Trial of telemedicine for patients on home ventilator support: feasibility, confidence in clinical management and use in medical decision-making

Telemedicine in nutritional management of children with severe neurological impairment: implication for quality of life

Children with severe neurological impairment (SNI) frequently present feeding problems requiring a close monitoring of their nutritional status. In addition to constant clinical monitoring of body composition and nutritional indexes in these patients, frequent reports of dietary intake and weight gain variations are useful to ensure proper nutritional management. Furthermore, non-oral feeding is often needed to avoid malnutrition or aspiration pneumonia, constantly necessitating medical assistance. Despite their necessity for frequent hospital accesses, these patients' disabilities represent an important obstacle to accessing care, generating anxiety and concern in children and their families. Telemedicine has proven to be a promising instrument for improving pediatric patients' healthcare in several fields. By breaking down geographical and temporal barriers, telehealth may represent a valuable tool to implement in clinical practice, in order to improve patients' outcomes and quality of life. The aim of this narrative review is to provide an overview of the main nutritional issues in children with SNI, the potential implications of telemedicine in their management and the available evidence regarding the effects and benefits of telehealth.

Psychologist's Unique Role in Improving Quality of Life of Children with Chronic Lung Diseases and Their Families

Pediatric chronic lung diseases burden their patients and families with heavy treatment loads, frequent extensive clinic visits to multiple providers, frequent emergency department visits and hospitalizations, and contribute to significant psychosocial issues with caregiver's burnout. The purpose of this chapter is to outline the psychosocial impact of the major pediatric chronic lung diseases and the unique role of the psychologist in relieving this burden. These include severe asthma, cystic fibrosis, bronchopulmonary dysplasia, and dependence on home mechanical ventilation.

Feasibility of Post-hospitalization Telemedicine Video Visits for Children With Medical Complexity

OBJECTIVES

To evaluate feasibility and acceptability of post-hospitalization telemedicine video visits (TMVV) during hospital-to-home transitions for children with medical complexity (CMC); and explore associations with hospital utilization, caregiver self-efficacy (CSE), and family self-management (FSM).

METHOD

This non-randomized pilot study assigned CMC (n=28) to weekly TMVV for four weeks post-hospitalization; control CMC (n=20) received usual care without telemedicine. Feasibility was measured by time to connection and proportion of TMVV completed; acceptability was measured by parent-reported surveys. Pre/post-discharge changes in CSE, FSM, and hospital utilization were assessed.

RESULTS

64 TMVV were completed; 82 % of patients completed 1 TMVV; 54 % completed four TMVV. Median time to TMVV connection was 1 minute (IQR=2.5). Parents reported high acceptability of TMVV (mean 6.42; 1 -7 scale). CSE and FSM pre/post-discharge were similar for both groups; utilization declined in both groups post-discharge.

DISCUSSION

Post-hospitalization TMVV for CMC were feasible and acceptable during hospital-to-home transitions.

The Transitions to Long-term In Home Ventilator Engagement Study (Transitions to LIVE): study protocol for a pragmatic randomized controlled trial

Background overview and rationale

We co-developed a multi-component virtual care solution (TtLIVE) for the home mechanical ventilation (HMV) population using the aTouchAway™ platform (Aetonix). The TtLIVE intervention includes (1) virtual home visits; (2) customizable care plans; (3) clinical workflows that incorporate reminders, completion of symptom profiles, and tele-monitoring; and (4) digitally secure communication via messaging, audio, and video calls; (5) Resource library including print and audiovisual material.

