New Guideline Approved to Combat Eating Disorders

ANTENATAL & NEONATAL GUIDELINES, EDUCATION AND LEARNING SYSTEM

Telephone(501) 526-7425 • Toll Free(866) 273-3835

Fall 2009

The National Guideline Clearinghouse announced on aug. 31, 2009 that our ANGELS guideline ,“Eating Disorders during Pregnancy and Postpartum,” was accepted and is available on their Web site at www.guideline.gov

Arkansas physicians participated in the review of the guideline through the High Risk Obstetrics Teleconference and the ANGELS Web site. This was a collaborative effort of obstetrics, maternal-fetal medicine, psychiatry and internal medicine specialists with review by a national expert on the topic.

The guideline was developed by Linda L. M. Worley, M.D., in collaboration with Samantha McKelvey, M.D.; Sara Tariq, M.D.; Curtis Lowery, M.D., with UAMS, and Joel Yager, M.D., with the University of New Mexico. For this and other obstetrical, neonatal, and pediatric guidelines, please visit http://www.uams.edu/angels/guidelines.asp.

ANGELS responds to H1N1 Concerns

As a rapid response to the severe illnesses among pregnant women and infants in the recent outbreak of novel H1N1 flu, vital information

was effectively communicated to existing telemedicine and teleconference sites across Arkansas. Both urban and rural healthcare providers joined together through interactive video teleconferences on Sept. 28, Oct. 1 and Oct. 2. These preparation and management teleconferences served as a problem-solving forum among various disciplines and included physician experts from infectious disease, obstetrics, maternal-fetal medicine, pediatrics, neonatology, family medicine and emergency medicine. Nursing specialists, infection control practitioners and Arkansas Department of Health experts contributed to the discussions as clinics and hospital units were linked across the state. More than 85 sites registered to attend the teleconferences. For those unable to attend via interactive video, health care providers were able to participate online via streaming video. By utilizing an existing clinical telemedicine and teleconference system, multiple clinical areas

and two telemedicine networks were engaged through one operational system. Through this network, health care providers were able to access timely information through systems that are familiar and recognized in their practices, rapidly and efficiently.

On Friday, Oct. 23, an additional nursing teleconference was offered as a result of nursing requests, “The Hospitalized Pregnant Patient with H1N1: Maternal, neonatal, and ICU perspectives.” The 90-minute panel discussion was led by Sarah Rhoads, D.N.P., A.P.N., and included UAMS nursing specialists from infection control, NICU, Labor and Delivery and critical care. The director of infection control with Arkansas Children’s Hospital and an expert nurse with immunizations and communicable diseases at ADH also provided their insight and expertise by participating on this panel.

approximately 32 sites connected across Arkansas for the nursing teleconference. This was also live streamed to desktops. More than 200 viewers have accessed the H1N1 teleconferences through these recordings.

by Barbara Smith

Arnold Glasgow said, “Success isn’t a result of spontaneous combustion. You must set yourself on fire.” We have been on fire here at ANGELS for several years now. The state of Arkansas continues to be motivated and mobilized with the expansion of our Telehealth Network. It is

awesome to see the difference we are making with the providers and patients we serve in Arkansas. But the results of the telemedicine network are not only thanks to the work of ANGELS—but the Center for Distance Health as well.

Twice a year the CDH is privileged to host students from the United States Telecommunications Training Institute (USTTI). These students represent countries from all over the world and come to the United States for policy and technical training. We take them through the rigors of both our educational and clinical enterprises surrounding Telehealth in Arkansas. They learn everything from how to make

a simple interactive video call, to understanding contractual and business models. It takes a lot of preparation time to pull off a visit like this. And it is a long three days for these individuals. I can’t tell you enough what an awesome job everyone with CDH does during these visits. It is a learning experience for the students and they take back a wealth of knowledge.

Part of the curriculum is to present the obstacles they face with health care, but it always leads to sharing the things they are proud of in their country as well. We are very lucky here in Arkansas with the availability of great health care, whether in person or through telemedicine. ANGELS will continue to remember this by not only taking care of Arkansans, but by helping others across the United States and around the world realize their potential for utilizing telemedicine. We are the fuel for the “fire.” It is going to continue to burn for all the right reasons, and the UAMS Center for Distance Health will continue to be successful.

