Clinical Challenges
Telemedicine for Neonatal Resuscitation Patricia Scheans, DNP, NNP-BC Disclosure The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity.
Abstract Maintaining high levels of readiness for neonatal resuscitation in low-risk maternity settings is challenging. The neonatal resuscitation program (NRP) algorithm is a community standard in the United States; yet training is biannual, and exposure to enough critical events to be proficient at timely implementation of the algorithm and the advanced procedures is rare. Evidence supports hands-free leadership to help prevent task saturation and communication to promote patient safety. Telemedicine for neonatal resuscitation involves the addition of remote, expert NRP leadership (a NICU-based neonatal nurse practitioner) via camera link to augment effectiveness of the low-risk birth center team. Unanticipated outcomes to report include faster times to transfer initiation and neuroprotective cooling. The positive impact of remote NRP leadership could lead to use of telemedicine to support teams at birthing centers throughout the United States as well as around the world. Keywords: newborn resuscitation; NICU; NRP; patient safety; teamwork; communication; telemedicine
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resuscitation is a clinical challenge. A n identif ied leader who is responsible for maintaining situational awareness and directing needed interventions is essential for helping to ensure a successful resuscitation.1 Resuscitation and stabilization of newborns can be emergently needed for any birth and are infrequent and high-risk events for maternity centers without intensive care nurseries or in-house pediatric coverage. The procedural skill set for neonatal emergencies includes positive pressure ventilation with a bag and mask; endotracheal intubation; chest compressions; and umbilical venous catheterization for emergency access for medications, blood, and volume replacement. The low-risk maternity center neonatal resuscitation team is generally composed of one or more nurses, a respiratory therapist (RT), and a pediatrician. The full team may not always be immediately available at the delivery because the RT may be working in another department and the pediatrician may have to be called in from home or office. This can be problematic for both the resuscitation team and the newly born patient.
Task saturation can occur when the number or complexity of tasks exceeds the ability of the practitioner to execute them at a high level.2 This can limit the effectiveness of the team and affect the quality of patient care. Consider the time-sensitive critical event of neonatal resuscitation. A team leader may be tasked with performing infrequently done, intricate skills such as umbilical line placement while simultaneously leading a team of staff members with varying skill sets and experience. Rapidly inserting a central line while assuring that the RT is attaining adequate chest rise with positive pressure ventilation, that chest compressions are appropriately performed by a newly graduate registered nurse (RN), as well as communicating clearly to obtain the correct dose of medication is daunting for even the most experienced NRP leader. Although the NRP may describe the need for leadership to shift depending on the personnel present and their identified roles/responsibilities during the resuscitation, in reality, this may be limited by available personnel and skill sets.1 In this digital age, it is appropriate to look to technology for a solution; the use
Accepted for publication April 2014.
