Key points

Introduction

In the past 2 decades, it has become increasingly evident that the quality of care provided in the pediatric intensive care unit (ICU) is improved when patients are actively cared for by pediatric critical care physicians. Research has demonstrated in both adult and pediatric ICUs that critically ill patients have a lower risk of death, shorter ICU and hospital length of stay, and receive higher care quality when critical care physicians are involved in their management. Specifically, researchers estimate that ICU mortality can be reduced by some 10% to 25% when critical care physicians direct patient care compared with ICUs whereby critical care physicians have little to no involvement in patient care.

Unfortunately, not all critically ill children are cared for in regionalized pediatric ICUs and they are not uniformly treated by pediatric critical care physicians. This circumstance is in part explained by the fact that regionalization of pediatric ICUs, although increasing quality and efficiencies of care, by its design, also creates disparities in access. Critically ill children from nonurban areas are frequently treated and cared for, by necessity, in hospitals that may lack the full spectrum of pediatric ICU services and/or pediatric critical care expertise. Magnifying this problem is the continued shortages of critical care physicians, for both adult and pediatric ICUs, which is expected to worsen in future years. Combined, regionalization and physician shortages make it difficult to guarantee that all critically ill patients are treated in a timely manner by qualified physicians in an appropriate full-service ICU.

Telemedicine, defined as the provision of health care over a distance using telecommunications technologies, can enable specially trained critical care physicians’ participation in the care all of critically ill patients in remote locations while simultaneously maintaining the regionalization of ICU services. This model of care, referred to as Tele-ICU, can be used to more efficiently increase access to specialty care services, including critical care physicians, to patients living in underserved and remote communities and in community hospitals where the full spectrum of ICU and critical care services is not available. By importing specialty expertise using telemedicine, emergency departments (EDs), inpatient wards, and nonspecialty ICUs are given the means to increase their capacity to provide higher quality of care to critically ill patients. Critical care physicians can also increase their efficiency with these technologies so that their expertise can be disseminated to more patients at more than one ICU or hospital at a time. The use of telemedicine technologies can also reduce the need to transfer less ill children to referral centers, reserving the limited pediatric ICU beds to those most in need of a regionalized center. For these reasons, the use of telemedicine by hospitals and physicians providing critical care services will continue to increase and be individualized to best fit the needs of the patients that they serve.

Although the use of Tele-ICU can help providers of critical care services address disparities in access to care, improve quality of care, and reduce overall health care costs, it will never replace the bedside pediatric critical care physician or eliminate the need to transfer critically ill children to regional pediatric ICUs. Instead, pediatric critical care physicians can use telemedicine and telehealth technologies as a tool to assist in the remote monitoring and treatment of patients where their services may not otherwise be immediately available. Herein, the author reviews how telemedicine can be used by pediatric critical care physicians and pediatric ICUs, focusing particularly on the delivery of care in remote hospital EDs, in critical care transport, in remote hospital inpatient wards, and in remote ICUs where pediatric critical care specialists are not immediately available.

Introduction

In the past 2 decades, it has become increasingly evident that the quality of care provided in the pediatric intensive care unit (ICU) is improved when patients are actively cared for by pediatric critical care physicians. Research has demonstrated in both adult and pediatric ICUs that critically ill patients have a lower risk of death, shorter ICU and hospital length of stay, and receive higher care quality when critical care physicians are involved in their management. Specifically, researchers estimate that ICU mortality can be reduced by some 10% to 25% when critical care physicians direct patient care compared with ICUs whereby critical care physicians have little to no involvement in patient care.

Unfortunately, not all critically ill children are cared for in regionalized pediatric ICUs and they are not uniformly treated by pediatric critical care physicians. This circumstance is in part explained by the fact that regionalization of pediatric ICUs, although increasing quality and efficiencies of care, by its design, also creates disparities in access. Critically ill children from nonurban areas are frequently treated and cared for, by necessity, in hospitals that may lack the full spectrum of pediatric ICU services and/or pediatric critical care expertise. Magnifying this problem is the continued shortages of critical care physicians, for both adult and pediatric ICUs, which is expected to worsen in future years. Combined, regionalization and physician shortages make it difficult to guarantee that all critically ill patients are treated in a timely manner by qualified physicians in an appropriate full-service ICU.

