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Telemedicine Pilot Project Between Sacred Heart Medical Center and Oregon Health & Science University Doernbecher Children’s Hospital. Telehealth Alliance of Oregon November 1, 2007. Presented by. Miles S. Ellenby, M.D., FAAP Associate Professor, Pediatrics & Anesthesiology
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Telemedicine Pilot ProjectBetween Sacred Heart Medical Center andOregon Health & Science University Doernbecher Children’s Hospital Telehealth Alliance of Oregon November 1, 2007
Presented by Miles S. Ellenby, M.D., FAAP Associate Professor, Pediatrics & Anesthesiology Division of Critical Care Medicine Doernbecher Children's Hospital Oregon Health & Science University Thomas Roe, M.D. Clinical Professor, Pediatrics, Oregon Health & Science University Clinical Practice Pediatrics, Eugene, OR Co-Pediatric Course Director, Oregon Medical Education and Research Collaborative
Disclosure The Accreditation Council for Continuing Medical Education (ACCME) requires all speakers to make a verbal disclosure of all relevant financial relationships with any commercial interest and the nature of the financial interest pertaining to this lecture.
Sacred Heart Medical Center and Oregon Health & Science University Sacred Heart Medical Center RiverBend – open August 2008 OHSU tram – opened January 2007 Sacred Heart Medical Center University District – renovation complete 2010
Sacred Heart Medical Center • 432 beds • Trauma II • Primary Service Area population: 336,811 • Secondary Service Area population: 343,464 • 100 miles from Oregon Health and Science University • Ground and Panda Air Transport available • Portland • Eugene OREGON Map Courtesy of KSA
SHMC Current State • Tele-PICU technology • Computerized Medical Record • PAC System (radiology) • CPOE – Neurology and Rehabilitation units up • Regionalization of healthcare for medical students • 32-bed NICU • No pediatric hospitalists – rollout pending • Regional hospital with 30-40% admissions from outside Lane County (primary service area)
SHMC Pediatrics Unit • Pediatric Care Unit opened Spring, 2002 • 16 beds, nurse manager, nurse educator • RNs are PALS certified • Levels of care: B to E • B – simple • C – bulk of patients (medical, surgery, trauma) • D – complex – would be in a PICU at another facility • E - stabilize and manage for immediate transport • Patient volume and complexity has increased
SHMC Pediatric Unit Transports • Current Transports to OHSU and Legacy • Automatic: ventilator, head trauma, heart, new cancer diagnosis • Potential: Sepsis, hematologic, neurology (unmanageable seizures) • Transports are frequently difficult on the family due to loss of work, expenses and lack of local support system. • CME Children’s Miracle Network Lions Guest House = 14 units
Pediatric Task Force on Regionalization of Pediatric Critical Care • Pediatric Task Force on Regionalization of Pediatric Critical Care: Consensus report for regionalization of services for critically ill or injured children. • Crit Care Med 2000;28:236-239. • Pediatrics Volume 105. 1 January 2000 • Mortality and morbidity of children with serious trauma or illness
A PICU at SHMC? Question was asked again in 2004: Is a PICU the answer to keep clinically appropriate patients at SHMC? • Determined not feasible - SHMC does not have enough volume to justify two intensivists and PICU at this time, however … • Acuity level of patients has increased since unit opened in 2002 • Many SHMC physicians interested in exploring options for PICU care • OHSU Critical Care physicians very motivated to start pilot and are technologically focused and skilled • Telemedicine application proven at UC Davis • Telemedicine pilot approved Fall 2006 • Pilot project started April 2007
Patient Transfer Data • SHMC transported 58 pediatric patients from January 2004 to Feb 2006 (26 months) • 2/3 of these patients needed a specialist or more intensive care than was available at SHMC. • 1/3 ended up on OHSU general pediatric ward as PICU services were not needed • Cost of transport • Air: $6,378 (fixed wing); $5,486 (rotor wing) • Ground: $5,832
