. Telemedicine has been an important tool to meet demands in intensive care units, especially the demand for specialized assistance. TeleICU is a Brazilian model of telemedicine that performs multidisciplinary telerounds in remote pediatric ICUs and develops continuing education activities for the healthcare teams. The project aims to systematize and to qualify care, as well as to reduce risks for patients admitted to pediatric ICUs engaged in the project. Preliminary results have demonstrated a positive impact regarding this approach, providing medical care to 6640 inpatients-day in two Brazilian pediatric ICUs, for 616 patients during 946 daily telerounds.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40124-021-00242-z.

The use of telemedicine in the PICU: A systematic review and meta-analysis

The use of telemedicine in ICUs has grown and is becoming increasingly recognized. However, its impact on PICUs remains unclear. This systematic review and meta-analysis aimed to evaluate whether telemedicine in the PICU has the potential to improve clinical and non-clinical outcomes. PubMed, Scopus, LILACS, and CINAHL electronic databases were searched to identify studies that assessed the impact of telemedicine on clinical outcomes, with no publication date restrictions. The reference lists of the selected articles were hand-searched for additional studies that had not been identified by the initial electronic search. Studies were included if they had a cohort design, used telemedicine, were conducted in PICUs or specialized PICUs, and were published in Portuguese, English, or Spanish. Two groups of reviewers independently screened titles and abstracts for inclusion. The same group of reviewers independently assessed the full-text articles for eligibility and extracted the following information: telecommunication method, intervention characteristics, patient characteristics, sample size, and main results. Studies were meta-analyzed using a random-effects model to estimate the pooled prevalence of PICU mortality and length of PICU stay. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 2703 studies initially identified, 2226 had their titles and abstracts screened. Of these, 53 were selected for full-text reading, of which 10 were included and analyzed. The main results of interest were length of PICU stay, number of deaths or mortality rate, and satisfaction of health professionals and family members. The results of meta-analysis show that the mortality rate reduced by 34% with an increase of the length of PICU stay in the PICUs with the use of telemedicine. Family members and health professionals were satisfied with the use of telemedicine. Telemedicine has the potential to improve PICU outcomes, such as mortality rate and family and staff satisfaction. However, it extended length of PICU stay in the studies included in this systematic review.

Reducing Infant Mortality Using Telemedicine and Implementation Science

Optimal perinatal regionalization is a proven evidence-based strategy to lower infant mortality. Telemedicine can engage community stakeholders, providers, and patients to facilitate optimal perinatal regionalization leading to lower infant mortality. Rural community caregivers and administrators can participate in forming optimal perinatal guidelines without leaving their community. The visual picture created by telemedicine facilitates better transport decisions; ensuring infants who are transferred to larger centers truly need it while supporting smaller nurseries by providing better consultation services and back transport of patients when appropriate. Telemedicine can also provide educational opportunities to community practices, leading to better evidence-based care.

Providing Early Attending Physician Expertise via Telemedicine to Improve Rapid Response Team Evaluations

OBJECTIVES

To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams.

DESIGN

Quasi-experimental; three pairs of control/intervention months: June/July; August/October; November/December.

SETTING

Single-center, urban, quaternary academic children's hospital with three-member rapid response team: critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice: rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU.

SUBJECTS

1) Patients evaluated by rapid response team, 2) rapid response team members.

INTERVENTIONS

Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU.

MEASUREMENTS AND MAIN RESULTS

As a marker of efficiency, the primary provider outcome was time the rapid response team spent per patient encounter outside the ICU prior to disposition determination. The primary patient outcome was percentage of patients requiring intubation or vasopressors within 60 minutes of ICU transfer. There were three pairs of intervention/removal months. In the first 2 pairs, the intervention was associated with the rapid response team spending less time on rapid response team calls (June/July: point estimate -5.24 min per call; p < 0.01; August/October: point estimate -3.34 min per call; p < 0.01). During the first of the three pairs, patients were significantly less likely to require intubation or vasopressors within 60 minutes of ICU transfer (adjusted odds ratio, 0.66; 95 CI, 0.51-0.84; p < 0.01).