Telemedicine, defined as the provision of health care over a distance using telecommunications technologies, can enable specially trained critical care physicians’ participation in the care all of critically ill patients in remote locations while simultaneously maintaining the regionalization of ICU services. This model of care, referred to as Tele-ICU, can be used to more efficiently increase access to specialty care services, including critical care physicians, to patients living in underserved and remote communities and in community hospitals where the full spectrum of ICU and critical care services is not available. By importing specialty expertise using telemedicine, emergency departments (EDs), inpatient wards, and nonspecialty ICUs are given the means to increase their capacity to provide higher quality of care to critically ill patients. Critical care physicians can also increase their efficiency with these technologies so that their expertise can be disseminated to more patients at more than one ICU or hospital at a time. The use of telemedicine technologies can also reduce the need to transfer less ill children to referral centers, reserving the limited pediatric ICU beds to those most in need of a regionalized center. For these reasons, the use of telemedicine by hospitals and physicians providing critical care services will continue to increase and be individualized to best fit the needs of the patients that they serve.

Although the use of Tele-ICU can help providers of critical care services address disparities in access to care, improve quality of care, and reduce overall health care costs, it will never replace the bedside pediatric critical care physician or eliminate the need to transfer critically ill children to regional pediatric ICUs. Instead, pediatric critical care physicians can use telemedicine and telehealth technologies as a tool to assist in the remote monitoring and treatment of patients where their services may not otherwise be immediately available. Herein, the author reviews how telemedicine can be used by pediatric critical care physicians and pediatric ICUs, focusing particularly on the delivery of care in remote hospital EDs, in critical care transport, in remote hospital inpatient wards, and in remote ICUs where pediatric critical care specialists are not immediately available.

Telemedicine for critically ill children in remote EDs

It is well documented that without pediatric expertise, critically ill children presenting to EDs receive poorer quality of care compared with the care provided in EDs with pediatric expertise. These EDs are also, at times, inadequately equipped to care for pediatric emergencies. In addition, the staff working in smaller, general EDs, including physicians, nurses, pharmacists, and support staff, are often less experienced in caring for critically ill children. Combined, the relative lack of equipment, infrastructure and experienced personnel can result in delayed or incorrect diagnoses, suboptimal therapies, and imperfect medical management. As a consequence, acutely ill or injured children receive lower quality of care than children presenting to EDs in regionalized children’s hospitals.

The use of telemedicine technologies for disaster victims or in remote or underserved EDs can be a means of obtaining subspecialty expertise by consultation. The benefit of using this technology as opposed to using the telephone (the current standard of care) is that the consultant (ie, the pediatric critical care physician) has the ability to have a virtual presence at the patients’ bedside. The consultant has access to high-definition patient views, the treating providers, the family, as well as monitors and equipment. Previous studies have demonstrated that the use of telemedicine in the ED to deliver consultations is similar to in-person consultations when comparing diagnostic accuracy, treatment plans, and plans for disposition. The use of telemedicine to urgently obtain a consultation from a neurologist in the ED to treat patients with an acute stroke is now common practice. Similarly, telemedicine is used to provide emergency medicine consultations to critical access hospitals, which are staffed by physician assistants. Both of these examples have been shown to result in high-quality, cost-effective care.

With regard to providing pediatric critical care consultations to remote EDs for critically ill children, there is increasing acceptance and evidence that this model of care can improve the quality of care and increase provider, patient, and parent-guardian satisfaction. Two studies have describe how pediatric critical care physicians use telemedicine to provide consultations to critically ill children presenting to rural EDs. Heath and colleagues, at the University of Vermont, concluded that the use of telemedicine was associated with improved patient care and was superior to telephone consultations. In another study by Dharmar and colleagues, it was shown that patients receiving telemedicine consultations in remote EDs received higher overall care quality when compared with similar patients receiving telephone consultations. Both of these programs also reported that referring ED physicians more frequently changed their diagnosis and/or therapeutic interventions compared with when consultations were provided by telephone. Finally, the use of telemedicine to provide critical care consultations has also been shown to result in significantly higher parent-guardian satisfaction and perceived quality when compared with telephone consultations.

Overall, although more research is needed, there is mounting evidence that pediatric critical care consultations to rural and underserved EDs using telemedicine can be used to help address disparities in access to specialists and, in doing so, improve the overall quality of care. It is also likely that because of better care and the reduction in unnecessary transports, telemedicine consultations to rural and underserved EDs can be provided in a cost-efficient manner that reduces the health care costs that would otherwise be encumbered if telemedicine were not used.