N E O N A T A L N E T W O R K VOL. 33, NO. 5, SEPTEMBER/OCTOBER 2014 © 2014 Springer Publishing Company283 http://dx.doi.org/10.1891/0730-0832.33.5.283
of telemedicine for neonatal resuscitation can address this problem. A potentially beneficial adjunct to the current method of delivering emergency care to newborns, telemedicine is already used for patient care for stroke, intensive care consultation, and other purposes. This novel health information technology provides the benefit of hands-free team leadership with the addition of a remote expert NRP leader in the form of a NICU-based neonatal nurse practitioner (NNP) or neonatologist via telemedicine. The goal of such a program is the improvement of team function and patient care through the provision of effective communication and leadership. This leadership can enhance adherence to NRP principles and result in more confident team members. Expert NICU-based practitioners serving as remote NRP team leaders via a telemedicine connection for neonatal resuscitation can provide expert, timely, consistent, hands-off leadership support to the team on the ground at low-risk maternity centers, augmenting the effectiveness of the team involved in resuscitation of critically ill newborns. Team behaviors are correlated with the quality of neonatal resuscitation; studies show that communication breakdowns are the root cause of 72 percent of perinatal deaths and injuries.3 There is broad consensus from expert groups and researchers that improving teamwork will help improve the quality of health care.3 The remote leader would not be task saturated with the performance of emergency procedures but could oversee the entire event and provide expert guidance and direction to the team at the low-risk maternity center hospital. Evidence supports the leader of a resuscitation being hands off to be able to observe, analyze, and direct the rest of the team, enabling them to see the whole picture.4
BACKGROUND
Evaluation of the literature on the general topic of patient safety related to critical events outlines the need for effective teamwork and leadership during these events. Research by Yates and colleagues5 and Thomas and colleagues3 supports the consensus that enhancing teamwork is an important strategy to help improve the overall quality of health care and support the hypothesis that NRP will be improved by the elimination of the detriment of task saturation. Research by Yates and colleagues5 for the Joint Commission yielded a thorough look at human factors as they relate to emergency situations and describes the need for excellent communication and clear leadership for effective teamwork during these high-risk, critical events. Few would argue the benefit of frequent real-world exposure to reinforce, cement, and improve technical and leadership skills, in any worker, in any workplace. Having a team leader for neonatal resuscitation who uses the algorithm and specialized skills on a frequent basis, such as an NNP based in a NICU, could potentially improve the outcome of the resuscitation because their clinical leadership hones effective communication and efficient teamwork.
The issues related to effective neonatal resuscitation are multitudinous and include such things as effective skills training, building muscle memory, communication skill development, and task saturation.6 Use of the American Academy of Pediatrics/American Heart Association’s Neonatal Resuscitation Program training and algorithm for these events is a community standard in the United States, but training is often only required every two years. Few nurses or clinicians receive enough exposure to these critical patient events, either in training or in practice, to become proficient at timely implementation of the algorithm. Because these stressful events are rare, there is not enough exposure to and experience with advanced procedures such as chest compressions, umbilical vein intravenous access, and endotracheal intubation. In one study, the average Neonatal Resuscitation Index (knowledge) score was low (69 percent). Many skills needed for full resuscitation are not performed very often, not even yearly, and low levels of comfort with the skills needed for full resuscitation are reported by staff and resuscitation team members.7 Hermansen and Hermansen6 report that errors in neonatal resuscitation related to the skills of the resuscitation team continue to occur. Knowledge and skills deteriorate after initial NRP training, even with newer teaching modalities such as computer-based, student-led learning and simulation with debriefing training.8,9 In a study by Thomas and colleagues,10 the mean NRP algorithm noncompliance rate ranged from 15.9 percent for preparation for the resuscitation event and the initial steps of NRP to 54.5 percent for instances where infants requiring airway support experienced multiple attempts before being successfully intubated. Compounding the neonatal resuscitation leadership and execution problem is the issue of community pediatricians becoming less comfortable responding to and leading neonatal resuscitations. Gaies and colleagues11 studied pediatric residents and their experience with performing procedures and leading neonatal resuscitations during their pediatric residencies. Interviews of the pediatric residency program directors yielded reports about their graduates’ competence. These levels of perceived competence ranged from 56 percent for umbilical line placement, to 60 percent for endotracheal intubation, to 55 percent for leadership of the resuscitation team. Recently, pediatric medicine has become more subspecialized with a defined split between inpatient/outpatient medicine. This has led to a concentration of neonatal expertise at tertiary centers with NICU.12 Low-risk maternity/delivery services have staff trained in neonatal resuscitation (a biannual class) but will never have a volume of events equal to that of a NICU. Employing an on-site expert around the clock would be expensive and a questionable use of health care resources. Leadership and clear communication are integral to team function during resuscitation events.4,10 Thomas and colleagues10 describe that leadership style and skill related to the
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emergency event were significantly correlated with the nurse team members’ rating of overall quality of the care provided during the resuscitation. Teamwork behaviors were associated with shorter resuscitation duration and higher performance scores in a study of the quality of simulated resuscitation training by Katakam and colleagues.13 In addition, task saturation can occur when the leaders must perform procedures; they then lose focus on the process and team performance.14 Team leaders can become task saturated when managing airway and intravenous access and directing and monitoring the rest of the team.14 The introduction of this new remote leader via technology would reduce leader task saturation and could increase neonatal resuscitation team members’ confidence in their skills and team response. This could have a significant impact on key issues that hospitals consider, such as staff acceptance, provider recruitment, and quality of care.