Objectives and brief methods

Our primary objective is to evaluate the TtLIVE intervention compared to a usual care control group using an eight-center, pragmatic, parallel-group single-blind (outcome assessors) randomized controlled trial. Eligible patients are children and adults newly transitioning to HMV in Ontario, Canada. Our target sample size is 440 participants (220 each arm). Our co-primary outcomes are a number of emergency department (ED) visits in the 12 months after randomization and change in family caregiver (FC) reported Pearlin Mastery Scale score from baseline to 12 months. Secondary outcomes also measured in the 12 months post randomization include healthcare utilization measured using a hybrid Ambulatory Home Care Record (AHCR-hybrid), FC burden using the Zarit Burden Interview, and health-related quality of life using the EQ-5D. In addition, we will conduct a cost-utility analysis over a 1-year time horizon and measure process outcomes including healthcare provider time using the Care Coordination Measurement Tool. We will use qualitative interviews in a subset of study participants to understand acceptability, barriers, and facilitators to the TtLIVE intervention. We will administer the Family Experiences with Care Coordination (FECC) to interview participants. We will use Poisson regression for a number of ED visits at 12 months. We will use linear regression for the Pearlin Mastery scale score at 12 months. We will adjust for the baseline score to estimate the effect of the intervention on the primary outcomes. Analysis of secondary outcomes will employ regression, causal, and linear mixed modeling. Primary analysis will follow intention-to-treat principles. We have Research Ethics Board approval from SickKids, Children’s Hospital Eastern Ontario, McMaster Children’s Hospital, Children’s Hospital-London Health Sciences, Sunnybrook Hospital, London Health Sciences, West Park Healthcare Centre, and Ottawa Hospital.

Discussion

This pragmatic randomized controlled single-blind trial will determine the effectiveness and cost-effectiveness of the TtLIVE virtual care solution compared to usual care while providing important data on patient and family experience, as well as process measures such as healthcare provider time to deliver the intervention.

Trial registration

ClinicalTrials.gov NCT04180722. Registered on November 27, 2019.

Emergency-department accesses in home care paediatric patients: Occurrence and risks of use in a six-year retrospective investigation in Northern Italy

Objective

To assess the determinants of ED use in paediatric patients enrolled in an Integrated Paediatric Home Care (IPHC) program.

Methods

A retrospective study was conducted using administrative databases on a cohort of patients enrolled in an IPHC program between January 1st, 2012, and December 31st, 2017, in Northern Italy. ED visits that occurred during the IPHC program were considered. Data were collected considering sociodemographic, clinical and organizational variables. A multivariable stepwise logistic regression analysis was performed. The dependent variable to identify possible associations was ED visit.

Results

A total of 463 ED visits occurred in 465 children, with an incidence rate of 1. The risk of ED visits significantly increased among children involved in the IPHC program after hospital discharge (OR 1.94). Additionally, the risk of ED visits increased significantly as the duration of IPHC increased (OR 5.80 between 101 and 200 days, to OR 7.84 between 201 and 300 days, OR 12.54 between 301 and 400 days and OR 18.67 to more than 400 days).

Conclusion

The overall results represent a practical perspective to contribute improving both the service quality of IPHC and reducing low acuity and improper ED use.

ERS Statement on pediatric long term noninvasive respiratory support

Long term noninvasive respiratory support, comprising continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV), in children is expanding worldwide, with increasing complexities of children being considered for this type of ventilator support and expanding indications such as palliative care. There have been improvements in equipment and interfaces. Despite growing experience, there are still gaps in a significant number of areas: there is a lack of validated criteria for CPAP/NIV initiation, optimal follow-up and monitoring; weaning and long term benefits have not been evaluated. Therapeutic education of the caregivers and the patient is of paramount importance, as well as continuous support and assistance, in order to achieve optimal adherence. The preservation or improvement of the quality of life of the patient and caregivers should be a concern for all children treated with long term CPAP/NIV. As NIV is a highly specialised treatment, patients are usually managed by an experienced pediatric multidisciplinary team. This Statement written by experts in the field of pediatric long term CPAP/NIV aims to emphasize on the most recent scientific input and should open up to new perspectives and research areas.

Mechanical Ventilation During Chronic Lung Disease

For infants with the most severe forms of chronic lung disease, regardless of etiology, chronic mechanical ventilation can provide stability, reduce acute respiratory events, and alleviate increased work of breathing. This approach prioritizes the baby's growth and development during early life. Once breathing comfortably, these infants can tolerate developmental therapies with the goal of achieving the best neurocognitive outcomes possible.

