Recent advances in telehealth adoption prompted by the COVID-19 pandemic have highlighted the potential for improved intensive care outcomes through implementing pediatric telehealth in rural and remote settings. Telemedicine consults can be used in a variety of intensive care scenarios including procedural support, resuscitation, specialty consults, and transport. Telemedicine consults for pediatric care in rural environments improve access, cost-effectiveness, and family-centeredness. Challenges to adopting telemedicine consults for intensive care unit level care include issues around training, technology, resource allocation, and attention to how implementation exacerbate or improve health disparities.
Key points
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Recent advances in telehealth adoption have demonstrated the potential for improved outcomes through implementing pediatric telehealth in rural and remote settings.
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Pediatric telemedicine consults can be used in a variety of intensive care unit (ICU) scenarios including procedural support, resuscitation, specialty consults, and transport.
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Telemedicine consults for ICU care in rural environments improve access, cost-effectiveness, and family-centeredness.
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Challenges to adopting pediatric telemedicine consults for ICU level care include issues around training, technology, resource allocation, and attention to how implementation approaches exacerbate or improve health disparities.
Introduction
The infant mortality rate (IMR), or the death of a child before their first birthday, is 6.0 per 1000 live births in the United States and the under 5 years child mortality rate is 22.7 per 100,000 population. These statistics are high when the United States is compared with other resource-rich countries. Mortality rates increase as urbanization levels decrease, with disparities in IMR increasing from 5.44 deaths per 1,000 births in large urban counties to 6.55 in rural counties. The regionalization of pediatric care improves the quality of care and reduces mortality rates, , but given the distribution of pediatric specialists which favors urban areas and lack of transportation ( Fig. 1 ), many pediatric patients present to smaller volume rural facilities with emergent conditions requiring specialist care and are transferred to larger urban centers. When they return home, limits in public transportation may make specialist follow up challenging prompting further local emergency room visits and referrals, perpetuating the cycle. Recent advances in telehealth adoption prompted by the COVID-19 pandemic have demonstrated the potential for improved outcomes through implementing pediatric telehealth in rural and remote settings.
Rural pediatric care and relevance of telemedicine
Telemedicine can improve access and quality of care for pediatric patients in underserved rural communities, reducing health care disparities and increasing provider, patient, and family satisfaction. Specifically, telehealth in rural and remote emergency departments can improve clinical effectiveness, care processes, and speed of care, depending on the context and acuity of patient presentation. While telehealth in pediatric primary care has been generally underutilized until recent years, , a range of pediatric specialist telehealth services including specialist consults in behavioral health, diabetes care and obesity management, physical therapy and rehabilitation services, sleep medicine services, and palliative care counseling have been described.
Types of telemedicine
Telemedicine can generally be classified into synchronous and asynchronous or store-and-forward models. Synchronous models involve using an audio and video connection to communicate in real-time and are particularly useful in acute and emergent conditions or for patients requiring intensive care. The use of synchronous telemedicine results in improved quality of care and resulted in a decrease in the transfer rate (31%–87.5%; 4 studies), a shorter length of stay (8.2 vs 15.1 d) (6 studies), a change or reinforcement of the medical care plan, a reduction in complications and illness severity, and a low hospital and standardized mortality rate.
Another approach to describing telemedicine is audio-only versus video telemedicine. Audio-only or phone telemedicine is particularly useful in settings where broadband Internet availability is low and depending on the condition, patient outcomes may be generally comparable with video telemedicine. , However, in other studies, video telemedicine had added benefits in improving provider diagnostic accuracy and reducing readmission rates. Video telemedicine can be provided using video-conferencing platforms with specially designed features to support telehealth such as pan-tilt-zoom cameras and the ability to use peripheral devices such as stethoscopes to remotely auscultate heart and lung sounds. These features are particularly useful for critical care and inpatient settings. However, in many ambulatory settings including home telehealth, regular video conferencing platforms may provide adequate audiovisual connection, particularly when accompanied by images sent through a Health Insurance Portability and Accountability Act (HIPAA) compliant platforms.