Background • OHSU interested in pursuing with SHMC • OHSU Telemedicine champions – Dana Braner, MD; Miles Ellenby, MD • SHMC Champions • Medical/Nursing • Manager/Educator Pediatric Unit • Administrative – Director Marketing and Business Planning • Physician support • Meetings held to increase interest • 2005 Telemedicine mini-conference UC Davis • 2006 first telemedicine colloquium – October 2006 • Grand rounds OHSU - SHMC • Multiple site visits and meetings
Barriers • Capital and operating costs to SHMC • Capital and operating costs to OHSU • Billing • Reimbursement • Credentialing • Legal and contract issues • Resistance from physicians
Operating Costs • Primarily Nursing Staff Education • $30,000 SHMC Foundation Education Endowment • 8 hour critical care core curriculum • 4 hour simulation lab experience OHSU • 4 hour job shadow OHSU PICU • 24 of 27 nurses participated • Post Anesthesia Care Unit job shadows (use of PALS) at SHMC • 2 hour didactic training on use of TM equipment • Ongoing teaching with scenarios to encourage MD/Staff use • Plan to follow-up with 4 hourcurriculum in 2008, where staff needs indicate
Effects of Pediatric Telemedicine on SHMC • Physician shortage • Transportation costs to the patient and facility • Decreased revenue • Safety and quality issues • Recruitment of medical providers
Benefits of Pediatric Telemedicine • Increase actual and perceived SHMC quality • Improve mortality • Decrease LOS • Decrease complications • Improve staff morale and expertise • Enhance training opportunities • Economic – increased revenues and margin • Increase collaboration with ED • Translation service • 24/7 PICU resource coverage
Additional Clinical Applications • Started use in Emergency Department August 2007 • Interpretive Services • Medical Education • Intra-campus potential – RiverBend to University District • Expansion to PHMG physician offices
Metrics and Tracking – Set goals and measure outcomes • Physician satisfaction • Patient satisfaction • Staff satisfaction • Number of uses relative to number of opportunities • Number of physicians using transports • Mortality • LOS • Financial issues
Summary of Pilot Project • Telemedicine consults by Doernbecher intensivists with SHMC pediatricians • Pilot Spring 2007 – Spring 2008; then evaluate for ongoing implementation • Staff Critical Care Core Educational training at OHSU • Credentialing OHSU pediatric critical care physicians • Financial Considerations • Contribution margin increase from reduced transports • Expenses – staff training, minimal capital • Payment for consults during trial – 1st 30 patients N/C, $500 each after 30 • Senate Bill 519 and State of Oregon reimbursement for Telemedicine
Impact of Telemedicine on Two PatientsCase Studies • 8 mo presented with hypotonia, lethargy, “cross-eyed”, loss of head control and visual tracking. • Workup initiated at SHMC including: • Head CT - normal • Brain MRI - normal • LP - 22 WBC’s, normal glucose, protein • Telemedicine consult performed • early agreement for transport based on worsening mental status & concern for potential loss of airway protection. • OHSU Transport Team dispatched by ground. • Shortly after departure, Transport Team received urgent cell phone call from SHMC RN’s expressing concern over worsening neuro exam. SHMC MD had departed. • RN’s were unable to call out as land lines were down.
Impact of Telemedicine on Two PatientsCase Studies • Transport Team informed PICU attending, questioning need to dispatch helicopter to expedite transport. • PICU attending was also unable to reach SHMC by phone, but Telemedicine equipment worked. • Led RN’s through repeat neuro exam including pupillary exam. • Neuro exam was unchanged from previous. • What had changed??? The RN’s had changed shift. • Transport continued by ground and was uneventful. • Infant was hospitalized x 16 days at OHSU, ultimately had full recovery from meningo-encephalitis (either viral, post-viral, or partially-treated bacterial).
Impact of Telemedicine on Two PatientsCase Studies • 2 mo hospitalized at SHMC with bronchiolitis. • By hospital day 5, infant was clinically improving but a CXR demonstrated a large pneumothorax.
Impact of Telemedicine on Two PatientsCase Studies • OHSU Transport Team urgently dispatched based on size of pneumothorax and possible need of emergent intervention. • Telemedicine consult performed. • Infant looked “so good” compared to CXR findings that a repeat film was requested by PICU attending. • Transport was cancelled with the new finding.