CONCLUSIONS

Early in the study, more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU, a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.

Paediatric tele-emergency care: A study of two delivery models

INTRODUCTION

Tele-emergency models have been utilized for decades, with growing evidence of their effectiveness. Due to the variety of tele-emergency department (tele-ED) models used in practice, however, it is challenging to build standardized metrics for ongoing evaluation. This study describes two tele-ED programs, one specialized and one general, that provide care to paediatric populations. Through an examination of model structures and patient populations, we gain insight into how evaluative measures should reflect tele-ED model design and purpose.

METHODS

Qualitative descriptions of the two tele-ED models are presented. We show a retrospective cohort analysis describing paediatric patients' key characteristics, reasons for visit, and disposition status by case/control status. Case/control patient encounter data were collected October 2015 through December 2017, from 15 spoke hospitals within each tele-ED program.

RESULTS

The two tele-ED models serve distinct paediatric populations, and measures of tele-ED utilization and disposition reflect those differences. In the specialized University of California (UC) Davis Health program, tele-ED was utilized in 36% of paediatric critical care encounters and 78% of those were transferred. In the Avera eCARE program, tele-ED was activated in 1.7% of paediatric encounters and 50.6% of those were transferred. When Avera eCARE paediatric encounters were stratified by severity, measures of tele-ED use and disposition status among high-severity encounters were more similar to UC Davis Health.

DISCUSSION

This study describes how design choices of tele-ED models have implications for evaluative measures. Measures of tele-ED model success need to reflect model purpose, populations served, and for whom tele-ED service use is appropriate.

The Impact of Telemedicine on Pediatric Critical Care Triage

OBJECTIVE

To examine the relationship between pediatric critical care telemedicine consultation to rural emergency departments and triage decisions. We compare the triage location and provider rating of the accuracy of remote assessment for a cohort of patients who receive critical care telemedicine consultations and a similar group of patients receiving telephone consultations.

DESIGN

Retrospective evaluation of consultations occurring between April 2012 and March 2016.

SETTING

Pediatric critical care telemedicine and telephone consultations in 52 rural healthcare settings in South Carolina.

PATIENTS

Pediatric patients receiving critical care telemedicine or telephone consultations.

INTERVENTION

Telemedicine consultations.

MEASUREMENTS AND MAIN RESULTS

Data were collected from the consulting provider for 484 total consultations by telephone or telemedicine. We examined the providers' self-reported assessments about the consultation, decision-making, and triage outcomes. We estimate a logit model to predict triage location as a function of telemedicine consult age and sex. For telemedicine patients, the odds of triage to a non-ICU level of care are 2.55 times larger than the odds for patients receiving telephone consultations (p = 0.0005). Providers rated the accuracy of their assessments higher when consultations were provided via telemedicine. When patients were transferred to a non-ICU location following a telemedicine consultation, providers indicated that the use of telemedicine influenced the triage decision in 95.7% of cases (p < 0.001). For patients transferred to a non-ICU location, an increase in transfers to a higher level of care within 24 hours was not observed.

CONCLUSION

Pediatric critical care telemedicine consultation to community hospitals is feasible and results in a reduction in PICU admissions. This study demonstrates an improvement in provider-reported accuracy of patient assessment via telemedicine compared with telephone, which may produce a higher comfort level with transporting patients to a lower level of care. Pediatric critical care telemedicine consultations represent a promising means of improving care and reducing costs for critically ill children in rural areas.

Telemedicine as a tool to bring clinical ethics expertise to remote locations

The American Society for Bioethics and Humanities promulgated standards for clinical ethics consultants and is currently developing a national Quality Attestation in Clinical Ethics Consultation to assist facilities in ensuring that those performing clinical ethics consultations meet minimum standards. As the field moves towards such professionalization, there is a need to provide access to qualified clinical ethicists at a broad range of medical facilities. Currently, however, there are insufficient numbers of trained clinical ethicists to staff all healthcare facilities, and many facilities lack the necessary resources to hire staff clinical ethicists. In this review, we describe several models for providing expert clinical ethics support to remote facilities that lack access to qualified clinical ethicists. Based on this analysis, we recommend telemedicine as the optimal model providing expert support to local ethics committee members tasked with providing clinical ethics consultation services.

