Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility

Tele-Critical Care Support Outside the Intensive Care Unit

Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the author reviews the role of TCC in supporting rapid response events, critical care in emergency departments, and disaster and pandemic responses. The ability to rapidly expand critical care services has important capacity and care quality implications. Moreover, as TCC infrastructure becomes less expensive, the opportunities to leverage this care modality also have potentially important financial benefits.

Pediatric Tele-Critical Care: Initial Experience with a Continuous Surveillance Model Aiming to Prevent Cardiac Arrest in Children with Critical Heart Disease

Introduction: Despite advances in treatment of children with critical heart disease, cardiac arrest (CA) remains a common occurrence. We provided virtual support to bedside teams (BTs) from a tele-critical care (TCC) unit in a pediatric cardiac intensive care unit (CICU) and focused on early detection of concerning trends (CT) and avoidance of CA. Virtual surveillance workflows included a review of remote monitoring, video feed from patient room cameras, medical records, and artificial intelligence tools. We present our initial experience with a focus on critical communications (CCs) to BTs. Methods: A retrospective, descriptive review of TCC activities was conducted from January 2019 to December 2022, involving electronic databases and electronic medical records of patients in the CICU, including related CCs to BTs, responses from BTs, and related CA. Results: We conducted 18,171 TCC activities, including 2,678 non-CCs and 248 CCs. Over time, there was a significant increase in the proportion of CCs related with CT (p = 0.002), respiratory concerns (<0.001), and abnormalities in cardiac rhythm (p = 0.04). Among a sample of 244 CCs, subsequent interventions by BTs resulted in adjustment of medical treatment (127), respiratory support (68), surgery or intervention (19), cardiac rhythm control (17), imaging study (14), early resuscitation (9), and others (10). Conclusions: CCs from a TCC unit in a pediatric CICU changed over time with an increased focus on CT and resulted in early interventions, potentially contributing to avoiding CA. This model of care in pediatric cardiac critical care has the potential to improve patient safety.

Impact of Rapid Response Teams on Pediatric Care: An Interrupted Time Series Analysis of Unplanned PICU Admissions and Cardiac Arrests

Pediatric rapid response teams (RRTs) are expected to significantly lower pediatric mortality in healthcare settings. This study evaluates RRTs' effectiveness in decreasing cardiac arrests and unexpected Pediatric Intensive Care Unit (PICU) admissions. A quasi-experimental study (2014-2017) at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, involved 3261 pediatric inpatients, split into pre-intervention (1604) and post-intervention (1657) groups. Baseline pediatric warning scores and monthly data on admissions, transfers, arrests, and mortality were analyzed pre- and post-intervention. Statistical methods including bootstrapping, segmented regression, and a Zero-Inflation Poisson model were employed to ensure a comprehensive evaluation of the intervention's impact. RRT was activated 471 times, primarily for respiratory distress (29.30%), sepsis (22.30%), clinical anxiety (13.80%), and hematological abnormalities (6.7%). Family concerns triggered 0.1% of activations. Post-RRT implementation, unplanned PICU admissions significantly reduced (RR = 0.552, 95% CI 0.485-0.628, p < 0.0001), and non-ICU cardiac arrests were eliminated (RR = 0). Patient care improvement was notable, with a -9.61 coefficient for PICU admissions (95% CI: -12.65 to -6.57, p < 0.001) and a -1.641 coefficient for non-ICU cardiac arrests (95% CI: -2.22 to -1.06, p < 0.001). Sensitivity analysis showed mixed results for PICU admissions, while zero-inflation Poisson analysis confirmed a reduction in non-ICU arrests. The deployment of pediatric RRTs is associated with fewer unexpected PICU admissions and non-ICU cardiopulmonary arrests, indicating improved PICU management. Further research using robust scientific methods is necessary to conclusively determine RRTs' clinical benefits.

Low Utilization of Synchronous Telemedicine in Pediatric Critical Care Interfacility Transport: Barriers and Lessons

OBJECTIVE

The use of telemedicine has increased and may enhance the care of children during medical transport. We aimed to evaluate the feasibility of synchronous telemedicine connectivity before interfacility transport of critically ill children by a pediatric transport team.

METHODS

We performed a prospective, observational feasibility study of the introduction of synchronous telemedicine into an established pediatric transport team from 2019 to 2020. The outcomes examined included connectivity, physician workload, transport team satisfaction, and patient care outcomes.

RESULTS

Among 118 eligible transports, telemedicine was considered in 23 transports (19%), including 11 transports in which an attempt to connect was sought and 12 in which telemedicine activation was offered but not attempted. The median connection time was 2.9 minutes (interquartile range, 1.7-4.4 minutes), and clinical care was altered in 1 case. Connection failed in 2 cases (18.2%). In 50% of cases, concurrent medical control physician workload prevented activation. There were no perceived benefits in 41.7% of cases. Team members indicated the desire for future telemedicine use in only 54.6% of cases.

