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TELEMEDICINE FOR NEWBORN

RESUSCITATION

Jennifer Fang, MD, MS

Division of Neonatal Medicine

MAYO CLINIC

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DISCLOSURES• In the past 12 months, I have had the following financial

relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial service(s) discussed in this CME activity:

– Unrelated licensed intellectual property with InTouch Health

• I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation

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1

OBJECTIVES

Recognize system-level challenges to optimal newborn resuscitation

Identify how telemedicine may improve access to subspecialty care and enhance the regional practice

Describe the impact telemedicine has on the quality of newborn resuscitations in the community setting

2

3

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IDENTIFYING A CLINICAL NEED

REGIONALIZATION of perinatal

care has IMPROVED OUTCOMES

for mothers and newborns

Neonates born at hospitals with

LOWER LEVELS OF NEWBORN

CARE are at INCREASED RISK

OF MORTALITY and morbidities

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THE CHALLENGE

FREQUENCY OF HIGH-RISK NEWBORN RESUSCITATION – once every 2-3 years

DELIVERY VOLUME – 200-500 deliveries/year

RESOURCES AVAILABLE – RN and FM or Pediatrician in clinic or at home

TECHNICAL SKILLS REQUIRED – Advanced airway management, central line placement, chest compressions, meds

ACHIEVE COMPETENCY – Residency training, decreased ICU exposure, competition for procedures

MAINTENANCE OF COMPETENCY – Complete NRP, frequent practice/simulation

MEDICAL TRANSPORT – Geography or weather can delay arrival of transport team

INCIDENCE OF HIGH-RISK RESUSCITATION – 1:1,000

Does the system allow for an outcome disparity based on birth location?

CULTURE OF SAFETY

MASTERY OF NRP

BRIEFING AND DEBRIEFING

SIMULATION

TELEMEDICINE

Can we close this quality gap using TELEMEDICINE?

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1

SIMULATION STUDY

Fang et al, Resusc 2014

46Study participants

(pediatric residents)

ASSIGNED

TO

Bedside providerled resuscitation

Bedside provider + telemedicine support

+2

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SCENARIO

“You have been called to the vaginal delivery of a full-term infant due to fetal bradycardia”

At delivery apneic and bradycardic with heart rate of 70 bpm

Scenario concluded once effective ventilation established MR. SOP(A) or successfully intubated patient

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• TELEMEDICINEreduced the time to effective ventilation by 35% (4.2 vs 2.7 minutes)

• 100% of participants in the telemedicine group performed all five corrective steps

• All participants in the control group placed an ET tube to effectively ventilate the baby

Control group(n=23)

Intervention group (n=23)

P

Time to effective ventilation in seconds, mean (range)

251 (125-479) 162 (98-233) <0.001

Stimulates the infant, n (%) 18 (78) 22 (96) 0.19

Positive pressure ventilation, n (%) 23 (100) 23 (100) NA

Number of first five corrective steps used, n (%)

0 5 (22) 0 <0.001

1 4 (17) 0

2 6 (26) 0

3 3 (13) 0

4 5 (22) 0

5 0 23 (100)

Use of the first five corrective steps, n (%)

