Slide 1

Pediatric Critical Care Telemedicine in Community Emergency Departments David McSwain, MD MPH Pediatric Critical Care Medicine Medical Director, MUSC Inpatient and Emergency Teleconsultation

Slide 2

Access to Subspecialty Care Only 3% of pediatric critical care physicians practice in rural areas. The vast majority of ED visits by children are made to general hospitals. 1 Children make up 27% of all ED visits nationwide. Only 6% of EDs in the US have all the necessary pediatric supplies. Only half have even 85% of necessary supplies. Critically ill patients transferred from outlying facilities have worse outcomes (mechanical ventilation, inotropes, PICU length of stay) compared to patients admitted from the same facility. 2 1.Institute of Medicine. 2006. Academic Emergency Medicine. 13(10) 2.Gregory et al. 2009. Pediatrics. 121(4): e906-e911

Slide 3

The Problem Hours can elapse from the time a community facility calls for assistance and the time a subspecialist sees a critically ill child. Assessing the acuity of injury or illness and determining appropriate pre-transfer interventions in a child over the telephone is at times extremely difficult. This can create an extraordinarily stressful experience for the patient, patients family, and the involved providers.

Slide 4

MUSC Pediatric Emergency and Critical Care Telemedicine Program (PECCT) $525,943 Duke Endowment grant for three years Pediatric emergency medicine and critical care physicians will be available 24/7 through the telemedicine program. Program designed to serve as foundation for future telemedicine programs Utilizes standard communication platforms to maximize adaptability Focusing on integrating existing telemedicine programs at MUSC into a unified system Goal is to optimize the ease of implementation for new and developing programs

Slide 5

Pilot Facilities Waccamaw Community Hospital Conway Medical Center

Slide 6

Slide 7

Telemedicine Units

Slide 8

Peripherals

Slide 9

Slide 10

Pilot Facility Status Conway Utilized credentialing-by-proxy Program fully implemented in May 2014 Georgetown/Waccamaw Initially used traditional credentialing Now proceeding with credentialing-by-proxy Revision of hospital bylaws pending Colleton Utilizing traditional credentialing Credentialing still in progress

Slide 11

Referral/Transfer Data Collecting data on all calls for pediatric emergency medicine or critical care for transfer or consultation. Since April 2012 776 records 432 surveys completed 424 did not use telemedicine 8 used telemedicine

Slide 12

Location at Referring Site 633 (89.5%) 28 (4.0%) 21 (3.0%) 16 (2.3%) 9 (1.3%)

Slide 13

Patient Transferred to MUSC? 25 transported patients (7.3%) could have been managed at referring facility 8 telemedicine consults 1 patient not transferred (12.5%) Facial burn. Would have been transferred if not for telemedicine. The following is NOT statistically significant!! NNT to avoid one transport: 9.5 98.0% 2.0%

Slide 14

Initial Transport Destination 23 (10.5%) non-TM patients could have been triaged to a lower level of care 12 to Intermediate 11 to Floor Three of eight telemedicine patients transferred to PICU 1 not transferred 3 to MUSC ED (then floor) 1 to Intermediate All triage decisions felt to be appropriate in retrospect Use of telemedicine influenced triage decision in 50% of cases 37.4% 47.1% 13.5% 2.1%

Slide 15

Transportation Helicopter: 27.6% Ground because unable to fly: 9.5% Ground: 58.4% Fixed-wing: 0.7% Private Vehicle: 3.8% Incorrect mode of transport for 25 patients (6.5%) Five ground transports should have gone via air 17 air transports should have gone by ground Telemedicine consults: 3 ground, 1 unable to fly, 3 helicopter All three ground transports would have been by helicopter if not for telemedicine All transport decisions judged to be appropriate in retrospect

Slide 16

Telemedicine Quality OverallDiagnosisRespiratoryCardiacNeurologic Telephone3.94.34.24.34.1 Telemedicine54.8555 Scale: 1 = very poor, 5 = excellent In all eight cases, examiners stated that telemedicine improved (2) or greatly improved (6) the overall quality of the initial consult.

Slide 17

Telemedicine Vignettes Teenager with near-drowning Gathered information during arterial line placement by ED physician Infant with SVT Diagnosis and management with cardiology fellow Toddler with AMS Directly observed lumbar puncture Teenager with rash and fever Ruled out TSS and confirmed stability for intermediate care Toddler with ataxia Lengthy discussion with parents involving PICU and ED physicians Child with facial burn Management recommendations provided and child discharged home

Slide 18

Slide 19

Slide 20

Access to Subspecialty Care Percent of population below poverty level Georgetown County: 21% Horry County: 22% Colleton County: 21% Percent of pediatric patients hospitalized at MUSC Georgetown County: 28% Horry County: 24% Colleton County: 51% ED/PICU calls September 1, 2012 August 31, 2013 Georgetown Memorial Hospital: 37 Waccamaw Medical Center: 32 Colleton Medical Center: 33 Conway Medical Center: 24 All facilities: 467 Four pilot facilities accounted for 27% of calls Number not transferred: 25 (5%)

Slide 21

Referral Sites Beaufort Memorial Hospital (78, 10.1%) Bon Secours Saint Francis Hospital (16, 2.1%) Clarendon Memorial Hospital (12, 1.6%) Colleton Medical Center (39, 5.1%) Conway Medical Center (48, 6.2%) East Cooper Regional Medical Center (16, 2.1%) Georgetown Memorial Hospital (49, 6.3%) Grand Strand Regional Medical Center (51, 6.6%) Greenville Memorial Hospital (14, 1.8%) Hampton Regional Medical Center (11, 1.4%) Hilton Head Medical Center and Clinics (15, 1.9%) McLeod Health - Florence (20, 2.6%) Moncks Corner Medical Center (22, 2.8%) Nason Medical Center (9, 1.2%) Orangeburg Regional Hospital (11, 1.4%) Palmetto Health Richland (10, 1.3%) Roper Berkeley Day Hospital (21, 2.7%) Southstrand Ambulatory Care (9, 1.2%) Summerville Medical Center (93, 12.0%) Trident Medical Center (47, 6.1%) Waccamaw Medical Center (47, 6.1%) Williamsburg Regional Hospital (8, 1.0%) Coastal Carolina Medical Center (8, 1.0%)

Slide 22

Disposition from MUSC ED