CONCLUSIONS

We found low utilization of synchronous telemedicine in interfacility pediatric transport. The identified barriers included reliable connectivity, physician workload, and low perceived benefit. Lessons learned and future research suggestions are presented to mitigate these barriers.

The Role of Tele-Critical Care in Rescue and Resuscitation

Tele-critical care (TCC) is a health care delivery model that connects medical information, interprofessional teams, patients, and families through advanced pathways, such as audio-video interfaces, machine learning, risk prediction algorithms, smart alarms, artificial intelligence, and physiologic sensing devices. TCC expands critical care services and expertise beyond the walls of the intensive care unit to logistic centers, emergency departments, general wards, war zones, disaster settings, and pandemics. This article describes the broad use of TCC for rescue and resuscitation and provides case presentations.

Comparison of Rapid-Response Systems Across Multisite Locations of a Pediatric Hospital System

OBJECTIVES

Rapid response (RR) systems reduce mortality and cardiopulmonary arrests outside the ICU. Patient characteristics, RR practices, and hospital context and/or mechanism influence post-RR outcomes. We aim to describe and compare RR function and outcomes within our institution's multiple sites.

METHODS

We conducted a 3-year retrospective study to compare RR use, clinical characteristics, and outcomes between our hospital's central campus (CC) and 2 satellite campuses (SCs). RR training and procedures are uniform across all campuses.

RESULTS

Among the 2935 RRs reviewed, 1816 occurred during index admissions at the CC and 405 occurred at SCs. CC, when compared with SCs, had higher age at RR (3.2 years vs 1.4 years), prevalence of complex chronic conditions (62.4% vs 34.4%), surgical complications (20.2% vs 5%), severity of illness, and risk of mortality (P < .001). CC had higher daytime RR activations, longer time from admission to RR, and more activations by nurses (P < .001). Respiratory diagnoses were most prevalent uniformly, but cardiac, neurologic, and hematologic diagnoses were higher at CC (P < .001). Cardiac and/or respiratory arrests during RR and transfers to the ICU were similar. Cardiorespiratory interventions post-RR, hospital length of stay, and mortality were higher and ICU stay was shorter (P < .01) in the CC. Outcomes were mainly affected by patient characteristics and not RR factors on multivariate analysis.

CONCLUSIONS

Patient illness severity, RR characteristics, and outcomes are significantly different in our multisite locations. Outcomes are predominantly affected by patient severity and not RR characteristics. Standardized RR training and procedures likely balance the effect of varying RR characteristics on eventual outcomes.

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.

Comparison of Two Telemedicine Delivery Modes for Neonatal Resuscitation Support: A Simulation-Based Randomized Trial

INTRODUCTION

Previous research has described technical aspects of telemedicine and the clinical impact of provider-to-patient telemedicine; however, little is known about provider-to-provider telemedical interventions.

OBJECTIVE

The primary aim of this study was to compare two telemedicine delivery modes on the quality of a simulated neonatal resuscitation. Our secondary aim was to evaluate the providers' task load.

METHODS

This was a prospective, single-center, randomized, simulation-based trial comparing a remote neonatal team leader ("teleleader") versus a remote consultant ("teleconsultant"). Participants resuscitated a simulated, apneic, and bradycardic neonate. Performance was assessed by video review and task load was measured by the self-reported NASA task load index (NASA-TLX) tool. In the teleleader group, one remote neonatal specialist assumed the role of team leader in the resuscitation. In the teleconsultant group, the same remote specialist assumed the role of teleconsultant.

RESULTS

Twenty-two participants were included in the analyses. The teleleader group was associated with a higher overall checklist score compared to teleconsultants (median score 68%, interquartile range [IQR]: 66-69 vs. 58%, IQR: 42-62; p = 0.016). No significant difference was seen in overall subjective workload as measured by the NASA-TLX tool. However, mental demand and frustration were significantly greater with teleconsultants compared to teleleaders (mean mental demand: 14.1 vs. 17.0 out of 21; frustration: 7.9 vs. 14.7 out of 21).

CONCLUSIONS

Simulated neonates randomized to teams with teleleaders received significantly better resuscitative care compared to those randomized to teams with teleconsultants. Mental demand and frustration were higher for providers in the teleconsultant compared to teleleader teams.

Use of Telemedicine to Improve Neonatal Resuscitation

Most newborn infants do well at birth; however, some require immediate attention by a team with advanced resuscitation skills. Providers at rural or community hospitals do not have as much opportunity for practice of their resuscitation skills as providers at larger centers and are, therefore, often unable to provide the high level of care needed in an emergency. Education through telemedicine can bring additional training opportunities to these rural sites in a low-resource model in order to better prepare them for advanced neonatal resuscitation. Telemedicine also offers the opportunity to immediately bring a more experienced team to newborns to provide support or even lead the resuscitation. Telemedicine can also be used to train and assist in the performance of emergent procedures occasionally required during a neonatal resuscitation including airway management, needle thoracentesis, and umbilical line placement. Telemedicine can provide unique opportunities to significantly increase the quality of neonatal resuscitation and stabilization in rural or community hospitals.