M – Adjusts mask Position 11 (48) 23 (100) <0.001

R – Repositions the head 16 (70) 23 (100) 0.009

S – Suctions mouth and nose 11 (48) 23 (100) <0.001

O – Opens mouth or lifts jaw 4 (17) 23 (100) <0.001

P – Increases positive inspiratory pressure

3 (13) 23 (100) <0.001

Endotracheal intubation, n (%) 23 (100) 0 <0.001

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CONCLUSION

Telemedicine significantly REDUCED THE TIME

to establish effective ventilation and IMPROVED

ADHERENCE to the NRP algorithm

This may be a means for regional providers to

support local providers during neonatal emergencies

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TELENEONATOLOGY

• Pilot began in MARCH OF 2013

• Program development and

expansion in partnership with CENTER FOR

CONNECTED CARE

• OVER 200 CONSULTS

provided to date

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SETTING – THE HUB

26 BED Level IV regional NICU

Staffed by 8 NEONATOLOGISTS

2500 deliveries per year

400 admissions per year

50% are out-born

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SETTING – THE SPOKES

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10 MAYO CLINIC

HEALTH SYSTEM sites

Staffed by PEDIATRICIANS and/or

FAMILY MEDICINE PHYSICIANS

7 – Level I nurseries

2 – Level II nurseries

1 – Level III nursery

5500 deliveries per year

146

1500

200

2400

102

1012

943

424393

310

69237

BEFORE TELENEONATOLOGY

43% of newborns at MAYO MIDWEST HOSPITALS

had immediate access to a Neonatologist

AS OF OCTOBER 2016

100% of newborns in the MAYO CLINIC MIDWEST REGION

have immediate access to a Neonatologist

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INDICATION FOR CONSULTATION

11

3

6

9

25

32

55

0 20 40 60

Other

Seizure

Abnormal exam finding

Congenital anomalies

Perinatal depression

Respiratory distress

Prematurity

Number of Cases

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PATIENT DISPOSITION

Transferred to the NICU

Remained in the MCHS

Transferred to the ISCN

Transferred to a different NICU

Died

33%

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95%

98%

96%

96%

PROVIDER SATISFACTION

Fang et al, Mayo Clin Proc 2016

Of local providers agree that the consulting neonatologist

worked collaboratively with their team

Of providers agree that the teleneonatology consult

improved patient safety and/or quality of care

Would use teleneonatology again and would recommend

its use to their colleagues

Agreed that there is a need for teleneonatology

at their hospital

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DOES TELEMEDICINE IMPROVE THE QUALITY

OF NEWBORN RESUSCITATION?

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Outborn neonates admitted to the Mayo Clinic NICUP

TELENEONATOLOGY OUTCOMES STUDY

Synchronous video telemedicine consult with a neonatologistI

Outborn matched controls cared for by the local teamC

Overall quality of the resuscitationO

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RETROSPECTIVE COHORT STUDY

• INTERVENTION – telemedicine consult during

resuscitation or initial stabilization

• CONTROL – cared for by the local team

– Preterm, matched by gestational age

– Term, matched by admission diagnosis

– Also matched to gender and level of newborn care

EXCLUSION CRITERIA – presence of the transport team

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• Abstracted data from the electronic health record

• Patient characteristics

• Resuscitation metrics

• Mortality and major morbidities

Gestational age, birth weight, gender, mode of delivery, pregnancy and intrapartum complications

Apgar scores, need for intubation, chest compressions, epinephrine, time/value of temperature, glucose, blood gas

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Blinded to the intervention, two neonatologists reviewed the patient characteristics and resuscitation metrics

Assigned a “resuscitation quality rating” using a 1 to 10 descriptive rating scale

▪ Significant deviation from the standard of care

▪ Resuscitation metrics never measured or significantly abnormal1

▪ Excellent resuscitation with no room for improvement

▪ All resuscitation metrics are measured and within normal limits10

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RESULTS

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Patient Characteristic Intervention Group (n=47) Controls (n=45)

Gestational Age, Mean (SD) 34.7 (5.5) 35.1 (4.8)

Gestational age category

Less than 29 weeks 9 (19%) 7 (16%)

29 0/7 to 33 6/7 weeks 9 (19%) 9 (20%)

34 0/7 to 36 6/7 weeks 10 (21%) 6 (13%)

37 0/7 weeks or greater 19 (40%) 23 (51%)

Birth weight (grams)

Mean (SD) 2491 (1150) 2531 (997)

Range (460-4833) (590-4270)

Gender

Female 19 (40%) 24 (53%)

Male 28 (60%) 21 (47%)

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Patient Characteristic Intervention Group (n=47) Controls (n=45)

Level of newborn care at referral hospital

Level I nursery 18 (38%) 19 (42%)

Level II nursery 29 (62%) 26 (58%)

Exposure to any antenatal steroids

Yes 3 (6%) 8 (18%)

No 24 (51%) 13 (29%)

Not indicated (e.g. GA >/= 37 0/7 weeks) 19 (40%) 23 (51%)

Indeterminate 1 (2%) 1 (2%)

Mode of delivery

Vaginal 22 (47%) 17 (38%)

Emergency C-section 19 (40%) 13 (29%)

C-section 5 (11%) 13 (29%)

Assisted vaginal delivery (vacuum or forceps) 1 (2%) 2 (4%)

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Patient Characteristic Intervention Group (n=47) Controls (n=45)

Pregnancy and intrapartum complications

Preterm labor 23 (49%) 15 (33%)

Meconium stained amniotic fluid 13 (28%) 12 (27%)

Persistent or deep decelerations in fetal heart rate 8 (17%) 15 (33%)

Preterm premature rupture of membranes 8 (17%) 7 (16%)

Twin gestation 6 (13%) 6 (13%)

Placental abruption 9 (19%) 2 (4%)

Congenital anomaly 4 (9%) 4 (9%)

Umbilical cord accident 2 (4%) 1 (2%)

