Telemedicine for neonatal resuscitation

Provider Perspectives on the Acceptability, Appropriateness, and Feasibility of Teleneonatology

OBJECTIVE

We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals.

STUDY DESIGN

Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models.

RESULTS

The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries.

CONCLUSION

Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable.

KEY POINTS

· Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

Modeling the Cost of Teleneonatology from the Health System Perspective

Introduction: Teleneonatology (TN) allows remote neonatologists to provide real-time audio-video telemedicine support to community hospitals when neonates require advanced resuscitation or critical care. Currently, there are no published economic evaluations of U.S. TN programs. Objective: To evaluate the cost of TN from the perspective of the health care system. Methods: We constructed a decision tree comparing TN to usual care for neonates born in hospitals without a neonatal intensive care unit (NICU) who require consultation. Our outcome of interest was total cost per patient, which included the incremental cost of a TN program, the cost of medical transport, and the cost of NICU or non-NICU hospitalization. We performed threshold sensitivity analyses where we varied each parameter to determine whether the base-case finding reverted. Results: For neonates requiring consultation after birth in a hospital without a NICU, TN was less costly ($16,878) than usual care ($28,047), representing a cost-savings of $11,168 per patient. Sensitivity analyses demonstrated that at least one of the following conditions would need to be met for TN to no longer be cost saving compared to usual care: transfer rate with usual care <12% (base-case = 82%), TN reducing the odds of transfer by <8% (base-case = 52%), or TN cost exceeding $12,989 per patient (base-case = $1,821 per patient). Conclusions: Economic modeling from the health system perspective demonstrated that TN was cost saving compared to usual care for neonates requiring consultation following delivery in a non-NICU hospital. Understanding the cost savings associated with TN may influence organizational decisions regarding implementation, diffusion, and retention of these programs.

Accuracy of Simulated Research Tasks by Community Hospitals Participating in a Multicenter Telemedicine Trial

Background/Aims: Clinical trials evaluating facility-to-facility telemedicine may include sites that have limited research experience. For the trial to be successful, these sites must correctly perform research-related tasks. This study aimed to determine whether health care professionals at community hospitals could accurately identify simulated study eligible patients and submit data to a research coordinating center. Methods: Twenty-seven community hospitals in the United States and Canada participated in this study. An electronic survey was sent to one designated health care professional at each site. The survey included a description of trial eligibility criteria and five written neonatal resuscitation scenarios. For each scenario, the participant determined whether the neonate was study eligible. One scenario required participants to submit 14 data elements to the coordinating center. Accuracy of study eligibility and data submission was summarized using standard descriptive statistics. Results: The survey response rate was 100% (27/27). Overall accuracy in determining study eligibility was 89% (120/135), and accuracy varied across the five scenarios (range 82-93%). Overall accuracy of data submission was 92% (310/336). Data were >95% accurate for 9 of the 14 data elements, with 100% accuracy achieved for 6 data elements. These results were used to clarify eligibility criteria, inform database design, and improve training materials for the subsequent clinical trial. Conclusions: Health care professionals at community hospitals accurately determined trial eligibility and submitted study data based on written clinical scenarios. Research teams conducting telemedicine trials with community hospitals should consider completing pre-trial simulation activities to identify opportunities for improving trial processes and materials.

Simulating Telehealth Experiences in the Neonatal Care Environment: Improving Access to Care

Telehealth in the neonatal environment can improve remote medical care and access to specialized care and training eliminating barriers for effective health care delivery. Clinicians are utilizing telehealth in their practice to provide specialized care and training in areas that have little access. Educating health care clinicians on the basics of telehealth is an essential component of clinical training programs. Use of simulation-based telehealth experiences as part of that training can provide hands-on learning in a safe, realistic environment. Simulation can prepare health care teams in using telehealth technology in managing patient care, postdischarge care, and specialized care programs.

Provider Perspectives on the Acceptability, Appropriateness, and Feasibility of Teleneonatology

OBJECTIVE

 We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals.

STUDY DESIGN

 Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models.

RESULTS

 The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries.

CONCLUSION

 Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable.

KEY POINTS

· Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

Use of telemedicine to support neonatal resuscitation

Neonatal tele-resuscitation programs use synchronous audio-video telemedicine systems to connect neonatologists with community hospital care teams during high risk resuscitations. Using tele-resuscitation, remote neonatologists can visualize and actively guide the resuscitation and stabilization of at-risk neonates. The feasibility of tele-resuscitation has been proven, and early evidence suggests that tele-resuscitation improves the quality of care, reduces unnecessary medical transports, and may generate a net savings to the health system. Community hospital staff and remote neonatologists are highly satisfied with tele-resuscitation programs. Tele-resuscitation presents an opportunity to improve healthcare delivery for neonates regardless of their birth location. The neonatology community should work to identify and rigorously study the value tele-resuscitation can bring to neonates, their families, and care teams.