The Association Between Insurance and Transfer of Noninjured Children From Emergency Departments

STUDY OBJECTIVE

Among children requiring hospital admission or transfer, we seek to determine whether insurance is associated with the decision to either admit locally or transfer to another hospital.

METHODS

This cross-sectional study used Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample. Pediatric patients receiving care in emergency departments (EDs) who were either admitted or transferred were included. Clinical Classifications Software was used to categorize patients into noninjury diagnostic cohorts. Multivariable logistic regression models adjusting for potential confounders, including severity of illness and comorbidities, and incorporating nationally representative weights were used to determine the association between insurance and the odds of transfer relative to admission.

RESULTS

A total of 240,620 noninjury pediatric ED events met inclusion criteria. Patient and hospital characteristics, including older age and nonteaching hospitals, were associated with greater odds of transfer relative to admission. Patients who were uninsured or had self-pay had higher odds of transfer (odds ratio [OR] 3.84; 95% confidence interval [CI] 2.08 to 7.09) relative to admission compared with those with private insurance. Uninsured and self-pay patients also had higher odds of transfer across all 13 diagnostic categories, with ORs ranging from 2.96 to 12.00. Patients with Medicaid (OR 1.05; 95% CI 0.90 to 1.22) and other insurances (OR 1.14; 95% CI 0.87 to 1.48) had similar odds of transfer compared with patients with private insurance.

CONCLUSION

Children without insurance and those considered as having self-pay are more likely to be transferred to another hospital than to be admitted for inpatient care within the same receiving hospital compared with children with private insurance. This study reinforces ongoing concerns about disparities in the provision of pediatric ED and inpatient care.

Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children's Hospital PICU

OBJECTIVES

To compare the severity of illness and outcomes among children admitted to a children's hospital PICU from referring emergency departments with and without access to a pediatric critical care telemedicine program.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic children's hospital PICU.

PATIENTS

Pediatric patients admitted directly to the PICU from referring emergency departments between 2010 and 2014.

INTERVENTIONS

None.

MEASUREMENTS

Demographic factors, severity of illness, and clinical outcomes among children receiving care in emergency departments with and without access to pediatric telemedicine, as well as a subcohort of children admitted from emergency departments before and after the implementation of telemedicine.

MAIN RESULTS

Five hundred eighty-two patients from 15 emergency departments with telemedicine and 524 patients from 60 emergency departments without telemedicine were transferred and admitted to the PICU. Children admitted from emergency departments using telemedicine were younger (5.6 vs 6.9 yr; p< 0.001) and less sick (Pediatric Risk of Mortality III score, 3.2 vs 4.0; p < 0.05) at admission to the PICU compared with children admitted from emergency departments without telemedicine. Among transfers from emergency departments that established telemedicine programs during the study period, children arrived significantly less sick (mean Pediatric Risk of Mortality III scores, 1.2 units lower; p = 0.03) after the implementation of telemedicine (n = 43) than before the implementation of telemedicine (n = 95). The observed-to-expected mortality ratios of posttelemedicine, pretelemedicine, and no-telemedicine cohorts were 0.81 (95% CI, 0.53-1.09), 1.07 (95% CI, 0.53-1.60), and 1.02 (95% CI, 0.71-1.33), respectively.

CONCLUSIONS

The implementation of a telemedicine program designed to assist in the care of seriously ill children receiving care in referring emergency departments was associated with lower illness severity at admission to the PICU. This study contributes to the body of evidence that pediatric critical care telemedicine programs assist referring emergency departments in the care of critically ill children and could result in improved clinical outcomes.

Profiling Interfacility Transfers for Hospitalized Pediatric Patients

BACKGROUND AND OBJECTIVE

The hospital-to-hospital transfer of pediatric patients is a common practice that is poorly understood. To better understand this practice, we examined a national database to profile pediatric interfacility transfers.