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Median (IQR) rating for the telemedicine group was 7(3,8) compared to 4 (3, 5) for the control group (median difference 1, P=0.002)

55%

30%

0%

20%

40%

60%

80%

100%

Telemedicine (n=47) Control (n=47)

P=0.02

Newborns with a Quality Rating 5

The quality of resuscitation was SIGNIFICANTLY IMPROVED for newborns who received a telemedicine consult

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57%

26%

0%

20%

40%

60%

80%

100%

Telemedicine (n=35) Control (n=35)

P=0.01

Newborns with a Quality Rating 5

Median time from birth to telemedicine consult was 12.1 MINUTES (IQR 5.0, 25.1)

For the 35 matched pairs that had a consult within 1 hour of birth – Median rating for the telemedicine group was 8compared to 4 for the control group (median difference 2, P=0.003)

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Resuscitation Metric

Telemedicine

(n=47)

Control

(n=47) P value

Patient’s temperature measured 37 (79%) 26 (58%) <0.05

Patient’s blood glucose

measured44 (94%) 38 (81%) <0.05

Blood gas measured

after delivery23 (49%) 13 (28%) <0.01

All 3 assessments done

(temp, glucose, blood gas) 20 (43%) 10 (21%) <0.01

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P=0.058

Patient Outcome

Intervention

(n=47)

Control

(n=45)

Death before discharge 3 (6%) 7 (16%)

Death or morbidity before discharge 11 (23%) 12 (27%)

Length of NICU stay (in days) 25.0 (34%) 19.6 (25%)

Chronic lung disease 4 (9%) 3 (7%)

Necrotizing enterocolitis 0 (0%) 2 (4%)

Severe retinopathy of prematurity 0 (0%) 1 (2%)

Periventricular-intraventricular

hemorrhage8 (17%) 4 (9%)

Severe periventricular-

intraventricular hemorrhage5 (11%) 2 (4%)

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RIGHT TIME

CONCLUSION• System-level challenges create an outcome

disparity for newborns based on birth location

• Teleneonatology consults may IMPROVE THE QUALITY of high-risk newborn resuscitations that occur in community hospitals

• Teleneonatology programs can enhance the healthcare delivery system for newborns

RIGHT PLACERIGHT CARE

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ACKNOWLEDGEMENTSDIVISION OF NEONATAL MEDICINE

CENTER FOR CONNECTED CARE

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SIMULATED TELENEONATOLOGY CONSULT

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QUESTIONS AND DISCUSSION

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REFERENCESFor more information on this subject, see the following publications• Lorch SA, Baiocchi M, Ahlberg CE, Small DS. The differential impact of delivery hospital on the

outcomes of premature infants. Pediatrics. 2012;130(2):270-278

• Brantley MD, Davis NL, Goodman DA, Callaghan WM, Barfield WD. Perinatal regionalization: a geospatial view of perinatal critical care, United States, 2010-2013. Am J Obstet Gynecol. 2016

• Fang JL, Carey WA, Lang TR, Lohse CM, Colby CE. Real-time video communication improves provider performance in a simulated neonatal resuscitation. Resuscitation. 2014 Nov; 85(11):1518-22. Epub 2014 Aug 15. PMID: 25132477

• Colby CE, Fang JL, Carey WA. Remote video neonatal consultation: a system to improve neonatal quality, safety and efficiency. Resuscitation. 2014 Feb; 85(2):e29-30. Epub 2013 Nov 19

• Scheans P. Telemedicine for neonatal resuscitation. Neonatal Netw. 2014;33(5):283-287

• Fang JL, Collura CA, Johnson RV, Asay GF, Carey WA, Derleth DP, Lang TR, Kreofsky BL, Colby CE. Emergency Video Telemedicine Consultation for Newborn Resuscitations: The Mayo Clinic Experience. Mayo Clin Proc 2016 Dec; 91 (12):1735-1743 Epub 2016 Nov 22 PMID: 27887680

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INDEX CASEphone call

from a

COMMUNITY

PEDIATRICIAN

Mother with no

prenatal care

presents with

placental abruption

LOCAL PEDIATRICIAN is concerned baby

may be peri-viable and is questioning whether

they should resuscitate the baby

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INDEX CASE

CONNECTED

via a video call

Neonate was

more mature

(est. 28 weeks)

and bigger (1 kg)

GUIDED RESUSCITATION – Mask PPV,

placed UVC, checked CBC, blood gas, glucose,

Managed acidosis and hypoglycemia

Admitted and

subsequently

discharged

from the

NICU without

morbidities