Applications of telehealth
Teleconsult
There are many examples of improved access, decreased costs, and effectively delivered care with the use of teleconsults in rural areas. Pediatric critical care teleconsults to community hospitalists is feasible and results in reduced Pediatric Intensive Care Unit (PICU) admissions. Emergency rooms without pediatric emergency medicine providers have benefited from teleconsults with Pediatric Emergency Medicine (PEM) staffed Emergency Departments (EDs) and/or pediatric intensivists. These teleconsults during the initial presentation in a rural ED support the goal of managing children in their local hospitals and minimizing preventable inter-facility transfers. They have also been shown to improve management and reduce medication errors. Home-based telehealth for children with medical complexity has been shown to be feasible, well received by caregivers, and may result in decreased hospitalizations. Another example involves nurse-facilitated diabetes care management at remote clinics while the pediatric clinician consults via telehealth. Caregiver assessment scales reported improvements in access to care (81%), confidence in communication quality and privacy (91%), and the vast majority (98%) showed interest in the use telemedicine for future health needs. Telepsychiatry is a specific example of teleconsults that have been used effectively to address mental health crises in EDs. Telepsychiatry was shown to be cost-efficient, improve clinical and operational efficiency, and improve the patient and family experience, without an increase in safety concerns based on 72 hour readmission rates.
Teleresuscitation
Teleresuscitation can be used to support clinicians during high-risk newborn resuscitations with improved access to neonatology expertise. This telehealth support improves the quality of care and reduces unnecessary transfers. Emergency rooms also benefit from teleresuscitation with the telehealth support of intensivist or pediatric emergency medicine expertise.
Telerounding
Telerounding harnesses the use of telehealth platforms to include remote participants in daily bedside rounds. Telerounding increases family participation when parents and caregivers face barriers to being present on rounds. Many ICUs have moved toward family-centered rounding and parents place a high value on these daily encounters with their team of clinicians; however, barriers including transportation difficulties and home-to-hospital distance often make their daily in-person presence unattainable. Offering video and/or audio-only-based remote participation of parents has been shown to increase parental engagement, reduce parental stress, potentially decrease length of stay by earlier parental involvement in discharge planning, and allow for cost-savings for parents who otherwise may have lost wages or benefits if they were to be in-person for rounds everyday. Telerounding also provides opportunities for specialty consultants to contribute during rounds while the entire bedside team and family is present and supports intensive care when patients are in isolation.
Teleprocedure
Telehealth can be used to remotely facilitate procedures or perioperative care. In pediatric orthopedic medicine, one study compared efficacy, duration, and parental satisfaction of in-person versus telehealth visits for a 4 week postop cast removal in the setting of type I supracondylar humeral fractures or occult elbow injuries. Telehealth visits were more efficient and there were higher satisfaction scores. There was no significant difference in fracture displacement, range of motion, or pain scores between groups at the 8 week postop visit that was in person for both groups. Telehealth has been studied for preoperative evaluations by pediatric hospitalists of medically complex patients undergoing elective orthopedic procedures. There was no statistically significant difference for the median number of hospitalist recommendations or progression to surgery between the in-person or telehealth consults.
Teletransport
Telehealth used during transport supports facilitation advanced care prior to arrival at the receiving hospital which can lead to earlier intervention and even improved outcomes as based on recommendations from the pediatric clinicians at the receiving hospital.
Teletherapy
Telehealth interventions in pediatric speech therapy and occupational therapy, though not widely used, have been shown to be successful. Teletherapy treatment has high family participation and satisfaction, as well as being clinically and cost-effective.
Transitions of Care
Poor transitions of care result in increased hospital admissions and readmissions, escalation of care once hospitalized, and poor patient experience and outcomes. Telehealth can facilitate improved care by creating a supported collaboration during various transitions of care. For instance, telehealth has been shown to improve handoffs between neonatologists and primary care providers for medically complex infants. A specific outpatient example is one of nurse-practitioner-led telehealth being used to improve outpatient pediatric tracheostomy management.