Chronic respiratory failure in bronchopulmonary dysplasia

Although survival has improved dramatically for extremely preterm infants, those with the most severe forms of bronchopulmonary dysplasia (BPD) fail to improve in the neonatal period and go on to develop chronic respiratory failure. When careful weaning of respiratory support is not tolerated, the difficult decision of whether or not to pursue chronic ventilation via tracheostomy must be made. This requires shared decision-making with an interdisciplinary medical team and the child's family. Although they suffer from increased morbidity and mortality, the majority of these children will survive to tolerate ventilator liberation and tracheostomy decannulation. Care coordination for the technology-dependent preterm infant is complex, but there is a growing consensus that chronic ventilation can best support neurodevelopmental progress and improve long-term outcomes.

Preventing Emergency Department Visits for Children With Medical Complexity Through Ambulatory Care: A Systematic Review

BACKGROUND

Children with medical complexity (CMC) represent a growing population with high emergency department (ED) utilization. How to reduce preventable ED visits is poorly understood.

OBJECTIVE

We sought to determine what components of ambulatory care programs focused on CMC were most effective in preventing ED visits.

DATA SOURCES

PubMed Plus, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases through October 2019, and hand search of bibliographies.

STUDY ELIGIBILITY CRITERIA

Two independent reviewers used a structured screening protocol to include English language articles summarizing studies that included CMC, emergency care, or ED utilization. Data on ED utilization were extracted.

RESULTS

Sixteen included studies described outpatient interventions to prevent ED utilization. Of these, studies that included 24/7 access to knowledgeable providers for acute care needs by phone (telehealth) or expedited or next-day appointments were the most consistently successful in reducing ED visits.

LIMITATIONS

Risk of bias was mixed across studies. The evidence base is currently small and observational nature of interventions and their evaluations limit definitive, generalizable recommendations.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Current research suggests that real-time access to knowledgeable providers and expedited appointments can prevent ED visits. Further study is needed to generalize these findings as well as investigate novel strategies such as telehealth to improve quality of care, decrease utilization, and provide cost-effective care for this vulnerable population.

Telemedicine in the management of patients with chronic respiratory failure

Patients with chronic respiratory failure are often required to attend multiple hospital appointments, which may be difficult due to their physical disabilities and the amount of equipment they are required to bring. Their caregivers often struggle with the lack of immediate care available when the patient suffers difficulties at home. Telemedicine is an opportunity to bridge the gap between home and healthcare professionals by allowing the healthcare team to reach into patients' homes to provide more frequent support. The evidence for the use of telemedicine in patients with chronic respiratory failure remains equivocal. Although the uptake of telemedicine has been slow, the SARS-CoV-2 pandemic has resulted in the rapid dissemination of telemedicine to allow the delivery of care to vulnerable patients while reducing the need for their attendance in hospital. Logistical and legal challenges to the delivery of telemedicine remain, but the pandemic may serve as a driver to ameliorate these challenges and facilitate wider use of this technology to improve the experience of patients with chronic respiratory failure.

Educational aims

To provide an overview of the rationale for delivering care via telemedicine for patients with chronic respiratory failure.To provide the evidence base for establishing a telemedicine service.To highlight the potential opportunities and challenges in delivering a telemedicine service for patients with chronic respiratory failure.

Impact of telemedicine on health outcomes in children with medical complexity: an integrative review