TELEMEDICINE APPLICATIONS
The socioeconomic implications of telemedicine as a methodology to improve access to health care while using limited resources efficiently are vast. Technology supports health care in a myriad of ways ranging from image transfer for specialist interpretation (e.g., tele-ophthalmology), to guiding interventions for high-risk illnesses (e.g., tele-stroke), to intensive care rounding (e.g., tele-ICU), to follow-up home care (e.g., pulmonary care), to patient education (e.g., diabetic teaching) and staff training (e.g., newborn stabilization training).15–19 Telemedicine can reduce time and money spent on travel and brings specialty care to places devoid of providers. In the neonatal care realm, reports of cost savings by reducing the expense of transferring neonatal patients has been reported by Armfield and colleagues. 20 Teamwork between centers with regionalized levels of care can occur with things such as tele-ICU rounding, and the use of telemedicine for NRP is an extension of that model: critical care support where you need it, when you need it.21 This process can leverage technology to build interdisciplinary, interfacility teams, bridging miles to bring tertiary care expertise to the bedside at rural or other low-risk care provision institutions. Studies of telemedicine are increasingly being published such as the one by Thomas and colleagues,19 who conducted a large observational study with 2,034 patients in six intensive care units (ICUs) of five hospitals in a large American health care system. The study validated the use of tele-ICU for patient rounding to expand the reach and availability of intensivist specialty expertise. In a recent review of the literature, Lewis and colleagues22 validated telemedicine’s ability to enhance continuity of care and increase access to specialized consultants in medically underserved and rural areas. Telemedicine has become increasingly common for many clinical situations, such as enabling intensive care specialists (intensivists) to monitor ICU patients from an off-site location.23 There are reports of telemedicine programs that
enable consultations with neonatologists and pediatric cardiology specialists via real-time live video teleconferencing and tele-echocardiography, allowing specialists to examine radiographic images and visually examine neonates remotely.21,24 Although this is not research per se, nor is it specific to neonatal resuscitation, it supports the idea that video visualization is of high enough quality to support the application of this technology to neonatal resuscitation. Garingo and colleagues25 used remote telemedicine technology in a prospective study using 304 patient encounters on 46 preterm and term neonates in an ICU. A neonatologist located remotely and an on-site neonatologist evaluated the same neonates, and the results were compared. The researchers found telemedicine to be feasible because the remote neonatologist was able to identify and assess the patients accurately and comparably to the on-site neonatologist’s findings. They also concluded that studies are needed on the use of telemedicine for the provision of clinical care in the NICU to assess impacts on clinical outcomes and health care costs. Areas to be studied might include the technology aspects such as security, the interpersonal aspects such as provider and patient acceptance, and the organizational aspects such as culture change.26
PRACTICAL APPLICATION, OUTCOMES, AND IMPLICATIONS
In addition to leading the team through the NRP algorithm during an acute event, prebriefing for role assignment and contingency planning as well as postevent debriefing can be performed via the telemedicine link. The use of a debriefing provides rapid input about processes and programmatic issues as well as emotional support of the team. These team “huddles” often include the directly involved staff—NICU resuscitation nurse, and pediatrician; as well as charge nurses, nursing supervisors, RTs, and any other team members who desire to provide feedback—and serve as a chance to describe the team’s performance (positive and negative) as well as other issues such as equipment and processes that team members would like to see worked on. New processes to review related to the adjunctive telemedicine aspect include any delays to the NICU remote provider “arriving on the scene” as well as the telemedicine equipment functionality from the perspective of both the Level I site and the NICU personnel. Because extensive neonatal resuscitation is only needed at approximately 1 percent of deliveries, it may be desirable to track the measurement of processes and outcomes with every telemedicine event.27
OUR TELEMEDICINE RESUSCITATION PROGRAM
In Portland, Oregon, the Level IV unit at Randall Children’s Hospital at Legacy Emanuel has partnered with five low-risk maternity centers to provide remote coverage