Discussion
Benefits of Telemedicine to Rural Areas
There are countless benefits of telemedicine to rural areas. Telehealth offers opportunities to increase accessibility, cost-effectiveness, and family centeredness. In one systemic review comparing satisfaction among caregivers and pediatric providers for telehealth versus in-person visits, telehealth services received more favorable or comparable satisfaction rating than in-person visits. The benefits included the “ease of use” and “reduced need for transportation.” The main improvement areas related to technological challenges, a limited personal interaction with the provider, and a lack of physical examination. The reduced travel time is significant in telehealth visits used for rural areas and leads to improved satisfaction in caregivers. Various specialties from neonatology to palliative care have effectively employed telehealth, offering a variety of visit types. , In surgical fields, comparable services of initial consultations, preoperative visits, postoperative visits, and follow-up visits have been documented.
There is evidence that telemedicine can improve the triaging of patients in emergency rooms, with early intervention from ICU specialists leading to children to arriving to receiving hospitals with lower illness severity at admission to the PICU. Importantly, early telehealth intervention with corresponding protocols and communication pathways have been shown to reduce preventable transfers and keep patients closer to home.
Telehealth can also decrease no-show rates because caregivers and patients have fewer barriers in getting to an in-person appointment. Decreasing no-show rates is important to improve health outcomes and decrease the overall cost burden to the health care system. In one such study of a pediatric asthma clinic, caregivers were offered the option of telehealth versus in-person follow-up visits. The no-show rate significantly decreased, and parents reported improved access, time saved, and simplicity in use.
Challenges
There are many challenges to the delivery of telehealth consults to improve intensive care unit (ICU) level care in rural communities. Common challenges include issues around necessary training, accessibility, available technology, cost, resource allocation, and attention to how implementation exacerbates or improves health disparities. ,
Cost
The primary barriers to telehealth, as reported in an analysis of a national representative survey of American Academy of Pediatrics post-residency member pediatricians in 2016, were insufficient payment and inability to bill for services. The study also considered what factors may convince nonusers to consider adopting telehealth. They found that 40% of nonusers would consider using telehealth for follow-up care if services significantly decreased patient travel time and improved access to specialists or pediatricians. When considering issues of cost, one must consider the cost of the technology itself as well as the human resources, as well as the actual billable services and cost to the family.
Equity/Disparities
Expanding telehealth in pediatrics requires user-friendly digital health, facilitating patient preferred language, and simplifying logistical processes to avoid worsening health disparities. One study examined telemedicine use within a large pediatric primary care network and identified that use differed based on child age, race, and ethnicity, and recent preventive care, highlighting the need for further work to increase equitable access to primary care telemedicine. Disparities have resulted in many medically under resourced communities, including people of color, language of care other than English, rural populations, and youth with special health care needs with additional barriers in accessing telehealth services. Disparities in access to hardware and Internet limit implementation and adoption of new technologies. Differences in digital literacy can also further worsen inequity. Employing user-friendly technology, facilitating care in the patient preferred language, and simplifying logistical processes are factors that will contribute to reducing health disparities.
Infrastructure
Rural telehealth infrastructure has been a major focus of funding for over two decades. Early demonstration projects supported by rural telehealth grants have formed the framework of today’s telehealth infrastructure. With the COVID-19 pandemic, more attention has been given to the need for infrastructure to support telehealth. While Internet connectivity is improving, broadband connections remain limited in rural settings which hinders the adoption of telehealth by rural communities.
Education/Awareness
The COVID-19 pandemic increased awareness of individuals and institutions of the benefits of telehealth. During the public health emergency, many new use cases involving inpatient and ambulatory telehealth, including “hospital at home” were explored. The success of many of these pilots has led to greater adoption of telehealth post-pandemic with most institutions continuing to maintain some telehealth appointments at a higher rate than pre-pandemic even while transitioning back to an in-person format for the majority of visits. As evidenced by a Google Scholar search, there is variable awareness and research being done on the various telehealth applications, with teleconsults and teletherapy leading the way ( Fig. 2 ).