Children with medical complexity (CMC) are a high priority population with chronic illnesses dependent on the use of health services, on technological systems to support their vital functions and characterized by multiple health needs. One of the main challenges linked to chronic conditions is finding solutions to monitor CMC at home, avoiding re-hospitalization and the onset of complications. Telemedicine enables to remotely follow up patients and families. An integrative review was performed to assess whether telemedicine improves health outcomes for CMC. Medline/PubMed, CINAHL, Cochrane Library, Web of Science, and Scopus were searched to identify studies describing the effect of using telemedicine systems on health outcomes for CMC. The PRISMA guidelines were used to select the papers. The methodological quality of the studies was evaluated through the Johanna Briggs Institute critical appraisal tools and the Cochrane Collaboration ROB 2.0. A total of 17 papers met the quality criteria and were included. Specialized telemedicine systems (tele-visits), telehealth, and tele-monitoring have been reported to reduce unplanned hospitalizations and visits, decrease total costs for healthcare services and families, and increase satisfaction for family members. No effect was found on the quality of life in children and their families.Conclusion: Available evidence supporting the use of telemedicine in CMC is favorable but limited. High-quality methodological studies including other unexplored health outcomes such as mental health, hospital readmissions, mortality, caregiver competences, and self-efficacy are needed to confirm the effectiveness of telemedicine systems in improving health outcomes for CMC. What is Known: • CMC are an extremely fragile patient population with frequent access to healthcare services compared with other chronic conditions. • There is conflicting evidence of the effectiveness of telemedicine clinical outcomes, healthcare utilization, and costs in pediatrics. What is New: • There is some evidence that for CMC, telemedicine reduces unplanned hospitalizations, healthcare service costs, and financial burden for families, while increasing caregivers' satisfaction with care. • Further research is needed to confirm the effectiveness of telemedicine systems in improving health for CMC.

Patient Safety in Ambulatory Pediatrics

Purpose of Review

The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics.

Recent Findings

The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety.

Summary

There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.

A Low-Cost Breath Analyzer Module in Domiciliary Non-Invasive Mechanical Ventilation for Remote COPD Patient Monitoring

Smart Breath Analyzers were developed as sensing terminals of a telemedicine architecture devoted to remote monitoring of patients suffering from Chronic Obstructive Pulmonary Disease (COPD) and home-assisted by non-invasive mechanical ventilation via respiratory face mask. The devices based on different sensors (CO₂/O₂ and Volatile Organic Compounds (VOCs), relative humidity and temperature (R.H. & T) sensors) monitor the breath air exhaled into the expiratory line of the bi-tube patient breathing circuit during a noninvasive ventilo-therapy session; the sensor raw signals are transmitted pseudonymized to National Health Service units by TCP/IP communication through a cloud remote platform. The work is a proof-of-concept of a sensors-based IoT system with the perspective to check continuously the effectiveness of therapy and/or any state of exacerbation of the disease requiring healthcare. Lab tests in controlled experimental conditions by a gas-mixing bench towards CO₂/O₂ concentrations and exhaled breath collected in a sampling bag were carried out to test the realized prototypes. The Smart Breath Analyzers were also tested in real conditions both on a healthy volunteer subject and a COPD suffering patient.

Follow-Up and Monitoring of Children Needing Long Term Home Ventilation

Once continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) is started in a child, and the child is discharged home, follow-up needs to be organized with regular visits in order to check the tolerance and efficacy of the treatment. But there is a lack of validated clinical guidelines, mainly because of the heterogeneity of the ventilator servicing, the costs and health care systems among countries. Therefore, visits timing and strategies to monitor CPAP/NIV are not clearly defined. Moreover, depending on various factors such as the underlying disorder, the medical stability, the age of the child, and socio-economic factors, follow-up usually ranges between 1 month and 3-6 months, or even 1 year following treatment initiation, with an overnight hospital stay, an out-patient visit, a home visit, via telemonitoring or telemedicine, alone or in combination. Apart from clinical evaluation, nocturnal oximetry and capnography monitoring and/or poly(somno)graphy (P(S)G) are usually carried out during the follow-up visits to monitor the delivered pressure, leaks, residual respiratory events and synchrony between the patient and the ventilator. Built-in software data of CPAP/NIV devices can be used to assess the adherence of treatment, to monitor pressure efficiency, leaks, asynchronies, and to estimate the presence of residual respiratory events under CPAP/NIV if P(S)G is not available or in alternance with P(S)G. The possibility of CPAP/NIV weaning should be assessed on a regular basis, but no criteria for the timing and procedures have been validated. Weaning timing depends on the clinical condition that justified CPAP/NIV initiation, spontaneous improvement with growth, and the possibility and efficacy of various upper airway, maxillofacial and/or neurosurgical procedures. Weaning may be allowed in case of the disappearance of nocturnal and daytime symptoms of sleep-disordered breathing (SDB) after several nights without CPAP/NIV and the objective correction of SDB on a P(S)G. But no parameters are defined. In any case, a long term follow-up is necessary to ascertain the weaning success. Large prospective studies, together with international and national guidelines, are required in order to build evidence for standardizing practice for the follow-up and weaning of CPAP/NIV in children.

