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Service Delivery Innovation Profile

Pediatric Critical Care Physicians Provide Remote Consultations to Emergency Departments in Underserved Rural Areas, Leading to Better Diagnosis and Treatment


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Snapshot

Summary

Pediatric emergency and critical care physicians at the University of California at Davis Children’s Hospital provide 24-hour evaluation and consultation services via interactive videoconferencing with patients and physicians in 24 emergency departments in rural and underserved areas of northern California.1 The program also provides these remote emergency departments with a standardized triage protocol with laminated reference cards and monthly pediatric critical care training in an effort to increase physician knowledge and improve consistency and quality of care. The program has been found to improve the diagnostic and treatment process and parent satisfaction; a comprehensive evaluation of the program’s impact on quality of care is currently underway.

Evidence Rating (What is this?)

Moderate: The available evidence consists of preliminary comparisons of key metrics between eight emergency departments (EDs) using remote telemedicine consultation and two EDs using traditional telephone consultations.
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Developing Organizations

University of California, Davis -- Center for Health and Technology; University of California, Davis -- Center for Health Research; University of California, Davis -- Children's Hospital; University of California, Davis -- School of Medicine, Department of Pediatrics
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Use By Other Organizations

Some institutions have adopted a similar model of care, including the Doernbecher Children's Hospital at Oregon Health and Science University; University of New Mexico; University of Arkansas for Medical Sciences; Loyola University Medical Center; Children's Mercy Hospitals & Clinics; and University of Vermont, Vermont Children’s Hospital at Fletcher Allen Health Care.

Date First Implemented

2004
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Patient Population

Vulnerable Populations > Children; Rural populationsend pp

Problem Addressed

Rural EDs often lack the resources to adequately assess and optimally treat acutely ill and injured children.
  • Ill-equipped rural facilities: Rural hospitals nationwide have a shortage of on-call pediatricians and pediatric specialists.2 Like their peer institutions in other states, rural hospitals in California lack physicians with experience in pediatric emergency medicine and often do not have essential pediatric medical equipment.3
  • High incidence of medication errors: The rate of medication errors for hospitalized children is three times greater than for adults.4 One study in northern California found a high incidence of medication errors among children treated for acute illness and injury in rural EDs.5
  • Greater risk: Children living in rural areas have higher mortality rates than do urban-dwelling children. In 1992, the incidence of fatal injuries among rural children was 44 percent higher than among urban children, while the death rate for children 1 to 14 years of age living in rural areas was 20 percent higher.6

What They Did

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Description of the Innovative Activity

The University of California at Davis (UC Davis) pediatric critical care telemedicine program provides a standardized triage protocol with laminated reference cards and 24-hour evaluation and consultation services via interactive videoconferencing with patients and physicians in 24 EDs in rural and underserved areas of northern California. The program also provides these EDs with monthly pediatric critical care training in an effort to increase physician knowledge and improve consistency and quality of care. Key elements of the program include the following:
  • Standardized triage protocol and laminated reference cards: Critical care physicians train triage nurses on use of a new, standardized triage protocol. In addition, all eight participating EDs receive laminated reference cards that list physiologic and diagnostic criteria for each triage category included in the new protocol.
  • Expert consultation through telemedicine: Expert consultations are available 24 hours a day, 7 days a week through interactive videoconferencing; remote sites can activate these sessions by paging pediatric critical care physicians at UC Davis Children’s Hospital Pediatric ED and intensive care unit (ICU), who then assist with history, examination, and interpretation of findings for category I and II (acutely ill or injured) pediatric cases. The consultation process is described below:
    • Initial assessment: A triage nurse assesses the pediatric patient using the standardized protocol described above. If the triage nurse determines a case to be category I or II, an ED physician at the remote hospital will assess the patient and decide whether a telemedicine consultation is appropriate.
    • Activating the consult: Once the ED physician determines a telemedicine consultation is necessary, the remote hospital ED obtains consent from the parent/guardian (if possible). The remote site then pages the on-duty UC Davis Children’s Hospital Pediatric ICU or ED physician and turns on the telemedicine unit. On-call pediatric critical care physicians also can connect through a home-based mobile telemedicine unit. The remote site is usually connected within 5 to 10 minutes.
    • Consultation: Once a connection has been established, the UC Davis pediatric emergency or critical care physician sees the examination room and everyone in it. The patient, parent or guardian, physician, nurse, and/or other parties can interact with the UC Davis physician in real time. The UC Davis physician assists remotely during the physical examination and reviews radiographs and laboratory results.
  • Monthly critical care training: UC Davis critical care pediatric physicians host monthly interactive lectures on a variety of topics related to pediatric critical care that are broadcast over secure Internet connections to remote ED sites. The program encourages staff at the remote sites to identify specific areas of need so that training sessions can be tailored to address them. In theory, these sessions provide training that otherwise would not occur due to the prohibitive time and travel requirements for onsite training at UC Davis. However, most remote EDs have not been tuning into these monthly sessions, perhaps due to the stationary location of the telemedicine units (which may limit the ability of staff to use them) and/or to other competing obligations. Program leaders are investigating ways to increase attendance, including providing continuing medical education credits.