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for newborn resuscitation. Over the last two years, the NNP team has supported 70 deliveries or 2% of births. The NNP serves as the team leader until the pediatric provider arrives on the scene from his or her office or home. Telephone initiation of the process allows nearly instantaneous communication with the NNP as she walks to the computer in her office in the NICU. She then logs in and remotely views the baby and team via the robotic camera at the birth center. The camera can zoom in and out, allowing for close viewing for procedural support as well as a broad view for prebriefing and debriefing with the group. The NNP can hand off to the pediatric provider, talk to family members, and arrange to transfer the baby. Based on 24 months of event tracking and debriefing of our program, overwhelmingly positive feedback has been received. All team members (as well as family members) feel supported; descriptions such as immediately feeling calmer to feeling empowered are common. In addition, two unintended, unpredicted, beneficial trends were identified. Because the previous process for transfer involved waiting for the pediatric provider to arrive to initiate the transfer of the baby to a higher level of care, this time interval has been shortened by having the receiving NICU involved in the care from the beginning. The entire transport process and handoff are streamlined because the receiving NICU provider is often the remote leader. In addition, the ability to immediately assess for encephalopathy and the need for neuroprotective cooling (a time-sensitive procedure) has enabled the time to initiation of (passive) cooling to be shortened dramatically .
FUTURE DIRECTIONS
The use of telemedicine for neonatal resuscitation holds potential for improved resource use in this age of health care reform. The expertise of NICU staff can be broadly shared via the remote leadership model. This could occur anywhere if there is the ability to transmit a visual image. Siegal describes how the innovative uses of information technology can provide global opportunities for better and more accessible health care in a “medical world-wide web.”28(p29) Cell phones and other smart devices could be used in making this type of support available to low-resource countries because of the border-free characteristic of Internet-based communication. Siegal 28 describes the anticipation of positive outcomes in countries such as India where the spending on health care is mismatched per capita, making telemedicine a promising way to provide medical care and public health education. The social, geographic, and economic implications related to the myriad of ways that NRP support via telemedicine could be implemented are far ranging, and no end is in sight. Telemedicine has socioeconomic impacts that could be far reaching not only in developed countries but also across country lines, as collaborations arise between developed and developing nations. This could effect social change; resources can be shared via telemedicine as opposed to the difficulty
and expense of sending a health care team or training enough health care providers for all. From an urban NICU hub, the spokes could reach across town to Level I hospital nurseries; to midwifery centers; to rural parts of the country; and to distant, low-resource countries. In order for telemedicine to continue to expand and improve access worldwide, work is being done entailing examination of a range of aspects, from streamlined credentialing via an endorsement process to a federal or even international process for licensure.28 The boundaries for any telemedicine program are limited by technology. The limits and quality of access would be based on the available technology, ranging from cameras designed for telemedicine that have encrypted audiovisual communication and stethoscope capability to smart cell phones from which images could be transmitted. It is reasonable to expect that this technology will continue to be enhanced like other technologies, and improvements may lower the price and add applications, as has been the case with computers and cell phones.
SUMMARY
In summary, the use of a remote neonatal resuscitation leader is an idea that is supported by an evaluation and extrapolation of the literature. Using telemedicine to augment the usual team composition by the addition of an expert neonatal care provider at a remote NICU location can potentially improve the teamwork and communication of low-risk maternity center resuscitation teams and thereby the outcomes of the inevitably stressful event of neonatal resuscitation. Experience has demonstrated acceptance by the teams and improvement in times to transfer to NICU care and neuroprotective cooling. The positive impact of remote NRP leadership could lead to broad use of telemedicine to support teams at community hospitals by tertiary centers not only throughout the United States but also around the world.