Telemedicine during transport of critically ill pediatric patients

The use of telemedicine by physicians to assist in the care of critically ill patients during transport could have the potential to improve processes of care at several levels. For example, telemedicine could allow physicians to be an immediate part of the monitoring, identification, and management of changes in the patients’ status that occur during transport. With more immediate physician supervision using telemedicine, medical decisions, including new medication orders, have the potential to occur more rapidly and efficiently than without direct physician supervision.

Currently, mobile telephone technologies are used to transmit 2-way audio as well as data, including electrocardiogram data. However, to create a model of care that uses telemedicine during transport, much more robust, mobile broadband telecommunications are needed. Only a handful of transport programs in the United States use these technologies because high-quality broadband mobile telecommunications is expensive and not always or easily available. This circumstance is particularly true if continuous video transmission or large data streaming is desired. Two common methods of transmitting video include the use of high-fidelity cell-phone service (sometimes combining several cell-phone lines) and the use of the Internet that can be available with citywide Wi-Fi or satellite services. Although satellite technologies can be used to provide mobile telemedicine connections, this technology is most often prohibitively expensive.

There have been anecdotal reports documenting the feasibility of cell-phone and Wi-Fi transmitted telemedicine consultations during transport. In one study, the outcomes of simulated adult trauma patients were compared among scenarios that used telemedicine and scenarios that used telephone communications during transport. The researchers found that use of telemedicine resulted in a reduction in adverse clinical events, including fewer episodes of desaturation, hypotension, and less tachycardia compared with identical simulated patients without telemedicine use. In addition, the researchers found that recognition rates for key physiologic signs and the need for critical interventions were higher in the transport simulations that used telemedicine. These data are encouraging and support the possibility that telemedicine can be used during patient transport. However, until more reliable and affordable mobile telecommunications are available to implement telemedicine during transport and more research is conducted on the impact that telemedicine has during transport, the effectiveness and benefit of this technology remain undetermined.

Critical care telemedicine consultations for hospitalized children

Pediatric critical care services are more regionalized and fewer than adult critical care services. As a result, children living in nonurban communities that may need critical care services have to be transferred a sometimes lengthy and risky transport to a pediatric ICU. Often, pediatric patients that are not critically ill are overtriaged and transferred to the regional center because there may be the potential for needing the specialty services provided by the pediatric ICU. This practice is particularly inefficient given the fact that regionalized quaternary pediatric ICUs are frequently running at full capacity. In fact, the transfer of some pediatric patients to a quaternary pediatric referral center is often not necessary if there is a closer hospital with adequate pediatric capabilities, such as a level II or community pediatric ICU, an intermediate or step-down pediatric care unit, or general ICU with pediatric expertise.

Admitting some of the less-ill children to hospitals other than regional, quaternary referral centers can result in high quality of care provided with similar length of stays, less resource use, and lower costs. It is, therefore, logical that some mildly or moderately ill children (eg, a child with asthma who requires continuous albuterol or a child with known diabetes and mild diabetic ketoacidosis) can be cared for in a level II or community pediatric ICU or other non–children’s hospital’s ICU under the care of pediatric nurses and physicians with supervision from a regional children’s hospital pediatric critical care team using telemedicine and remote monitoring.

Telemedicine can be used by pediatric critical care clinicians using a broad range of applications to assist in the care of hospitalized children in a variety of clinical scenarios. Physician consultations, nurse and physician monitoring, and medical oversight can range from a simple model of intermittent, need-based consultations (consultative model) to a model that integrates continuous monitoring and proactive medical decision making (continuous care model). In a consultative model, a pediatric critical care physician can provide bedside telemedicine consultations to patients in a remote inpatient ward, high-acuity unit, or ICU. Such consultations could prompt a variety of clinical interventions, including recommendations on diagnostic studies, medications, or other therapies. The consultation may also conclude that the patient should be transported to the regional pediatric ICU. This type of model could result in a range of interventions from a one-time consultation to multiple videoconferencing interactions during the course of the day or hospital stay.

In the continuous care model, telemedicine can be used in combination with comprehensive electronic remote monitoring as well as oversight by critical care physicians and nurses. In such a model, a remote team of physicians and nurses are able to monitor many patient beds, sometimes several ICUs. This continuous care model of telemedicine is more proactive with medical interventions and can involve nontelemedicine guidelines, such as the implementation of evidence-based standards. This Tele-ICU model is created by centralizing electronic health records, ICU monitoring technologies and nurse/physician video oversight. Continuous care Tele-ICUs can be created internally by a large health system, or can be contracted out to a third party technology and physician organizations that specialize in remote ICU monitoring services.