Context of the Innovation

UC Davis is a public research university located in the heart of California’s Central Valley. One of 10 campuses in the University of California system, UC Davis supports numerous medical service and research centers, including the Center for Health and Technology and the Center for Health Services Research. The Center for Health and Technology houses UC Davis’ telemedicine program, which has been nationally recognized as a leader in video-based telemedicine, distance learning, and applied medical informatics technologies. James Marcin, MD, MPH, a critical care pediatric physician and associate professor at UC Davis, has an ongoing relationship with the Center for Health and Technology and is always looking for innovative ways to improve health care access and quality of care for children in underserved areas of California. He is often approached about the need for additional training and ongoing subspecialty support during his monthly training sessions and lectures. These requests led to Dr. Marcin’s decision to work with various UC Davis departments to develop this program.

Did It Work?

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Results

Preliminary unpublished findings from a review of 67 cases at eight telemedicine sites and two control sites using traditional telephone consultations suggest that the program improves the diagnostic and treatment process and parent satisfaction. Surveys suggest that both consulting and remote physicians believe that the telemedicine consultations are superior to traditional telephone consultations. A more comprehensive evaluation of the program’s impact on quality of care is currently underway.
  • Better diagnostic/treatment process and decisionmaking: The remote consultation program resulted in changes to diagnostic testing, treatment plans (including medication), and admission and method of transfer decisions. Specifically, survey results of consulting physicians suggest that telemedicine consultations at treatment sites were more likely than telephone consultations at control sites to result in: (1) additional diagnostic studies ordered (47.78 vs. 13.34 percent; p = 0.01), and (2) changes to or addition of medications (55.23 vs. 7.14 percent; p = 0.01).
  • Higher levels of parent satisfaction: The program resulted in higher levels of parent satisfaction with the treatment process. Results from a parent satisfaction survey yielded a mean score on a 7-point adjectival scale for the survey questions to be significantly higher with telemedicine (N = 46) than telephone consultation (N = 28) for courtesy of ED nurses (6.69 vs. 5.74, p <0.01), courtesy of ED physicians (6.60 vs. 5.74, p <0.01), knowledge and skill of the ED physician (6.44 vs. 5.56, p <0.01), explanation of what was done for a child (6.39 vs. 5.41, p <0.02), overall ED quality of care (6.41 vs. 5.63), and overall ED experience (6.37 vs. 5.33, p <0.01); except for the survey question “explanation of what was happening with child" (6.10 vs. 5.56), which was higher but not significant.
  • Greater perceived value by physicians: Both the consulting and remote physicians believe that the program enhances the value of the consultation process. Specifically, consulting physicians at intervention and control sites used a 7-point scale to rank the degree to which the consultation assisted in the medical management of the patient; the mean score was 6.63 for telemedicine consultations compared with 5.0 for telephone consultations at control sites. In addition, referring physicians used a 7-point scale to rank their overall satisfaction with the consultation process; the mean score was 6.89 for telemedicine consultations, compared with 5.67 for telephone consultations.
  • Further evaluation underway: An evaluation of data from all intervention sites using a pre- and post-implementation test design with matched comparison groups will assess the program’s impact on the following: quality of care, medication errors, rate of appropriate patient admissions and transfers, and parent/guardian satisfaction with the medical care provided.