REFERENCES
1. American Heart Association, American Academy of Pediatrics. Who is the resuscitation team leader? NRP Instructor Update. 2013;22(1). http:// www2.aap.org/nrp/docs/IU/2013_SpringSummer.pdf. Accessed July 28, 2014. 2. Davis B, Welch K, Pritts T. Enhanced critical care air transport team training for mitigation of task saturation. Defense Technical Information Center Web site. Published March, 2013. http://www.dtic.mil/cgi-bin/ GetTRDoc?AD=ADA586447. Accessed July 25, 2014. 3. Thomas EJ, Sexton J, Lasky R, Helmreich R, Crandell S, Tyson J., et al. Teamwork and quality during neonatal care in the delivery room. J Perinatol. 2006;26:163-169. 4. Plaat F. Neonatal resuscitation—the team needs a leader. Clin Risk. 2008;14:43-45. http://dx.doi.org/10.1258/cr.2008.080014. 5. Yates G, Bernd D, Sayles S, Stockmeier C, Burke G, Merti G. Building and sustaining a systemwide culture of safety. Jt Comm J Qual Patient Saf. 2005;31(12):684-689. http://www.ingentaconnect.com/content/ jcaho/jcjqs/2005/00000031/00000012/art00005. Accessed July 25, 2014.
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6. Hermansen MC, Hermansen MG. Pitfalls in neonatal resuscitation. Clin Perinatol. 2005;32(1):77-95. http://dx.doi.org/10.1016/j. clp.2004.10.002. 7. Jukkala A, Henly S. Provider readiness for neonatal resuscitation in rural hospitals. J Obstet Gynecol Neonatal Nurs. 2009;38:443-452. http:// dx.doi.org/10.1111/j.15526909.2009.01037.x. 8. Curran V, Aziz K, O’Young S, Bessell C. Evaluation of the effect of a computerized training simulator (ANAKIN) on the retention of neonatal resuscitation skills. Teaching and Learning in Medicine: An International Journal. 2005;16(2):157-164. doi: 10.1207/s15328015tlm1602_7. 9. Rovamo L, Mattila M, Andersson S, Rosenberg P. Assessment of newborn resuscitation skills of physicians with a simulator manikin. Arch Dis Child Fetal Neonatal Ed. 2011;96:F383-F389. http://dx.doi.org/10.1136/ adc.2010.194043. 10. Thomas E, Sexton J, Lasky R, Helmreich R, Crandell D, Tyson J. Teamwork and quality during neonatal care in the delivery room. J Perinatol. 2006;26:163-169. http://dx.doi.org/10.1038/sj.jp.7211451. 11. Gaies MG, Landrigan CP, Hafler JP, Sandora TJ. Assessing procedural skills training in pediatric residency programs. Pediatrics. 2007;120:715722. http://dx.doi.org/10.1542/peds.2007-0325.12. 12. Oshimura J, Sperring J, Bauer B, Rauch D. Inpatient staffing within pediatric residency programs: work hour restrictions and the evolving role of the pediatric hospitalist. J Hosp Med. 2012;7(4):299-303. http:// dx.doi.org/10.1002/jhm.952. 13. Katakam LI, Trickey AW, Thomas EJ. Speaking up and sharing information improves trainee neonatal resuscitation. J Patient Saf. 2012;8(4):202209. http://dx.doi.org/10.1097/PTS.0b013e3182699b4f. 14. Edwards RJ. Task saturation in orthopaedic nursing: recognising the dangers and formulating solutions (concurrent). J Orthop Nurs. 2009;13(1):31. http://dx.doi.org/10.1016/j.joon.2009.02.038.