University of Arkansas for Medical Sciences4301 W. Markham St., #518little Rock, aR 72205-7199

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by Michael Manley

a Word From Outreach

The ANGELS Call Center is taking triage another step with interactive video (IAV). Using interactive video paired with a 24/7 RN-staffed Call Center allows staff to comprehensively triage and provide direct care for patients. In 2007, the ANGELS Call Center began using interactive video for a project with a local

Arkansas women’s prison, providing obstetrical triage for their pregnant population. Using interactive video allows the nurse to objectively gather information by assessing the patient visually in addition to the standard algorithms. Over the past year, ANGELS and CDH has added many projects requiring Call Center support and has effectively expanded the role of interactive video in the ANGELS Call Center.

Pediatric Emergency DepartmentsIAV allows the emergency departments that have a Tandberg unit for AR SAVES to also utilize the equipment when a pediatric patient comes into their emergency department and needs a consult with ACH pediatrician. X-rays can be viewed and the decision for transport can be made. The pediatrician can meet with parents and answer questions and alleviate anxiety related to their child being transported to Little Rock for specialized care.

TeleNursery Virtual/interactive hospital rounds include many of the states NICUs. They are able to ‘back transports’ from UAMS and ACH to decompress the busy tertiary care center. Smaller NICUs in rural areas may request Neonatal consult or transport. The Call Center reports the census of the OB unit and any expected OB transport that could affect the tertiary centers nursery census.

Tele OB Rounds L&D units around the state are connected through IAV with an obstetrician at the tertiary center hosting virtual hospital rounds. They are able to offer consults on difficult cases and are also able to accept ‘back transports’ from UAMS to allow room for less stable patients needing access.

Neonatal ConsultsThe consulting neonatologist can assess the neonate via IAV while speaking with the referring physician. The Call Center will receive the incoming consult request and facilitate and maintain the IAV connection, while documenting the consult for potential stats and research.Neonatal Transport after ACH dispatch calls the ANGELS Call Center, the Call Center sets up the interactive call between the referring site physician, the on-call neonatologist, Angel One dispatch, the transport team’s room

and the content server to record interactions. The Call Center also documents recommendations and call outcomes.

OB Consults and Transport The receiving nurse and physician meet the patient via IAV before she is transported. This decreases patient anxiety about going to an unfamiliar hospital and allows the physician and the nurse to visually assess patient.

Postpartum Moms Some babies are transported to the ACH NICU for care. Sometimes the postpartum mom is unable to see her baby. The interactive video connection between the postpartum unit where the mom is located and NICU can allow mom to see her baby earlier and begin the bonding process or sometimes to say goodbye to a baby that is dying but mom is not able make it to the bedside.

AR SAVES Telestroke programarkansas ranks #1 nationally for stroke related mortality. Rural Arkansas does not have the necessary access to a subspecialist (neurologist) to provide emergent stroke treatment. Telestroke consults through AR SAVES facilitates the administration of tPA (clot busting) medication to eligible patients. The call center provides the access point for emergency medicine physicians at referring, rural hospitals to an on-call telestroke neurologist. The call center facilitates the IAV call between referring and consulting physician. The triage nurse stays in conference with the neurologist and the rural emergency department throughout entire consult: documenting the consult and facilitating the location of an ICU bed at a tertiary care facility if tPA is given. The call center also participates in monthly ‘training drills’ required with each of the participating emergency departments.

ANGELS Call Center expands the role of Interactive Video

New employee to welcome: Debbe Lane PSC

by Donna Williams

New Call Center Employee Debbe Lane, PSC

We have several exciting projects in the works that are related to telemedicine research. It is ANGELS’ goal to reach the unreachable potential research participant. We use teleconferencing for clinical care and now we are expanding this network to researchers and research participants. Teleconferencing can be used to interview research participants in the vicinity of their home. This is unusual for research studies because generally, the research participant has to travel to the study site or the research study personnel have to travel to the research participant. This project will make research

studies more population based and open the potential number of participants. We are currently evaluating several programs related to ANGELS. We strive to evaluate and use these evaluations to improve programs and services. As a part of our program evaluation, we look at the following: patient satisfaction, provider satisfaction and outcome measures. We are in the process of publishing several articles in scholarly journals to ensure that the lessons we’ve learned become part of medical literature. Additionally, we regularly present our findings at medical conferences to demonstrate the effect the ANGELS program has on people throughout the state.

The Research Corner

at the beginning of 2009, aNGElS began developing a program to offer fetal echocardiography and pediatric echocardiography to rural sites in Arkansas via telemedicine.

