Rushed to the emergency room, the infant had been vomiting greenish-colored material, which could indicate a possible bowel obstruction. “That’s a surgical emergency,” said Dr. Nicholas Slamon, a specialist in pediatric critical care at the Alfred I. duPont Hospital for Children in Wilmington.
The emergency room swiftly requested a transport to the children’s hospital, part of the Nemours Health System. A specially trained nurse was dispatched to accompany the child.
At the referring hospital, the nurse used an Apple iPad® and the FaceTime® video conferencing program to communicate with Slamon. She provided him with the child’s vital statistics. He asked her to turn the camera on the baby, which she did with the touch of a button.
“I saw a smiling, happy baby, who was kicking his feet,” Slamon recalled. “His belly wasn’t distended, and he was nice and pink. He didn’t look like a baby with a bowel obstruction.”
The real time video feed was part of the study that Slamon organized with Dr. Shetal Patel, Dr. James Hertzog and Dr. Scott Penfil. Conducted from July through September 2012, the study replaced the critical care transport team’s usual cell phone communication with the Apple iPad and FaceTime.
According to the results, 75 percent of the medical command officers participating in the study felt video conferencing provided a better understanding of the patient’s condition, and 66 percent felt that video conferencing assisted the determination of the correct patient disposition. Seventy-five percent felt it should be used routinely for inter-hospital transport.
“Based on the success of the study, we are eager to continue to leverage technology to help improve patient outcomes,” said Michele Sowa, MSN, RN, the Nemours critical care transport nurse manager at Alfred I. duPont Hospital for Children.
The study, which was funded by the Nemours Fund for Children’s Health, underscores the growing use of telemedicine to improve patient outcomes and the quality of care.
Effective communication is key for the critical care transport team at the Alfred I. duPont Hospital for Children, which moves patients either by van or helicopter from surrounding hospitals in the tri-state region.
“The emergency rooms do a great job of trying to stabilize pediatric patients, but because it’s a specialized population they’re not often able to have as much success as we do here in a freestanding children’s hospital,” Slamon said. “They do everything they can and then call our transport team to provide essentially a mobile intensive care unit.”
Traditionally, the transport team nurse arrives at the referring hospital and collects information, such as lab results and X-rays. He or she then reports back to the children’s hospital via cell phone.
The hospital uses the information to determine which department will admit the patient upon arrival. If the patient needs fluids or medication, the doctor can also give instructions to the nurse during the phone call.
But the calls fell short in one respect. “Even though we have great transport nurses who can give us a description of the patient, we couldn’t see them,” said Dr. Shetal Patel. “It was the one piece that was missing.”
The study used iPads for numerous reasons. For one, the iPad is durable, portable —and affordable. The grant was for $2,000, which purchased three iPads.
Because Apple’s FaceTime program is encrypted on both sides of the video stream, it complies with patient privacy laws. (No transmissions were recorded.) And since many of the users already have personal iPhones and iPads, which share a similar interface, little training was required.
Based on the referring hospital’s report, patients are scored on a level from one through five. Level one patients are in critical condition. Level five patients might have a cold or a fracture. The study focused only on levels one through three. Parents of the participating children signed a consent form, as did children over the age of 7.
Using the iPad, transport team nurses engaged in face-to-face conversation with staff back at the children’s hospital. “We could read their facial expressions and body language and get a sense during the conversation about what was going on,” Slamon said.
Doctors could ask the nurse to zoom in on a wound or the patient’s face and fingernails. When the nurse zoomed in on the chest, the doctor could determine the breathing pattern.
The nurse cold also turn the camera on the monitor, so doctors could view the EKG pattern and heart rate.
“The resolution was excellent; the connections were excellent,” Slamon said. “The audio quality was perfect, and then it gives you this video image… that was clear, crisp —sharp images with good color.”
Color, he explained, is an important assessment tool in pediatrics. Infant skin might be pink, gray or mottled, depending on the child’s condition.
The study relied on Wi-Fi, which was an issue in referring hospitals whose Internet service couldn’t handle video conferencing. The next phase will include 4G technology.
Although the iPad was only used when nurses were at the referring hospital, Slamon and Patel foresee its use in the van or the helicopter if a patient’s condition changes en route to Wilmington. Slamon said iPads could also be used within the hospital, especially if doctors in the intensive care unit can’t immediately make it down to the ER for a consult.
“Our initial study was to prove it could be done, and I think we’ve been able to do that,” Slamon said.
Sowa is a believer. “The first phase of the FaceTime study allowed the critical care transport team to bring the physician to the bedside at the referring facility which optimized patient care,” she says.
The average iPad conference calls were 50 seconds shorter than cell phone communication. “Does a little bit of time help you get the patient back to the hospital quicker and potentially impact their outcome?” Slamon asked. “Maybe. We can’t say for sure, but that will be part of our further research.”
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