24. Armfield N, Donovan T, Wootton R. Realtime video in the neonatal intensive care nursery. J Telemed Telecare. 2005;11(suppl 2):S108-S113. http://dx.doi.org/10.1258/135763305775124605. 25. Garingo A, Friedlich P, Tesoriero L, Patil S, Jackson P, Seri I. The use of mobile robotic telemedicine technology in the neonatal intensive care unit. J Perinatol. 2012;32:55-63. http://dx.doi.org/10.1038/jp.2011.72. 26. Dixon B, Hook J, McGowan J. Using telehealth to improve quality and safety: findings from the AHRQ portfolio. http://healthit.ahrq.gov/ sites/default/files/docs/page/Telehealth_Issue_Paper_Final_0.pdf. Published 2008. Accessed July 25, 2014. 27. American Academy of Pediatrics; American Heart Association. Textbook of Neonatal Resuscitation. 6th ed. Lake Grove Village, IL: American Academy of Pediatrics; 2011. 28. Siegal G. Enabling globalization of health care in the information technology era: telemedicine and the medical world wide web. Va J Law Technol. 2012;17:1-34. http://www.vjolt.net/vol17/issue1/v17i1_1Siegal.pdf. Accessed July 25, 2014. 29. Lewis P, Bell M, Larson D, Weems J. Telehealth provider credentialing. http://www.ruralhealthweb.org/index.cfm?objectid=80D9D4983048-651A-FE40E722C34DD8AD. Accessed July 25, 2014.
About the Author
Patricia Scheans, DNP, NNP-BC, provides clinical support for neonatal care at Legacy Health in Portland, Oregon. For further information, please contact: Patricia Scheans, DNP, NNP-BC 3935 NE Skidmore Street Portland, OR 97211 E-mail: [email protected]
15. Burkow T, Vognild L, Østengen G, et al. Internet-enabled pulmonary rehabilitation and diabetes education in group settings at home: a preliminary study of patient acceptability. BMC Med Inform Decis Mak. 2013;5(13):33. 16. Kulshrestha M, Lewis D, Williams C, Axford A. A pilot trial of tele-ophthalmology services in north Wales. J Telemed Telecare. 2010;16(4):196-197. http://dx.doi.org/10.1258/jtt.2010.004009. 17. Loewen L, Seshia MM, Fraser Askin DF, Cronin C, Roberts S. Effective delivery of neonatal stabilization education using videoconferencing in Manitoba. J Telemed Telecare. 2003;9(6):334-338. 18. Rubin M, Wellik K, Channer D, Demaerschalk B. A systematic review of telestroke. Postgrad Med. 2013;125(1):45-50. http://dx.doi. org/10.3810/pgm.2013.01.2623. 19. Thomas E, Lucke J, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302(24):26712678. http://dx.doi.org/10.1001/jama.2009.1902. 20. Armfield N, Donovan T, Bensink M, Smith A. The costs and potential savings of telemedicine for acute care neonatal consultation: preliminary findings. J Telemed Telecare. 2012;18(8):429-433. http://dx.doi. org/10.1258/jtt.2012.GTH101. 21. South Central Telehealth Resource Center. Tele-nursery. http:// learntelehealth.org/elink/tele-nursery/. Accessed July 25, 2014. 22. Lewis E, Thomas C, Wilson M, Mbarika V. Telemedicine in acutephase injury management: a review of practice and advancements. Telemed J E Health. 2012;18(6):434-445. http://dx.doi.org/10.1089/ tmj.2011.0199. 23. Ekelanda A, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform. 2010;79(11):736-771. http://dx.doi.org/10.1016/j.ijmedinf.2010.08.006.
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Telemedicine for Neonatal Resuscitation Patricia Scheans, DNP, NNP-BC Disclosure The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity.
