A Hybrid Form of Telemedicine: A Unique Way to Extend Intensive Care Service to Neonates in Medically Underserved Areas

Introduction

Late premature infants are at higher risk than full-term infants for a wide range of neonatal morbidities, including respiratory distress syndrome, hyperbilirubinemia, hypoglycemia, sepsis, feeding difficulties, and poor neurodevelopmental outcomes. ¹ Consequently, these infants may require short-term intensive therapy and experience higher hospital readmission rates. Typically, these infants can be managed at Level II neonatal intensive care units (NICUs); however, given the nationwide shortage of neonatologists and resultant shortage of Level II NICU beds, many of these infants in medically underserved areas (MUAs) are cared for by pediatricians with limited training in neonatology. ²

Moderately ill late preterm infants are frequently transferred to higher care level facilities, almost universally located in urban areas. Unfortunately, the majority of people, particularly in rural states, live >50 miles from these facilities. ³ This significantly increases the economic cost of services, which now includes hospital transfer, family displacement, and the emotional cost of limited visitation, and family stress. ⁴

NICUs, following American Academy of Pediatrics (AAP) guidelines, vary in level of care they provide, based on staffing levels and equipment availability as described in Table 1. Recent changes to the AAP guidelines for neonatal care added in-house neonatal services to the scope of Level II NICUs. ⁵ The unavailability of neonatologists in MUAs has prompted innovative solutions to meet this requirement.

Telemedicine has been utilized in adult and pediatric populations to extend healthcare to MUAs. ^6,7 Although research has demonstrated that critical care services can be provided using telemedicine, most studies were conducted in adult and pediatric settings. ^{8 –10} To date, neonatal telemedicine use has been limited to consultation, retinopathy of prematurity screening, education, and family involvement. ^{11 –14} Feasibility trials investigating the use of telemedicine to conduct physical examinations have shown promise; however, no studies examining telemedicine use as a primary means of providing care to premature infants in the NICU have yet been done. ¹⁵

Our group previously described the establishment of Level II neonatal services utilizing a hybrid telemedicine system in southwestern Oklahoma. ² Owing to the unique nature of this setup, this study was designed to assess the treatment outcomes of late premature infants managed by the hybrid telemedicine system in this satellite Level II NICU at Comanche County Memorial Hospital (CCMH) compared with conventional management provided to a medically similar population in a large referral Level IV NICU at Oklahoma University Medical Center (OUMC).

Materials and Methods

This retrospective noninferiority study was done at OUMC and CCMH. OUMC is a tertiary care teaching hospital with a Level IV NICU (92 beds). This NICU has 24/7 continuous intensivist coverage, with bedside rounds once a day. CCMH is a community-based hospital with a Level II NICU (eight beds). This NICU at CCMH has 24/7 neonatal nurse practitioner (NNP) coverage with neonatologists physically present 3 days a week, and uses telemedicine to round for the remaining 4 days. Study was separately approved by the Institutional Review Board at the University of Oklahoma Health Sciences Center (OUHSC), which provides approvals for OUMC, and by the research committee at CCMH, Lawton.

Infants between 32 and 35 weeks gestational age (GA) admitted either to the CCMH or OUMC between July 2013 and June 2015 were included. Control group at OUMC included only infants who were transported out from areas geographically comparable with CCMH. Infants requiring mechanical ventilation >24 h or advanced subspecialty services were excluded.

The telemedicine communication system used for rounds met stringent requirements of American Telemedicine Association guidelines for clinical practice. ¹⁶ The system included a Polycom^® (Pleasanton, CA) videoconferencing unit (HDX 7000) that utilized a dedicated link to the hospital server at CCMH, which also met federally mandated HIPPA guidelines. The signal was transmitted through a secure fiber optic connection to the campus at OUMC and routed through the OUMC secure network to the individual neonatologist's secure laptop or desktop. The Polycom unit was equipped with audiovisual capabilities and used an ethernet connection. The mobile cart had a power supply from the included portable battery, which can last about 2–3 h without being connected to electrical power.

The NNP contacted the neonatologist by page system or a phone call to initiate daily rounds by telemedicine. Upon receiving a page from the NNP, the remote intensivist at OUMC initiated a videoconference call using the portable laptop computer or office desktop using the Polycom interface. Once the call is accepted, the system enters full operation mode and the cart is mobilized to the patient's bedside for rounds. The NNP presents pertinent patient information, including all organ systems, during daily rounds. The infant is examined by a physician with NNP assistance. The plan for the day is discussed among the team members. Parents are informed and encouraged to participate in daily rounds. Besides utilizing telemedicine for rounds, if NNP needed advice regarding patient management for rest of the day, physician was contacted using phone and telemedicine was used as needed.

