Telemedicine in Pediatric Intensive Care Units: Perspectives From a Brazilian Experience.
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ABSTRACT: Purpose of review
To present the implementation of a telemedicine project (TeleICU) in pediatric intensive care units (ICU) throughout different Brazilian regions.Recent findings
Although telemedicine in pediatric ICUs has shown evidence of benefit in numerous studies with potential to 18 mitigate existing disparities, in Brazil, its use is still under development. Brazil has several opportunities for implementing this resource since, according to the National Registry of Healthcare 20 Establishments (NRHE), there is a discrepancy in the density of pediatric intensive care physicians per patient and the availability 21 of pediatric ICU beds per number of inhabitants.Summary
Health technologies are being widely used to fill gaps in the healthcare system. Telemedicine has been an important tool to meet demands in intensive care units, especially the demand for specialized assistance. TeleICU is a Brazilian model of telemedicine that performs multidisciplinary telerounds in remote pediatric ICUs and develops continuing education activities for the healthcare teams. The project aims to systematize and to qualify care, as well as to reduce risks for patients admitted to pediatric ICUs engaged in the project. Preliminary results have demonstrated a positive impact regarding this approach, providing medical care to 6640 inpatients-day in two Brazilian pediatric ICUs, for 616 patients during 946 daily telerounds.Supplementary information
The online version contains supplementary material available at 10.1007/s40124-021-00242-z.
SUBMITTER: Jacovas VC
PROVIDER: S-EPMC8274668 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThe role of telemedicine in intensive care has been increasing steadily. Tele-intensive care unit (ICU) interventions are varied and can be used in different levels of treatment, often with direct implications for the intensive care processes. Although a substantial body of primary and secondary literature has been published on the topic, there is a need for broadening the understanding of the organizational factors influencing the effectiveness of telemedical interventions in the ICU.ObjectiveThis scoping review aims to provide a map of existing evidence on tele-ICU interventions, focusing on the analysis of the implementation context and identifying areas for further technological research.MethodsA research protocol outlining the method has been published in JMIR Research Protocols. This review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A core research team was assembled to provide feedback and discuss findings.ResultsA total of 3019 results were retrieved. After screening, 25 studies were included in the final analysis. We were able to characterize the context of tele-ICU studies and identify three use cases for tele-ICU interventions. The first use case is extending coverage, which describes interventions aimed at extending the availability of intensive care capabilities. The second use case is improving compliance, which includes interventions targeted at improving patient safety, intensive care best practices, and quality of care. The third use case, facilitating transfer, describes telemedicine interventions targeted toward the management of patient transfers to or from the ICU.ConclusionsThe benefits of tele-ICU interventions have been well documented for centralized systems aimed at extending critical care capabilities in a community setting and improving care compliance in tertiary hospitals. No strong evidence has been found on the reduction of patient transfers following tele-ICU intervention.International registered report identifier (irrid)RR2-10.2196/19695.
| S-EPMC8600441 | biostudies-literature
Project description:Telemedicine coverage of intensive care units is an organizational innovation that has been touted as a means to improve access to and quality of critical care. The purpose of this narrative review is to discuss the different organizational models of intensive care unit telemedicine and factors that have influenced its adoption and to review the existing literature to consider whether it has lived up to its promise. We conclude by suggesting future directions to fill in some of the existing gaps in the literature.
| S-EPMC6322009 | biostudies-literature
Project description:BackgroundTelemedicine has been deployed to address issues in intensive care delivery, as well as to improve outcome and quality of care. Implementation of this technology has been characterized by high variability. Tele-intensive care unit (ICU) interventions involve the combination of multiple technological and organizational components, as well as interconnections of key stakeholders inside the hospital organization. The extensive literature on the benefits of tele-ICUs has been characterized as heterogeneous. On one hand, positive clinical and economical outcomes have been shown in multiple studies. On the other hand, no tangible benefits could be detected in several cases. This could be due to the diverse forms of organizations and the fact that tele-ICU interventions are complex to evaluate. The implementation context of tele-ICUs has been shown to play an important role in the success of the technology. The benefits derived from tele-ICUs depend on the organization where it is deployed and how the telemedicine systems are applied. There is therefore value in analyzing the benefits of tele-ICUs in relation to the characteristics of the organization where it is deployed. To date, research on the topic has not provided a comprehensive overview of literature taking both the technology setup and implementation context into account.ObjectiveWe present a protocol for a scoping review of the literature on telemedicine in the ICU and its benefits in intensive care. The purpose of this review is to map out evidence about telemedicine in critical care in light of the implementation context. This review could represent a valuable contribution to support the development of tele-ICU technologies and offer perspectives on possible configurations, based on the implementation context and use case.MethodsWe have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and the recommendations of the Joanna Briggs Institute methodology for scoping reviews. The scoping review and subsequent systematic review will be completed by spring 2021.ResultsThe preliminary search has been conducted. After removing all duplicates, we found 2530 results. The review can now be advanced to the next steps of the methodology, including literature database queries with appropriate keywords, retrieval of the results in a reference management tool, and screening of titles and abstracts.ConclusionsThe results of the search indicate that there is sufficient literature to complete the scoping review. Upon completion, the scoping review will provide a map of existing evidence on tele-ICU systems given the implementation context. Findings of this research could be used by researchers, clinicians, and implementation teams as they determine the appropriate setup of new or existing tele-ICU systems. The need for future research contributions and systematic reviews will be identified.International registered report identifier (irrid)DERR1-10.2196/19695.