Implementation and Outcomes of a Telehealth Neonatology Program in a Single Healthcare System

Background: Intermountain Healthcare, an early adopter and champion for newborn video-assisted resuscitation (VAR), identified a reduction in facility-level transfers and an estimated savings of $1. 2 million in potentially avoided transfers in a 2018 study. This study was conducted to increase understanding of VAR at the individual, newborn level. Study Aim: To compare transfers to a newborn intensive care unit (NICU), length of stay (LOS), and days of life on oxygen between newborns managed by neonatal VAR and those receiving standard care (SC). Methods: This retrospective, nonequivalent group study includes infants born in an Intermountain hospital between 2013 and 2017, 34 weeks gestation or greater, and requiring oxygen support in the first 15 minutes of life. Data came from billing and clinical records from Intermountain's enterprise data warehouse and chart reviews. We used logistic regression to estimate neonatal VAR's impact on transfers. Negative binomial regression estimated the impact on LOS and days of life on supplemental oxygen. Results: The VAR intervention was used in 46.2 percent of post-implementation cases and is associated with (1) a 12 percentage points reduction in the transfer rate, p = 0.02, (2) a reduction in spoke hospital (SH) LOS of 8.33 h (p < 0.01) for all transfers; (3) a reduction in SH LOS of 2.21 h (p < 0.01) for newborns transferred within 24 h; (4) a reduction in SH LOS of 17.85 h (p = 0.06) among non-transferred newborns; (5) a reduction in days of life on supplemental oxygen of 1.4 days (p = 0.08) among all transferred newborns, and (6) a reduction in days of life on supplemental oxygen of 0.41 days (p = 0.04) among non-transferred newborns. Conclusion: This study provides evidence that neonatal VAR improves care quality and increases local hospitals' capabilities to keep patients close to home. There is an ongoing demand for support to rural and community hospitals for urgent newborn resuscitations, and complex, mandatory NICU transfers. Efforts may be necessary to encourage neonatal VAR since the intervention was only used in 46.2 percent of this study's potential cases. Additional work is needed to understand the short- and long-term impacts of Neonatal VAR on health outcomes.

Using telehealth to support pediatricians in newborn care

This clinical scenario-based review will discuss how telehealth programs improve access to specialty care for neonates, their caregivers, and primary care pediatricians. Tele-resuscitation supports pediatricians during complex, high-risk newborn resuscitations, improves the quality of delivery room care, and reduces odds of transfer to a higher level of care. Neonatologists and other pediatric specialists use telehealth to provide more effective consultations that positively influence management decisions and patient outcomes. When neonatologists provide video visits to home and meet virtually with primary care pediatricians, infants discharged from the NICU experience fewer emergency room visits and hospital re-admissions. With further implementation and dissemination of neonatal telemedicine programs, it is important that these programs continue to be thoughtfully designed to achieve measurable value that is relevant to patients and caregivers, providers, healthcare systems, and payers.

Telemedicine, a tool for follow-up of infants discharged from the NICU? Experience from a pilot project

OBJECTIVE

Follow-up of infants from the NICU by neonatologist is limited to premature and complicated infants although parents of infants with advanced gestation may have concerns as well. We compared parental questions of infants < 35 weeks gestation (group A), during virtual telemedicine visits, to ≥35 week infants (group B).

STUDY DESIGN

In a retrospective cohort study, questions asked by parents were extracted from the electronic medical record of all infants post discharge from the NICU, after their pediatrician visit.

RESULTS

Gestation and birth weight of infants in group A were significantly lower than group B but their stay was longer. There were no significant differences in the number of parents who had questions, between the groups (A 68.1% vs B 67.3%, p = 0.91, 95% CI 0.46-1.99, OR = 0.96).

CONCLUSIONS

Telemedicine is a feasible tool for follow-up of NICU infants post discharge. Parents of infants with advanced gestation and weight may benefit from NICU follow-up.

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.

Developing a Newborn Resuscitation Telemedicine Program: A Follow-Up Study Comparing Two Technologies

Background: Early work has demonstrated that newborn resuscitation telemedicine programs (NRTPs) are feasible and improve the quality of high-risk newborn resuscitations in community settings. Research evaluating the telemedicine technology requirements for NRTPs is limited. Objective: To compare the quality and reliability of two telemedicine technologies for providing NRTP consults. We hypothesized that the InTouch Lite Version 2 (ITH Lite) would provide a higher-quality user experience and superior reliability when compared with a wired telemedicine cart. Methods: From December 1, 2015 to August 31, 2017, providers completed electronic surveys assessing technology performance after each NRTP consult and incident reporting/resolution was monitored. Survey questions assessed the overall, audio, and video quality using a 1-5 Likert scale. Reliability was assessed based on the ability to connect on first-attempt, unplanned disconnections, and the frequency and impact of reported incidents. Results: During the study period, 118 NRTP consults were performed (n = 25 wired cart; n = 93 ITH Lite) and 155 surveys were completed (n = 26 wired cart; n = 129 ITH Lite). Overall and video quality were similar between the two technologies, but audio quality (mean ± standard deviation) was superior using the ITH Lite (4.61 ± 0.72 vs. 4.08 ± 1.13, p < 0.01). Ability to connect on first attempt was improved with the ITH Lite (96% vs. 73%, p < 0.01). Fewer incidents were reported per activation (0.5:1 vs. 0.9:1) and more incidents were proactively resolved using the ITH Lite (93% vs. 68%, p < 0.01). Conclusion: The ITH Lite demonstrated improved audio quality and reliability when compared with a wired cart. Organizations should consider connection reliability and audio/video quality when selecting a NRTP technology.