Patient outcome measures, including length of stay, type and duration of respiratory support, length of antibiotic therapy, and time to full enteral feedings, were collected by chart review. For this study, length of stay was reflective of total hospital stay as both centers have practice of infant's rooming in day before discharge. Comparisons were done by stratifying GA in four groups: 32 weeks (32–32 6/7), 33 weeks (33–33 6/7), 34 weeks (34–34 6/7), and 35 weeks. Between-groups comparisons were performed using chi-square or Fisher's exact test as appropriate for the type of data analyzed. Length of stay was assessed for normality using the Shapiro–Wilk test and robust regression was used to construct a multivariable regression model to test the independent effect of location (OUMC vs. CCMH) on length of stay while controlling for GA, gender, respiratory distress syndrome, and 1 min APGAR scores. Two-tailed tests were used with a significance level of 0.05. All analyses were performed using SAS vs 9.3 (SAS Institute, Cary, NC).

Results

During study period, 87 neonates at CCMH and 56 neonates at OUMC met the eligibility criteria to be included in the analysis. GA distribution is shown in Table 2. About 40% of neonates at CCMH were <33 weeks compared with 55% at OUMC. Demographic information is shown in Table 3. Prematurity, respiratory distress syndrome, transient tachypnea of newborn, and hypoglycemia were the top four diagnosis at both centers. Compared with neonates at OUMC, neonates at CCMH had shorter hospital stays, reached full enteral feeds sooner, had fewer total days of supplemental oxygen, and had fewer days on noninvasive ventilation support (Table 4). Antibiotics use beyond 48 h was seen in 8% of CCMH patients compared with 25% at OUMC, whereas the sepsis incidence rate was similar at both centers (0.45/1,000 live births vs. 0.5/1,000 live births, respectively). Length of stay was not normally distributed, so the multivariable regression model was created using robust regression methods. Location had a significant independent effect (p = 0.0131) on length of stay while controlling for GA, gender, respiratory distress syndrome, and 1 min APGAR scores. Specifically, study participants at CCMH showed a reduced length of stay of 2.23 days (95% CI 0.46, 3.99) compared with those at OUMC.

Discussion

Our results showed that patient outcome measures for infants managed by the hybrid telemedicine system at a satellite Level II NICU were not inferior to conventional management provided to similar infants at a referral Level IV NICU. To our surprise, some of the patient outcome measures were even better for infants who were managed at the satellite Level II NICU utilizing telemedicine.

One of the explanations for this observation could be that infants who were managed at our satellite NICU utilizing telemedicine did not experience the stress of being transported to a tertiary care center. Another major impact factor could be higher family participation in the infants' care, as these families were closer to home. This telemedicine setup allowed infants to be able to stay at local hospital closer to their home instead of being transferred to the more distant, regional Level IV NICU. Even though families were not utilizing telemedicine to virtually visit their infant, the convenience of having their baby closer to home made it feasible for families to spend more time with their infants and permitted longer mother–infant bonding. This factor could influence the infant's time to full enteral feeding, indirectly influencing length of stay.

This study brings a potential solution for one of the major healthcare access issues in the field of neonatology. Brantley et al. recently published detailed assessment regarding the lack of access to obstetric and neonatal critical care in the United States. ³ Lack of access to care can have serious consequences, such as excess morbidity and mortality rates for neonates. Our findings indicate that telemedicine can be utilized as a primary means of providing care for selected premature infants in a Level II NICU without compromising medical outcomes and quality of care. Our approach has additional potential benefits regarding reduction of costs associated with transport, duration of hospitalization, and use of a higher level of care than needed, which could also optimize bed occupancy use at referral Level IV NICUs. ¹⁷

This study has some limitations. Despite its retrospective nature, the data were collected prospectively on an electronic data capture system and no subject was excluded for lack of data. The small sample size could be considered as another weakness; however, with our original aim to demonstrate a noninferiority, we found a clear trend toward a benefit in favor of the hybrid telemedicine group.

Conclusions

This hybrid telemedicine system is a safe and effective strategy that may be used in extending intensive care to late premature neonates in MUAs.