METHODS

We used the 2012 Kids' Inpatient Database to examine characteristics of hospitalized pediatric patients (<21 years; excluding pregnancy diagnoses) with a transfer admission source. We performed descriptive statistics to compare patient characteristics, utilization, and hospital characteristics between those admitted by transfer versus routine admission. We constructed a multivariable logistic regression model to identify patient characteristics associated with being admitted by transfer versus routine admission.

RESULTS

Of the 5.95 million nonpregnancy hospitalizations in the United States in 2012, 4.4% were admitted by transfer from another hospital. Excluding neonatal hospitalizations, this rate increased to 9.4% of the 2.10 million nonneonatal, nonpregnancy hospitalizations. Eighty-six percent of transfers were to urban teaching hospitals. The most common transfer diagnoses to all hospitals nationally were mood disorder (8.9%), other perinatal conditions (8.7%), prematurity (4.8%), asthma (4.2%), and bronchiolitis (3.8%). In adjusted analysis, factors associated with higher odds of being admitted by transfer included having a neonatal principal diagnosis, male gender, white race, nonprivate insurance, rural residence, higher illness severity, and weekend admission.

CONCLUSIONS

Interfacility transfers are relatively common among hospitalized pediatric patients. Higher odds of admission by transfer are associated not only with higher illness severity but also with principal diagnosis, insurance status, and race. Further studies are needed to identify the etiologies and clinical impacts of identified transfer differences.

Addressing health disparities in rural communities using telehealth

The regionalization of pediatric services has resulted in differential access to care, sometimes creating barriers to those living in underserved, rural communities. These disparities in access contribute to inferior healthcare outcomes among infants and children. We review the medical literature on telemedicine and its use to improve access and the quality of care provided to pediatric patients with otherwise limited access to pediatric subspecialty care. We review the use of telemedicine for the provision of pediatric subspecialty consultations in the settings of ambulatory care, acute and inpatient care, and perinatal and newborn care. Studies demonstrate the feasibility and efficiencies gained with models of care that use telemedicine. By providing pediatric subspecialty care in more convenient settings such as local primary care offices and community hospitals, pediatric patients are more likely to receive care that adheres to evidence-based guidelines. In many cases, telemedicine can significantly improve provider, patient, and family satisfaction, increase measures of quality of care and patient safety, and reduce overall costs of care. Models of care that use telemedicine have the potential to address pediatric specialists' geographic misdistribution and address disparities in the quality of care delivered to children in underserved communities.

The role of telemedicine in pediatric critical care

Telemedicine technologies involve real-time, live, interactive video and audio communication and allow pediatric critical care physicians to have a virtual presence at the bedsides of critically ill children. Telemedicine use is increasing and will be a common in remote emergency departments, inpatient wards, and intensive care units for pediatric care. Hospitals and physicians that use telemedicine technologies provide higher quality of care, are more efficient in resource use with improved cost-effectiveness, and have higher satisfaction among patients, parents, and remote providers. More research will result in improved access to pediatric critical care expertise.

Pediatric Critical Care Telemedicine Program: A Single Institution Review

BACKGROUND

Rural and community emergency departments (EDs) often receive and treat critically ill children despite limited access to pediatric expertise. Increasingly, pediatric critical care programs at children's hospitals are using telemedicine to provide consultations to these EDs with the goal of increasing the quality of care.

MATERIALS AND METHODS

We conducted a retrospective review of a pediatric critical care telemedicine program at a single university children's hospital. Between the years 2000 and 2014, we reviewed all telemedicine consultations provided to children in rural and community EDs, classified the visits using a comprehensive evidence-based set of chief complaints, and reported the consultations' impact on patient disposition. We also reviewed the total number of pediatric ED visits to calculate the relative frequency with which telemedicine consultations were provided.

RESULTS

During the study period, there were 308 consultations provided to acutely ill and/or injured children for a variety of chief complaints, most commonly for respiratory illnesses, acute injury, and neurological conditions. Since inception, the number of consultations has been increasing, as has the number of participating EDs (n = 18). Telemedicine consultations were conducted on 8.6% of seriously ill children, the majority of which resulted in admission to the receiving hospital (n = 150, 49%), with a minority of patients requiring transport to the university children's hospital (n = 103, 33%).