Health Care Professionals' Perspectives on Teleneonatology Through the Lens of Normalization Process Theory

BACKGROUND AND AIMS

Little research has been done on tele-intensive care unit (ICU) implementation across different types of ICUs, and there exist few studies that have used qualitative research methods to analyze the human and organizational factors influencing optimization of telemedicine for newborn resuscitation. The objective of this study was to understand health care professionals' acceptance, utilization, and integration of video telemedicine for newborn resuscitation (termed teleneonatology) in community hospital settings.

METHODS

Focus group and individual interviews were conducted with 49 health care professionals at six affiliated health system hospitals. Data were gathered from physicians (n = 18), nurses (n = 30), and a nurse practitioner. Data were inductively analyzed using a thematic approach, and then constructs from normalization process theory (NPT) were deductively applied. NPT rendered a general framework to describe and assess how care teams perceive the implementation of teleneonatology and how they interact with this telemedicine service in their local setting.

RESULTS

Local health care professionals accepted teleneonatology as an important, helpful service, yet its implementation was perceived as both valuable and a threat to professional traditions. Utilization may depend on perceived benefit, mutual understanding of the guidelines, and expectations of use, and other relational, human, contextual, and system factors. Participants in this study agreed on the need for collective work to successfully integrate teleneonatology into the local practice.

DISCUSSIONS

NPT uncovered that successful implementation of a teleneonatology program may be facilitated by strong interpersonal relationships among care teams, continuous programmatic training and education, and communicating the clinical value of teleneonatology, including its opportunities and benefits.

Using Simulation to Develop Care Models for Rapid Response and Code Teams at a Satellite Facility

BACKGROUND

Our institution recently completed an expansion of an acute care inpatient unit within a satellite hospital that does not include an on-site ICU or PICU. Because of expected increases in volume and acuity, new care models for Rapid Response Teams (RRTs) and Code Blue Teams were necessary.

OBJECTIVES

Using simulation-based training, our objectives were to define the optimal roles and responsibilities for team members (including ICU physicians via telemedicine), refine the staffing of RRTs and code Teams, and identify latent safety threats (LSTs) before opening the expanded inpatient unit.

METHODS

The laboratory-based intervention consisted of 8 scenarios anticipated to occur at the new campus, with each simulation followed by an iterative debriefing process and a 30-minute safety talk delivered within 4-hour interprofessional sessions. In situ sessions were delivered after construction and before patients were admitted.

RESULTS

A total of 175 clinicians completed a 4-hour course in 17 sessions. Over 60 clinicians participated during 2 in situ sessions before the opening of the unit. Eleven team-level knowledge deficits, 19 LSTs, and 25 system-level issues were identified, which directly informed changes and refinements in care models at the bedside and via telemedicine consultation.

CONCLUSIONS

Simulation-based training can assist in developing staffing models, refining the RRT and code processes, and identify LSTs in a new pediatric acute care unit. This training model could be used as a template for other facilities looking to expand pediatric acute care at outlying smaller, more resource-limited facilities to evaluate new teams and environments before patient exposure.

Infant Resuscitation Practices of Midwives in a Developing Country

BACKGROUND

Effective basic newborn resuscitation is an important strategy to reduce the incidence of birth asphyxia and associated newborn outcomes. Outcomes for newborns can be markedly improved if health providers have appropriate newborn resuscitation skills.

PURPOSE

To evaluate the skills of midwives in newborn resuscitation in delivery rooms in Jordan.

METHODS

Data were collected from observation of 118 midwives from National Health Service hospitals in the north of Jordan who performed basic newborn resuscitation for full-term neonates. A structured checklist of 14 items of basic skills of resuscitation was used. Descriptive statistics were used to analyze the data.

RESULTS

The results highlighted the lack of appropriate performance of the 8 necessary skills at birth by midwives. About 17.8% of midwives had performed the core competencies at birth (ie, assessing breathing pattern/crying, cleaning airways) appropriately and met the standard sequence. Less than half of midwives assessed skin color (40.7%) and breathing pattern or crying (41.5%) appropriately with or without minor deviations from standard sequences. Of the 6 skills that had to be performed by midwives at 30 seconds up to 5 minutes after birth, 4 skills were not performed by about one-quarter of midwives.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The midwives' practices at the 2 hospitals of this study were not supported by best practice international guidelines. The study showed that a high proportion of midwives had imperfect basic newborn resuscitation skills despite a mean experience of 8 years. This highlights the critical need for continuing medical education in the area of basic newborn resuscitation. The results highlight the need for formal assessment of midwives' competence in basic newborn resuscitation. National evidence-based policies and quality assurance are needed to reflect contemporary practice.

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.