Telemedicine for General Pediatrics

The use of telemedicine (TM) to deliver health care has been growing throughout the United States and internationally through asynchronous and synchronous technology. It has proven to be an effective way of delivering health care at a distance. There are multiple ways that a practice can offer these services, from direct-to-consumer to consultations in ambulatory or inpatient services. TM can be used to deliver care in homes, schools, and virtually anywhere that a patient and provider can access technology. For rural communities, emergency departments and inpatient specialty consults that were not available previously are now routine. TM also has been proven to be effective in decreasing costs to patients and increasing access in pediatrics while providing high degrees of satisfaction among patients and providers. [Pediatr Ann. 2019;48(12):e479-e484.].

Use of Synchronous Digital Health Technologies for the Care of Children With Special Health Care Needs and Their Families: Scoping Review

BACKGROUND

Use of synchronous digital health technologies for care delivery to children with special health care needs (having a chronic physical, behavioral, developmental, or emotional condition in combination with high resource use) and their families at home has shown promise for improving outcomes and increasing access to care for this medically fragile and resource-intensive population. However, a comprehensive description of the various models of synchronous home digital health interventions does not exist, nor has the impact of such interventions been summarized to date.

OBJECTIVE

We aim to describe the various models of synchronous home digital health that have been used in pediatric populations with special health care needs, their outcomes, and implementation barriers.

METHODS

A systematic scoping review of the literature was conducted, guided by the Arksey and O'Malley Scoping Review Framework. MEDLINE, CINAHL, and EMBASE databases were searched from inception to June 2018, and the reference lists of the included systematic reviews and high-impact journals were hand-searched.

RESULTS

A total of 38 articles were included in this review. Interventional articles are described as feasibility studies, studies that aim to provide direct care to children with special health care needs, and studies that aim to support family members to deliver care to children with special health care needs. End-user involvement in the design and implementation of studies is evaluated using a human-centered design framework, and factors affecting the implementation of digital health programs are discussed in relation to technological, human, and systems factors.

CONCLUSIONS

The use of digital health to care for children with special health care needs presents an opportunity to leverage the capacity of technology to connect patients and their families to much-needed care from expert health care providers while avoiding the expenses and potential harms of the hospital-based care system. Strategies to scale and spread pilot studies, such as involving end users in the co-design techniques, are needed to optimize digital health programs for children with special health care needs.

Transitioning from an ICU ventilator to a portable home ventilator

There is a variety of portable ventilators on the market, each with its' own features. A clinician needs to understand the unique characteristics of the ventilators available in his or her region, as well as the nuances of primary and secondary settings for these portable home ventilators in order to create a comfortable breath that allows for adequate gas exchange for the patient. Understanding the interplay of the portable home ventilator and the ventilator circuit is also a key component of transitioning a patient to a portable home ventilator. This review details characteristics of some of the more commonly used machines in the United States, as well as the settings to be considered in supporting a child with chronic respiratory failure outside of the hospital. As more patients are being discharged from the hospital with mechanical home ventilation, new ventilators are being developed that expand upon features of current machines.

Practical use of telemedicine in the chronically ventilated infant

Telemedicine, or the use of electronic communication technology to improve patient health, is becoming more widely adopted as a means of bringing together patients, providers and family members to facilitate evaluation, monitoring, diagnosis and treatment. A particularly vulnerable group consists of children with dependence on technology, such as chronic mechanical ventilation. This chapter will provide an overview of how telehealth technology is currently being used, for supporting this patient population through 1) inpatient support 2) integration with the medical home 3) bridging care transitions 4) remote patient management and 5) multispecialty consultations. We will also discuss the impact on quality and cost, the current research environment and practical points for implementation into clinical practice.