Evidence Rating (What is this?)

Moderate: The available evidence consists of preliminary comparisons of key metrics between eight emergency departments (EDs) using remote telemedicine consultation and two EDs using traditional telephone consultations.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Site recruitment: Program leaders initially recruited eight sites (two pilot sites plus six others), and then added two additional sites. All participating EDs are located in rural and/or underserved areas.
  • Site preparation: Once sites agreed to participate, the program dispatched a technician to assess their technology needs and coordinate with Internet technology specialists on location. A UC Davis pediatric critical care physician met with hospital administrators to answer any questions and make sure they understood the process and were still agreeable to program participation. This physician later returned to the remote ED, usually with a technician, for a kickoff meeting with ED physicians and personnel, typically held in conjunction with regularly scheduled staff meetings.
  • Training: All triage nurses in participating hospitals received training on use of the standardized triage protocol and laminated reference cards. In addition, the program offered all personnel from the participating EDs formal telemedicine education through the UC Davis Telemedicine Education Program. Sessions included a 1-day overview and a 3-day expansive course. Information provided in February 2012 indicates that more than 1,800 providers, administrators, and technicians have gone through this course.

Resources Used and Skills Needed

  • Staffing: Staffing for the program includes the following:

    • Pediatric emergency and/or critical care physicians: Currently, four pediatric emergency medicine and seven pediatric critical care physicians from UC Davis’ Children’s Hospital ICU volunteer their time to provide 24-hours-a-day, 7-days-a-week consultations to 10 rural and/or underserved hospital EDs. These physicians also conduct the initial and monthly training sessions, with assistance from a technician.

    • Technical assistance staff: Technicians from the Center for Health and Technology are available around the clock to provide technical support and conduct weekly “test calls.” These weekly calls not only test the system but also increase remote provider familiarity with the equipment and operating procedures. Tests are conducted at varying times and days of the week to accommodate all shifts.

    • Telemedicine coordinators: A telemedicine coordinator oversees program operations, including hospital agreements, assignment of staff roles, equipment testing, provider training, quality assurance, and program evaluation. This person typically spends between 10 and 25 percent of his or her time in this role, depending on consultation volume.
  • Equipment: All intervention and remote sites have pagers to contact experts at UC Davis. To provide confidential interactive audio and video capabilities, videoconferencing units are connected with fractionated T1 lines, triple Integrated Services Digital Network lines, or secure and encrypted high-speed Internet connections.
  • Costs: The cost of equipment at remote sites ranges from $15,000 to $25,000, depending on capital needs. Telecommunications costs range from $50 to $200 per month, depending on the type of connection used. Staff costs vary significantly depending on volume. The current cost of each consultation is negligible because most physicians volunteer their time. However, the program is working toward securing third-party insurance reimbursement of $250 per consultation. Because UC Davis sponsors the monthly pediatric critical care trainings, the program cost for these trainings is negligible, consisting only of the cost to set up a camera and telecommunication charges during the broadcast.
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Funding Sources

Agency for Healthcare Research and Quality; Health Resources and Services Administration
Implementation and evaluation of the two pilot sites were funded by a $608,850 grant from the Agency for Healthcare Research and Quality [Grant No.: K08 HS013179]. The program is currently funded internally at these two sites. The implementation and evaluation of the program at the eight other sites are being funded by a $598,998 grant from the Health Resources and Services Administration.7 Currently all sites are being transitioned to become self-sustaining programs.

Information provided in February 2012 indicates that the program was awarded a 3-year $752,753 grant to expand this program (Grant number RC1HD064098-01) from the Office for the Advancement of Telehealth, Health Resources and Services Administration (HRSA).end fs

Adoption Considerations

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Getting Started with This Innovation

  • Secure buy-in and commitment from key stakeholders: Ensure the commitment of dedicated pediatric critical care physicians to provide as-needed consultations in addition to initial and monthly training. For their part, rural providers must be willing to seek and accept expert guidance from these physicians. Support from hospital administrators and a “champion” (e.g., the telemedicine coordinator at the remote site) is also essential.
  • Strike a balance between need and commitment when choosing sites: Remote sites must have both a need for the program (e.g., an adequate volume of cases to justify the investment, but not too much volume that adequate in-house expertise already exists) and strong desire among key staff to participate.