| S-EPMC7808887 | biostudies-literature
Project description:BACKGROUND:Early identification of children at risk for cardiac arrest would allow for skill training associated with improved outcomes and provides a prevention opportunity. OBJECTIVE:Develop and assess a predictive model for cardiopulmonary arrest using data available in the first 4?h. METHODS:Data from PICU patients from 8 institutions included descriptive, severity of illness, cardiac arrest, and outcomes. RESULTS:Of the 10074 patients, 120 satisfying inclusion criteria sustained a cardiac arrest and 67 (55.9%) died. In univariate analysis, patients with cardiac arrest prior to admission were over 6 times and those with cardiac arrests during the first 4?h were over 50 times more likely to have a subsequent arrest. The multivariate logistic regression model performance was excellent (area under the ROC curve?=?0.85 and Hosmer-Lemeshow statistic, p?=?0.35). The variables with the highest odds ratio's for sustaining a cardiac arrest in the multivariable model were admission from an inpatient unit (8.23 (CI: 4.35-15.54)), and cardiac arrest in the first 4?h (6.48 (CI: 2.07-20.36). The average risk predicted by the model was highest (11.6%) among children sustaining an arrest during hours >4-12 and continued to be high even for days after the risk assessment period; the average predicted risk was 9.5% for arrests that occurred after 8 PICU days. CONCLUSIONS:Patients at high risk of cardiac arrest can be identified with routinely available data after 4?h. The cardiac arrest may occur relatively close to the risk assessment period or days later.
| S-EPMC6258339 | biostudies-literature
Project description:BACKGROUND:Point-of-care ultrasonography (POCUS) has recently become a useful tool that intensivists are incorporating into clinical practice. However, the incorporation of ultrasonography in critical care in developing countries is not straightforward. METHODS:Our objective was to investigate current practice and education regarding POCUS among Brazilian intensivists. A national survey was administered to Brazilian intensivists using an electronic questionnaire. Questions were selected by the Delphi method and assessed topics included organizational issues, POCUS technique and training patterns, machine availability, and main applications of POCUS in daily practice. RESULTS:Of 1533 intensivists who received the questionnaire, 322 responded from all of Brazil's regions. Two hundred and five (63.8%) reported having access to an ultrasound machine dedicated to the intensive care unit (ICU); however, this was more likely in university hospitals than in non-university hospitals (80.6 vs. 59.6%; risk ratio [RR]?=?1.35 [1.16-1.58], p?=?0.002). The main applications of POCUS were ultrasound-guided central vein catheterization (49.4%) and bedside echocardiographic assessment (33.9%). Two hundred and fifty-eight (80.0%) reported having at least one POCUS-trained intensivist in their staff (trained units). Trained units were more likely to perform routine ultrasound-guided jugular vein catheterization than non-trained units (38.6 vs. 16.4%; RR?=?2.35 [1.31-4.23], p?=?0.001). The proportion of POCUS-trained intensivists and availability of a dedicated ultrasound machine were both independently associated with performing ultrasound-guided jugular vein catheterization (RR?=?1.91 [1.32-2.77], p?=?0.001) and (RR?=?2.20 [1.26-3.29], p?=?0.005), respectively. CONCLUSIONS:A significant proportion of Brazilian ICUs had at least one intensivist with POCUS capability in their staff. Although ultrasound-guided central vein catheterization constitutes the main application of POCUS, adherence to guideline recommendations is still suboptimal.
| S-EPMC5972134 | biostudies-literature
Project description:IntroductionDelirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments.MethodsWe collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children's Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool.ResultsFive hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022.ConclusionsUsing pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.