Long-term ventilation for children with chronic lung disease of infancy

PURPOSE OF REVIEW

Modern medical advances have resulted in an increased survival after extremely preterm birth. However, some infants will develop severe bronchopulmonary dysplasia (BPD) and fail to wean from invasive or noninvasive positive pressure support. It remains unclear which infants will benefit from tracheostomy placement for chronic ventilation. Once the decision to pursue chronic ventilation has been made, questions remain with respect to the timing of tracheotomy surgery, optimal strategies for mechanical ventilation, and multidisciplinary care in both the inpatient and outpatient settings. The appropriate time for weaning mechanical ventilation and tracheostomy decannulation has similarly not been determined.

RECENT FINDINGS

Although there remains a paucity of randomized controlled trials involving infants with severe BPD, a growing body of evidence suggests that chronic ventilation via tracheostomy is beneficial to support the growth and development of severely affected preterm children. However, delivering such care is not without risk. Chronic ventilation via tracheostomy requires complex care coordination and significant resource utilization.

SUMMARY

When chronic respiratory insufficiency limits a preterm infant's ability to grow and develop, chronic invasive ventilation may facilitate neurodevelopmental progress and may lead to an improved long-term outcome.

Medical complications in a telemedicine home care programme for paediatric ventilated patients

INTRODUCTION

Advances in paediatric medicine have increased survival rates for patients with severe chronic illnesses, of which the most complex are ventilator-dependent children (VDCs). Although home care improves their quality of life, morbidity and mortality rates are high. Our aim was to study the medical complications (events) that occur at home and assess the usefulness of telemedicine in their detection and treatment.

METHODS

A prospective clinical study (2007-2017) was performed for tracheotomised VDCs. We used a high-density data telemedicine monitoring system from our Paediatric Intensive Care Unit and analysed events during the first two years of home care to study how different variables inter-correlated with the four most common ones: hospital admissions, admissions avoided, event durations and life-threatening events (LTEs); the significance level was set at an alpha of 0.05 in all cases.

RESULTS

All our VDCs were included (n = 12); there were 141 events, and these were homogeneously distributed over the study period. The incidence was higher in children who were ventilator dependent for more than 12 h a day (70.9%, p < 0.001) and the main cause was respiratory (69.5%, p < 0.001). Telemedicine was the main initial care and monitoring approach (86.5% and 90.1%, respectively, p < 0.001); 13 events were LTEs, nine were resolved telemedically, four required medicalised transfer to hospital and three resulted in a hospital admission.

DISCUSSION

Clinical complications are frequent in VDCs receiving home care, and respiratory decompensation is the most frequent cause. Telemedicine facilitated diagnosis and early treatment, and was useful in managing LTEs.

Bridging the Stressful Gap Between ICU and Home: Medical Simulation for Pediatric Patients and Their Families

OBJECTIVES

Introduce an expanding role for pediatric critical care and medical simulation to optimize the care for children with technology dependence.

DATA SOURCES

Limited review of literature and practice for current teaching paradigms, vulnerability of the patient population, and efficacy of simulation as a medical educational tool.

CONCLUSIONS

In accordance with new care models and patient need, critical care requires parallel evolution of care practices, including new educational and care models, in order to maximally reduce risk, fear, and anxiety and to insure quality and consistent care in the community for patients and families transitioning between the ICU and home environments.

Home-Based Telemedicine for Children with Medical Complexity

Background: Children with medical complexity (CMC) are high utilizers of health care services. Telehealth encounters may provide a means to improve care outcomes for this population.

Objective: To evaluate the feasibility, usability, and impact of an in-home telehealth device in the care of CMC.

Methods: This single-center feasibility study employed a nonblinded randomized clinical trial design. English-speaking caregivers of children within a pediatric complex care program with home Wi-Fi were eligible for participation. Participants were randomized 1.5:1 with stratification based on tracheostomy status to a control group that received usual care or an intervention group that received a telehealth device for in-home use. Patients were followed up for 4 months. The primary outcome was successful device connectivity and data transmission. Data included clinician encounter device usability; caregiver satisfaction; and encounter type, purpose, and cost. Descriptive statistics, negative binomial regression, and Kaplan–Meier plot were used for analysis.