Sustaining This Innovation

  • Actively pursue alternative funding sources: Because public funding can shift with new budget priorities, and grant funding is usually time-limited, active pursuit of alternative funding sources, including third-party reimbursement, is essential. Aside from the minimal costs associated with the monthly training, technical support, and communication lines, it may be possible to make this program essentially "self-sufficient" through third-party reimbursement for consultations.
  • Provide competent, responsive technical assistance: Remote sites needs ongoing guidance on efficient use of the technology and prompt resolution of any technical problems that arise. High-quality information technology and videoconferencing personnel are needed to establish, maintain, and troubleshoot telecommunications and equipment.

Use By Other Organizations

Some institutions have adopted a similar model of care, including the Doernbecher Children's Hospital at Oregon Health and Science University; University of New Mexico; University of Arkansas for Medical Sciences; Loyola University Medical Center; Children's Mercy Hospitals & Clinics; and University of Vermont, Vermont Children’s Hospital at Fletcher Allen Health Care.

More Information

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Contact the Innovator

James Marcin MD, MPH
Professor
University of California, Davis School of Medicine/Pediatrics
2516 Stockton Blvd.
Sacramento, CA 95817-2208
Phone: (916) 734-4726
Fax: (916) 456-2235
E-mail: jpmarcin@ucdavis.edu

Innovator Disclosures

Dr. Marcin has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Cole SL, Medrano S, Satterfield MW, et al. Providing pediatric emergency medicine expertise to rural emergency departments. Telemed J E Health. 2004;10(1):S97-8.

Marcin JP, Nesbitt TS, Kallas HJ, et al. Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural northern California. J Pediatr. 2004;144(3):375-80. [PubMed]

Grant K08 HS13179. Grants On-Line Database, Agency for Healthcare Research and Quality, 2007. Available at: http://gold.ahrq.gov/projectsearch/grant_summary.jsp?grant=K08+HS13179-05.

Marcin J. Summaries of Independent Scientist (K) Awards. Agency for Healthcare Research and Quality. Available at: http://archive.ahrq.gov/fund/training/Kawdsum60.htm.

Marcin JP, Schepps DE, Page KA, et al. The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report. Pediatr Crit Care Med. 2004;5(3):251-6. [PubMed]

Marcin JP, Trujano J, Sadorra C, et al. Telemedicine in rural pediatric care: the fundamentals. Pediatr Ann. 2009;38(4):224-6. [PubMed]

Dharmar M, Smith AC, Armfield NR, et al. Telemedicine for children in need of intensive care. Pediatr Ann. 2009;38(10):562-6. [PubMed]

Footnotes

1 All participating hospitals are located in rural areas, rural towns, or small towns as defined by California’s Office of Statewide Health Planning and Development or Federal Health Care Financing Administration and/or are “underserved” according to Health Resources and Services Administration definitions of Health Professional Shortage Area, Medically Underserved Areas, and Medically Underserved Populations.
2 Shortage of Physician Specialists. Advocacy page. American College of Emergency Physicians Web site. Available at: http://www.acep.org/advocacy.aspx?id=21658
3 Kon AA, Marcin JP. Using telemedicine to improve communication during paediatric resuscitations. J Telemed Telecare. 2005;11(5):261-4. [PubMed]
4 Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20. [PubMed]
5 Marcin JP, Dharmar M, Cho M, et al. Medication errors among acutely ill and injured children treated in rural emergency departments. Ann Emerg Med. 2007;50(4):361-7. [PubMed]
6 Clark SJ, Savitz LA, Randolph RK. Rural children's health. West J Med. 2001;174(2):142-7. [PubMed]
7 The original two pilot sites are part of the current program evaluation. The two new sites that recently joined the program are not part of the formal evaluation.
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 27, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 14, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.