1. Telemedicine in Pediatrics: Assessment of Critical Care Patients Project Team: Kathleen Webster MD, Jenny Wang MD, Dina Calamur MD, Cindi LaPorte RN, Sandra Swanson RN,MSOD Confidential: For Quality Improvement Purposes Only

2. Background Evidence and Best Practice: Intensivists improve ICU patient outcomes 1 Leapfrog Group 2 : 5 min response 8 hr/day; ideally 24/7 LUMC Initiative: > PGY4 immediately available in ICU Pediatric Critical Care Unit at RMCH 800 admissions/yr: 57% between 5pm and 8am 3 pediatric intensivists  In House at least 8-12 hrs Apr-May, 12-15 hrs Jan-Mar  PGY2 or 3 in house, no fellows 1 Pronovost JAMA 2002;288:2151-2162 2 http://www.leapfroggroup.org/media/file/Fact_Sheet_IPS_080327.pdf Confidential: For Quality Improvement Purposes Only

3. Admissions to PCCU Vulnerable Populations Infants (under 1 year)  21% of all admissions  72% occur at night Transfers from 4Peds  9% of all admissions  63% occur at night  High risk group Previous studies show 2 fold increase in mortality for transfer pts vs admit from ED 3 Solid line: intensivist may not be in house Dotted line: +/- intensivist in house 3 Odetola et al, Pediatr Crit Care Med 2008;9:20-25 All Admissions Confidential: For Quality Improvement Purposes Only

4. Project Aim Opportunity  Increase intensivist presence through use of telemedicine  Target vulnerable populations Goal  100% of patients in target populations will have evaluation by pediatric intensivist and creation of treatment plan within 1 hour of admission Confidential: For Quality Improvement Purposes Only

5. Solutions: Telemedicine Connection Two way audio visual connection  Allows patient assessment, including stethoscope and dialogue with team  Intensivist can connect from anywhere Proven to be accurate 4 and useful 5 for real time assessments Guidelines for use were created Nightly test calls conducted to increase familiarity Monthly chart review of target populations to assess compliance 4 Kofos Pediatrics 1998;102;58 http://www.pediatrics.org/cgi/content/full/102/5/e58http://www.pediatrics.org/cgi/content/full/102/5/e58 5 Marcin Pediatr Crit Care Med 2004;5:251-256 Confidential: For Quality Improvement Purposes Only

6. Patient Evaluation by Intensivist Within 1 Hour of Admission Patients Less Than 12 months OldPatients Transferred From 4Peds in person telemedicine Confidential: For Quality Improvement Purposes Only

7. Impact on Mortality Pre-Telemedicine (Apr 06-Mar07) Post-Telemedicine (Apr 07-Mar 08) PCCU admissions764872 PCCU mortality1.4%1.7% Infant admissions163 (21%)202 (23%) Infant mortality2.5%0.5% Transfer admissions66 (8.6% of PICU admits 1.6% of 4Peds admits) 59 (6.7%of PICU admits, 1.3% of 4Peds admits) Transfer mortality1.5%6.8% Confidential: For Quality Improvement Purposes Only

8. Pediatric Critical Care Telemedicine Use Number of evaluations Confidential: For Quality Improvement Purposes Only

9. Conclusions Use of telemedicine technology is effective in reaching goals for intensivist evaluation of pediatric critical care patients in target populations Infant Evaluation  100% target reached  33% of evaluations are by telemedicine  Decreased mortality seen Transfer Patient Evaluation  100% target reached, 59% by telemedicine  Fewer transfers  Higher mortality “Other” Uses  Deteriorating inpatient  Ward/IMC pt evaluated but transfer averted  Code Supervision Confidential: For Quality Improvement Purposes Only

10. Next Steps Continue to monitor goals Evaluate “other” uses Evaluate at risk patients through use of Tele-Rapid Response Team  Monitor mortality of transfer patients Tele-link with ED to facilitate early intervention and triage Confidential: For Quality Improvement Purposes Only