Results: Twenty-four patients were enrolled (9 controls, 15 in the intervention group) in September 2016. The telehealth device was attempted in 73 encounters. Device connectivity was successful 96% of the time. Image and sound quality were acceptable in 98% of visits. Caregivers expressed their overall satisfaction with the device. The hospitalization rate was lower in the intervention group (0.77 vs. 1.14 intensive care unit days/patient-months), resulting in $9,425/USD per patient savings compared with the control group.

Conclusion: Despite small sample size and short observation period, this study demonstrated that use of an in-home telehealth device is feasible, well received by caregivers, and can result in decreased hospitalizations when compared with usual care.

Usefulness of telemedicine for home ventilator-dependent children

INTRODUCTION

Medical care for ventilator-dependent children must avoid hospital confinement, which is detrimental to the patient, their family and Paediatric Intensive Care Unit. Our objective was to assess the role of telemedicine in facilitating early and permanent discharge of such patients to home care.

METHODS

This was a prospective clinical study (2007-2017) in tracheotomised ventilator-dependent children. We used a Big Data Telemedicine home system (Medlinecare 2.1) from the Paediatric Intensive Care Unit. Specialised home-nursing services were available. Clinical events were analysed using the Chi-square test (significance p < 0.05). Families subsequently completed a satisfaction survey. The Paediatric Intensive Care Unit management indicators were analysed.

RESULTS

All of our ventilator-dependent children were included (n=12). At time of discharge from the Paediatric Intensive Care Unit, they all required continuous mechanical ventilation and met the criteria of groups I-III of the OTA classification. In the first two years there were 141 events; the main cause was respiratory (69.5%, p < 0.001) and telemedicine was the main care approach (86.5%, p < 0.001). Eleven events required hospitalisation (7.8%) but 38 (27.0%) hospitalisations were avoided. The emergency readmission time accounted for 0.99% of the total time. Six patients were decannulated, and one patient died due to primary cardiac arrest. All the families considered that the telemedicine had helped to avoid hospital visits, was not an intrusion into their privacy, and improved the child's safety and quality of life. An improvement in Paediatric Intensive Care Unit indicators was achieved.

DISCUSSION

Telemedicine facilitated early and permanent discharge of our ventilator-dependent children to home care without affecting their quality of care.

Virtual Telemedicine Visits in Pediatric Home Parenteral Nutrition Patients: A Quality Improvement Initiative

BACKGROUND

Despite being less costly than prolonged hospitalization, home parenteral nutrition (HPN) is associated with high rates of post-discharge complications, including frequent readmissions and central line-associated bloodstream infections (CLABSIs). Telemedicine has been associated with improved outcomes and reduced healthcare utilization in other high-risk populations, but no studies to date have supported effectiveness of telemedicine in pediatric HPN.

METHODS

We prospectively collected data on pediatric patients managed at a single HPN program who participated in postdischarge telemedicine visits from March 1, 2014 to March 30, 2016. We excluded patients with a history of HPN and strictly palliative care goals. Univariate analysis was performed for primary outcomes: Community-acquired CLABSI and 30-day readmission rate.

RESULTS

Twenty-six families participated in the pilot initiative with median (interquartile range) patient age 1.5 (5.7) years old, diagnosis of short bowel syndrome in 16 (62%), and in-state residence in 17 (55%). Ishikawa (fishbone) diagram identified causes of post-discharge HPN complications. Areas of focus during telemedicine visit included central venous catheter care methods, materials, clinical concerns, and equipment. Compared to historical comparison group, the telemedicine group experienced CLABSI rates of 1.0 versus 2.7 per 1,000 line days and readmission rates of 38% versus 17% (p = 0.03, 0.02, respectively).

CONCLUSIONS

Telemedicine visits identified opportunities for improvement for families newly discharged on HPN. In a small cohort of patients who experienced telemedicine visits, we found lower CLABSI rates alongside higher readmission rates compared with a historical comparison group. Further studies are needed to optimize telemedicine in delivering care to this high-risk population.

Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models

OBJECTIVE

To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure.

DESIGN

All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data.

SETTING

Tertiary children's hospital.

SUBJECTS

Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs.

CONCLUSIONS

Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.

Transition from in-hospital ventilation to home ventilation: process description and quality indicators

The current demographic development of our society results in an increasing number of elderly patients with chronic diseases being treated in the intensive care unit. A possible long-term consequence of such a treatment is that patients remain dependent on certain invasive organ support systems, such as long-term ventilator dependency. The main goal of this project is to define the transition process between in-hospital and out of hospital (ambulatory) ventilator support. A further goal is to identify evidence-based quality indicators to help define and describe this process.

This project describes an ideal sequence of processes (process chain), based on the current evidence from the literature. Besides the process chain, key data and quality indicators were described in detail. Due to the limited project timeline, these indicators were not extensively tested in the clinical environment.

The results of this project may serve as a solid basis for proof of feasibility and proof of concept investigations, optimize the transition process of ventilator-dependent patients from a clinical to an ambulatory setting, as well as reduce the rate of emergency re-admissions.

Telemedicine Support Groups for Home Parenteral Nutrition Users

Patients receiving home parenteral nutrition (HPN), a life-sustaining intravenous (IV) infusion that provides nourishment and hydration to patients with short gut or inflammatory bowel diseases, are often isolated and not in visual contact with peers or health providers. One completed clinical trial (Clinical Trials.gov NCT0190028) and 1 ongoing clinical trial (Clinical Trials.gov NCT02987569) are evaluating a mobile videoconferencing-delivered support group intervention for patients on HPN and their caregivers. This home-based telemedicine intervention uses encrypted tablet-based videoconferencing to connect multiple families in real time. The twice-daily IV regimen is challenging for patients who may experience infusion catheter-related bloodstream infections, difficulties with fatigue, loss of sleep, depressive disorders, and worry over the potential life-threatening side effects and the expenses of this therapy. Using secure telemedicine, the facilitated support group intervention aims to enhance HPN home care, daily functioning, and quality of life. The authors provide the rationale for the telemedicine approach with HPN users and caregivers. They provide "how-to" information about the content and process of the facilitated support group sessions via secure videoconferencing. They share lessons learned from the ongoing evaluation of the telemedicine approach.

The intensive care medicine clinical research agenda in paediatrics

BACKGROUND

Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care.

METHODS

Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years?

RESULTS

(1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings.

CONCLUSION

Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.

The role of regional centers and University children's Hospital in development of home mechanical ventilation network

Application of home mechanical ventilators represents the future in the treatment of children with chronic respiratory insufficiency. In this way patients are treated in the home environment, they have full support from their families, they are protected against nosocomial infections and their condition is monitored by medical staff. The role of regional centers is very important in the future development of the home mechanical ventilation network. Doctors in these centers under the full support of the University Children's Hospital physicians can assist and monitor the treatment of children on the household respirators.

Using telemedicine in the care of newborn infants after discharge from a neonatal intensive care unit reduced the need of hospital visits

AIM

This study examined the use of telemedicine as a means to follow up infants discharged from a Swedish neonatal intensive care unit to home health care.

METHODS

Families were randomised to either a control group receiving standard home health care (n = 42 families) or a telemedicine group receiving home health care with telemedicine support (n = 47 families) after discharge from the hospital. Both groups had follow-up hospital appointments with the neonatal nurse. In the telemedicine group, appointments were supplemented by the use of a specially designed web page and video calls.

RESULTS

The use of the web page and video calls decreased the number of emergency visits to the hospital (p = 0.047). In the telemedicine group, 26% of the families felt they had more scheduled appointments than necessary, whereas only 6% of the families in the control group thought so (p = 0.037). The parents were highly satisfied with the use of telemedicine. Although the nurses were favourable to using telemedicine, the rigid organisation of the home healthcare programme and the nurses' schedules and work routines prevented its optimal use.

CONCLUSION

The use of telemedicine decreased the need of hospital visits. Organisational adaptations would be necessary to make the best use of telemedicine.