| S-EPMC9278948 | biostudies-literature
Project description:The purpose of this study is to estimate the costs and cost-effectiveness of a telemedicine intensive care unit (ICU) (tele-ICU) program.We used an observational study with ICU patients cared for during the pre-tele-ICU period and ICU patients cared for during the post-tele-ICU period in 6 ICUs at 5 hospitals that are part of a large nonprofit health care system in the Gulf Coast region. We obtained data on a sample of 4142 ICU patients: 2034 in the pre-tele-ICU period and 2108 in the post-tele-ICU period. Economic outcomes were hospital costs, ICU costs and floor costs, measured for average daily costs, costs per case, and costs per patient.After the implementation of the tele-ICU, the hospital daily cost increased from $4302 to $5340 (24%); the hospital cost per case, from $21,967 to $31,318 (43%); and the cost per patient, from $20,231 to $25,846 (28%). Although the tele-ICU intervention was not cost-effective in patients with Simplified Acute Physiology Score II 50 or less, it was cost-effective in the sickest patients with Simplified Acute Physiology Score II more than 50 (17% of patients) because it decreased hospital mortality without increasing costs significantly.Hospital administrators may conclude that a tele-ICU program aimed at the sickest patients is cost-effective.
| S-EPMC3103644 | biostudies-literature
Project description:ObjectiveTo describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS.MethodsThis was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice.ResultsOn the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only.ConclusionOur results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.
| S-EPMC8275089 | biostudies-literature
Project description:Background:The pediatric intensive care units (PICUs) in developing countries have a higher mortality outcome due to a wide variety of causes. Identifying differences in the structure, patient characteristics, and outcome between PICUs with different resources may add evidence to the need for incorporating more PICUs with limited resources in the contemporary critical care research to improve the care provided for severely ill children. Methods:A retrospective study was conducted at Egyptian and Japanese PICUs as examples of resource-limited and resource-rich units, respectively. We collected and compared data of nonsurgical patients admitted between March 2018 and February 2019, including the patients' demographics, diagnosis, PICU length of stay, outcome, predicted risk of mortality using pediatric index of mortality-2 (PIM-2), and functional neurological status using the Pediatric Cerebral Performance Category (PCPC) scale. Results:The Egyptian unit had a lower number of beds with a higher number of annual admission/bed than the Japanese unit. There was a shortage in the number of the skilled staff at the Egyptian unit. Nurse?:?patient ratios in both units were only similar at the nighttime (1?:?2). Most of the basic equipment and supplies were available at the Egyptian unit. Both actual and PIM-2 predicted mortalities were markedly higher for patients admitted to the Egyptian unit, and the mortality was significantly associated with age, severe sepsis, and PIM-2. The length of stay was shorter at the Egyptian unit. Conclusion:The inadequate structure and the burden of more severely ill children at the Egyptian unit appear to be the most important causes behind the higher mortality at this unit. Increasing the number of qualified staff and providing cost-effective equipment may help in improving the mortality outcome and the quality of care.
| S-EPMC7103036 | biostudies-literature
Project description:BACKGROUND:Healthcare-associated infections (HAIs) represent serious complications for patients within pediatric cardiac intensive care units (CICU). HAIs are associated with increased morbidity, mortality and resource utilization. There are few studies describing the epidemiology of HAIs across the entire spectrum of patients (surgical and nonsurgical) receiving care in dedicated pediatric CICUs. METHODS:Retrospective analyses of 22,839 CICU encounters from October 2013 to September 2016 across 22 North American CICUs contributing data to the Pediatric Cardiac Critical Care Consortium clinical registry. RESULTS:HAIs occurred in 2.4% of CICU encounters at a rate of 3.3 HAIs/1000 CICU days, with 73% of HAIs occurring in children <1 year. Eighty encounters (14%) had ?2 HAIs. Aggregate rates for the 4 primary HAIs are as follows: central line-associated blood stream infection, 1.1/1000 line days; catheter-associated urinary tract infections, 1.5/1000 catheter days; ventilator-associated pneumonia, 1.9/1000 ventilator days; surgical site infections, 0.81/100 operations. Surgical and nonsurgical patients had similar HAIs rates/1000 CICU days. Incidence was twice as high in surgical encounters and increased with surgical complexity; postoperative infection occurred in 2.8% of encounters. Prematurity, younger age, presence of congenital anomaly, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT) 4-5 surgery, admission with an active medical condition, open sternum and extracorporeal membrane oxygenation were independently associated with HAIs. In univariable analysis, HAI was associated with longer hospital length of stay and durations of urinary catheter, central venous catheter and ventilation. Mortality was 24.4% in patients with HAIs versus 3.4% in those without, P < 0.0001. CONCLUSIONS:We provide comprehensive multicenter benchmark data regarding rates of HAIs within dedicated pediatric CICUs. We confirm that although rare, HAIs of all types are associated with significant resource utilization and mortality.
| S-EPMC6019633 | biostudies-literature