CONCLUSIONS

This single institutional, university children's hospital-based review demonstrates that a pediatric critical care telemedicine program used to provide consultations to seriously ill children in rural and community EDs is feasible, sustainable, and used relatively infrequently, most typically for the sickest pediatric patients.

Telemedicine: Pediatric Applications

Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of telemedicine in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine's current use bears testimony to its effectiveness and potential. Telemedicine's widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits.

Options for tele-intensive care unit design: centralized versus decentralized and other considerations: it is not just a "another black sedan"

This article seeks assist physicians or administrators considering establishing a Tele-ICU. Owing to an apparent domination of the Tele-ICU field by a single vendor, some may believe that there is only one design option. In fact, there are many alternative design formats that do not require the consumer to possess high-level technical expertise. As when purchasing any major item, if the consumer can formulate basic concepts of design and research the various vendors, then the consumer can develop the Tele-ICU system best for their facility, finances, availability of staff, coverage model, and quality metric goals.

Medical co-morbidities and practice

All-oral treatments of hepatitis C (HCV) have been trialled in patients with hereditary bleeding disorders and found to be effective. Further refinements of dosing and duration are being established. Importantly for patient acceptability these regimens are interferon-free. Cohort studies in older patients with haemophilia direct the need for attention to weight control, exercice, assessment of cardiovascular risk, especially hypertension and detection of osteoporosis. Where patients live a long way from a comprehensive care centre, telemedicine connections can engage centre experts with the patient and his/her local practitioners in devising and monitoring care plans.

Reliability of circulatory and neurologic examination by telemedicine in a pediatric intensive care unit

OBJECTIVE

To test the hypothesis that telemedicine can reliably be used for many aspects of circulatory and neurologic examinations of children admitted to a pediatric intensive care unit (PICU).

STUDY DESIGN

A prospective, randomized study in a 14-bed PICU in a tertiary care, academic-affiliated institution. Eligible patients were >2 months or <19 years of age, not involved in a concurrent study, had parents/guardian able to sign an informed consent form, were not at end-of-life, and had an attending who not only deemed them medically stable, but also felt that the study would not interrupt their care. Other than the Principal Investigator, 6 pediatric intensivists and 7 pediatric critical care fellows were eligible study providers. Two physician providers were randomly assigned to perform circulatory and neurologic examinations according to the American Heart Association/Pediatric Advanced Life Support guidelines in-person and via telemedicine. Findings were recorded on a standardized data collection form and compared.

RESULTS

One hundred ten data collection forms were completed. For many aspects of the circulatory and neurologic examinations, outcomes showed substantial to perfect agreement between the in-person and telemedical care providers (kappa = 0.64-1.00). However, assessments of muscle tone had a kappa = 0.23, with a kappa = 0.37 for skin color.

CONCLUSIONS

Telemedicine can reliably identify normal and abnormal findings of many aspects of circulatory and neurologic examinations in PICU patients. This finding opens the door to further studies on the use of telemedicine across other disciplines.

Standards and Guidelines in Telemedicine and Telehealth

The development of guidelines and standards for telemedicine is an important and valuable process to help insure effective and safe delivery of quality healthcare. Some organizations, such as the American Telemedicine Association (ATA), have made the development of standards and guidelines a priority. The practice guidelines developed so far have been well received by the telemedicine community and are being adopted in numerous practices, as well as being used in research to support the practice and growth of telemedicine. Studies that utilize published guidelines not only help bring them into greater public awareness, but they also provide evidence needed to validate existing guidelines and guide the revision of future versions. Telemedicine will continue to grow and be adopted by more healthcare practitioners and patients in a wide variety of forms not just in the traditional clinical environments, and practice guidelines will be a key factor in fostering this growth. Creation of guidelines is important to payers and regulators as well as increasingly they are adopting and integrating them into regulations and policies. This paper will review some of the recent ATA efforts in developing telemedicine practice guidelines, review the role of research in guidelines development, review data regarding their use, and discuss some of areas where guidelines are still needed.