The goal is to provide increased access to fetal echo and other pediatric cardiology services to patients in rural areas of the state. By providing easier access for patients, we hope to accomplish several goals:

Increase awareness to local physicians of fetal echocardiogram 1. guidelines and recommendationsIncrease the detection rate of Congenital Heart Disease2. Provide care to patients in their local communities and reduce 3. travel time and costs for those patients Increase knowledge of Congenital Heart Disease to 4. obstetricians, neonatologists and pediatricians in the communityProvide review of pediatric echocardiograms by the pediatric 5. cardiologists at ACH from hospitals and echocardiography labs across the state. Increase efficiency and turn-around times of pediatric 6. echocardiograms throughout the state to the referring physicians.

This program is being coordinated between ANGELS and pediatric cardiology at ACH. A sonographer certified in pediatric cardiology and specializing in fetal echocardiography was added to the ANGELS staff. We are coordinating with Renee Bornemeier, M.D., associate professor in pediatric cardiology and director of the fetal heart program at ACH.

Several sites have been selected to begin the fetal echo pilot project including the aHECs at Fayetteville, Jonesboro, Texarkana and Pine Bluff. Additional sites are also being evaluated for possible inclusion.The first Fetal Echo Telemedicine clinic was held on Sept. 22, 2009.

The second stage in the project will be to connect hospitals performing pediatric echocardiography to the pediatric cardiologists at ACH for review and reporting. Education and training will be offered to sonographers and physicians in the state who provide pediatric echocardiographic procedures.

by Lori Heil

by David Fletcher and Sarah Rhoads

Currently tele-nursery rounds are held on Monday, Wednesday and Friday at 8:15 a.m. for a brief census rounds that include questions, consults and follow-up information given as needed. Also, tele-OB rounds are held on Monday, Wednesday and Friday at 8:00 a.m. and include a brief census rounds,

questions answered in a peer review format, consults and follow-up information provided.

Rounds are hosted by Sam Greenfield, M.D., at the following sites:

Telemedicine Outreach Utilizing Collaborative Healthcare (TOUCH) OB and Nursery Roundsby Shannon Lewis

Jefferson Regional, Pine Bluff• Mercy Medical Center, Rogers• National Park Medical Center, • Hot SpringsOuachita Medical Center, • Camden

St. Bernard’s, Jonesboro• St Edwards, Fort Smith• St Michaels, Texarkana• Washington Regional Medical • Center, FayettevilleWillow Creek, Johnson•

Fetal and Pediatric EchocardiographyUtilizing Telemedicine

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American Telemedicine Association PresentationsTelemedicine: A Business ModelRoy Kitchen, M.S. COM Center for Distance Health Business Administrator University of Arkansas for Medical SciencesLittle Rock, Ark.

Telemedicine and Neonatal Intensive Care: Regionalization and Supporting your CompetitionR. Whit Hall, M.D.ProfessorNeonatologyUAMS Medical CenterLittle Rock, Ark.

Julie Hall-Barrow, Ed.D., assistant professor, UAMS College of Public Health; education director, UAMS Center for Distance Health chaired an Outpatient Panel Discussion on telemedicine. The panel included various specialties that offered examples in pediatric obesity, neurology and pulmonary management. Sustainable models were discussed, and important management and programmatic issues to ensure a successful outpatient program was explored.

Bryan l. Burke, Jr., M.D., F.a.a.P., associate professor, Section of Neonatology, UAMS chaired the education panel. The education session had three primary goals: the first goal was to showcase innovative tele-education programs targeting health professional and parents; the second goal was to show how to do research in the area of tele-education and to publish the results of this research; and the third goal was to begin a conversation on how tele-education can be used to provide resident education and physician CME to broad regions of the country.

aNGElS, OB/GYN and Peds Faculty published in the October 2009 issue of Pediatric annals:Guest EditorialTelemedicine – Guest Editor, Bryan l. Burke Jr., M.D., F.a.a.P.

Tele-education: Linking Educators with Learners via Distance TechnologyChristopher E. Smith, M.D., F.a.a.P. and Beatrice a. Boateng, Ph.D. are with aCH and UaMS

Telemedicine and Neonatal Regionalization of Care – Ensuring that the Right Baby Gets to the Right NurseryJulie Hall-Barrow, Ed.D; R. Whit Hall, M.D.; and Bryan L. Burke Jr., M.D.

Practical Applications of Telemedicine for PediatriciansNeil E. Herendeen, M.D., M.S. and G. Bradley Schaefer, M.D.

Telemedicine and Child Abuse ExaminationsRandell alexander, M.D., Ph.D. and Karen Farst, M.D., M.P.H.

New Ideas in Nursing: TelehealthSarah J. Rhoads, D.N.P., A.P.N.; Shannon Lewis, B.S.N., R.N.; Theresa Bubenzer, M.S.N., F.N.P.; and Rachel E. Ott, B.a.

December 24 Cancelled due to the Christmas holiday

December 31 Cancelled due to the New Year holiday

January 7 Translational Research Topic

January 14 Prevention of Adolescent Sports Injuries

Upcoming Education Events

To sign on for these interactive video conferences, please call 501-686-8666.

Pediatric Reportby Julie Hall-Barrow

Coming SoonThe ACH Burn Center will be offering consults to patients that arrive at EDs that are equipped with tele-medicine equipment. The use of the tele-stroke equipment will allow clinical personnel within the burn center to quickly triage burn patients prior to transport. In addition, the ACH burn center is developing an out-patient center with the Center for Distance Health to alleviate long travel times for out-patients.

Telemedicine continues to make great strides in the pediatric arena. In conjunction with ANGELS and the Center for Distance Health (CDH), a new and exciting program for rural hospital emergency departments began August 1, 2009. Beth Storm, M.D., is leading a project that

provides pediatric emergency consults to hospitals that have clinical telemedicine units located in their EDs! Utilizing the CDH tele-stroke units, physicians at Arkansas Children’s Hospital (ACH) have been able to visualize pediatric patients and provide recommendations for treatment and transport.

Tele-nursery rounds are key in regionalizing neonatal care in Arkansas. Within 15 minutes, 17 nurseries in the state are updated on available beds and possible back transports headed their way! In addition, referring physicians and nurses can be provided with a status update of patients that have been transported to Arkansas Children’s Hospital (ACH).

Utilizing the system for Health EmergenciesThrough this integrated system all nurseries participated in H1N1 updates that were hosted by ANGELS. These interactive video teleconferences served as a problem-solving forum to promote a collaborative discussion of H1N1 in pregnant women and neonates. This panel discussion involved not only infectious disease specialists, obstetricians, neonatologists, pediatricians, and nurses but also emergency department physicians, family practice physicians and those providing health care at Area Health Education Centers. Prevention and preparation strategies in addition to management guidelines were discussed.

The ANGELS team has been working with Angel One Dispatch to “GO LIVE” with neonatal consults/transports that originate with dispatch. If dispatch receives a call from a designated tele-nursery site, the neonatologist will be connected interactively to the site and recorded through the ANGELS Call Center. This program allows all parties to see and listen to the referring physician, visually examine the baby and review any films related to the patient.

NEED ECHO Training?Lori Heil is crossing our state to educate OB providers on “best views” for hearts during an ultra-sound. If your practice is interested in participating please call the ANGELS Call Center and ask for Lori.

Telemedicine UpdateTelemedicine is constantly increasing services for our Arkansas community. Most recently Gordon low, aPN was awarded a $735,000, a three-year grant from the federal Health Resources and Services Administration (HRSA) and its Office for the Advancement of Telehealth (OAT) titled “Arkansas System to Access Rural Telecolposcopy.” The grant will expand the existing telecolposcopy program, Arkansas START (System To Access

Rural Telecolposcopy), from its current single site in Hempstead County to two additional sites, one in Cross County in northeast Arkansas and one in Johnson County in northwest Arkansas. The project design incorporates an OB/GYN at the telemedicine “Hub” at UAMS, who overseas and supervises the exams with APNs, who perform the exams at the distant “spoke” sites. We speculate that we have the potential to see approximately 1500 women annually who wouldn’t otherwise have access to colposcopy services. In addition to providing a needed service, the goal of the project is to assess the effectiveness and sensitivity of telecolposcopy being performed at multiple sites simultaneously. W.C. Hitt, M.D., is the PI of the project and Low is the project manager.

In other news, Danny Wilkerson, an associate professor of anesthesiology obstetrics and gynecology, recognized a need to bring anesthesia pre-op into the UAMS local OBGYN clinics via Telemedicine. This venue will provide pre-op anesthesia services to high-risk patients during their scheduled appointment. Talk about killing two birds with one stone. Great idea Dr. Wilkerson!

In northwest Arkansas, medical students are getting a head start with telemedicine knowledge thanks to W. Workman, M.D., and Noelle Agan, M.S., certified genetic counselor for ANGELS. Agan is providing a venue for these students to observe and learn the advantages of telemedicine in health care.

by Rosalyn Perkins