Abstract Maintaining high levels of readiness for neonatal resuscitation in low-risk maternity settings is challenging. The neonatal resuscitation program (NRP) algorithm is a community standard in the United States; yet training is biannual, and exposure to enough critical events to be proficient at timely implementation of the algorithm and the advanced procedures is rare. Evidence supports hands-free leadership to help prevent task saturation and communication to promote patient safety. Telemedicine for neonatal resuscitation involves the addition of remote, expert NRP leadership (a NICU-based neonatal nurse practitioner) via camera link to augment effectiveness of the low-risk birth center team. Unanticipated outcomes to report include faster times to transfer initiation and neuroprotective cooling. The positive impact of remote NRP leadership could lead to use of telemedicine to support teams at birthing centers throughout the United States as well as around the world. Keywords: newborn resuscitation; NICU; NRP; patient safety; teamwork; communication; telemedicine
S
k i l l e d l e a de r s h i p o f n e on a t a l
resuscitation is a clinical challenge. A n identif ied leader who is responsible for maintaining situational awareness and directing needed interventions is essential for helping to ensure a successful resuscitation.1 Resuscitation and stabilization of newborns can be emergently needed for any birth and are infrequent and high-risk events for maternity centers without intensive care nurseries or in-house pediatric coverage. The procedural skill set for neonatal emergencies includes positive pressure ventilation with a bag and mask; endotracheal intubation; chest compressions; and umbilical venous catheterization for emergency access for medications, blood, and volume replacement. The low-risk maternity center neonatal resuscitation team is generally composed of one or more nurses, a respiratory therapist (RT), and a pediatrician. The full team may not always be immediately available at the delivery because the RT may be working in another department and the pediatrician may have to be called in from home or office. This can be problematic for both the resuscitation team and the newly born patient.
Task saturation can occur when the number or complexity of tasks exceeds the ability of the practitioner to execute them at a high level.2 This can limit the effectiveness of the team and affect the quality of patient care. Consider the time-sensitive critical event of neonatal resuscitation. A team leader may be tasked with performing infrequently done, intricate skills such as umbilical line placement while simultaneously leading a team of staff members with varying skill sets and experience. Rapidly inserting a central line while assuring that the RT is attaining adequate chest rise with positive pressure ventilation, that chest compressions are appropriately performed by a newly graduate registered nurse (RN), as well as communicating clearly to obtain the correct dose of medication is daunting for even the most experienced NRP leader. Although the NRP may describe the need for leadership to shift depending on the personnel present and their identified roles/responsibilities during the resuscitation, in reality, this may be limited by available personnel and skill sets.1 In this digital age, it is appropriate to look to technology for a solution; the use
Accepted for publication April 2014.
N E O N A T A L N E T W O R K VOL. 33, NO. 5, SEPTEMBER/OCTOBER 2014 © 2014 Springer Publishing Company283 http://dx.doi.org/10.1891/0730-0832.33.5.283
of telemedicine for neonatal resuscitation can address this problem. A potentially beneficial adjunct to the current method of delivering emergency care to newborns, telemedicine is already used for patient care for stroke, intensive care consultation, and other purposes. This novel health information technology provides the benefit of hands-free team leadership with the addition of a remote expert NRP leader in the form of a NICU-based neonatal nurse practitioner (NNP) or neonatologist via telemedicine. The goal of such a program is the improvement of team function and patient care through the provision of effective communication and leadership. This leadership can enhance adherence to NRP principles and result in more confident team members. Expert NICU-based practitioners serving as remote NRP team leaders via a telemedicine connection for neonatal resuscitation can provide expert, timely, consistent, hands-off leadership support to the team on the ground at low-risk maternity centers, augmenting the effectiveness of the team involved in resuscitation of critically ill newborns. Team behaviors are correlated with the quality of neonatal resuscitation; studies show that communication breakdowns are the root cause of 72 percent of perinatal deaths and injuries.3 There is broad consensus from expert groups and researchers that improving teamwork will help improve the quality of health care.3 The remote leader would not be task saturated with the performance of emergency procedures but could oversee the entire event and provide expert guidance and direction to the team at the low-risk maternity center hospital. Evidence supports the leader of a resuscitation being hands off to be able to observe, analyze, and direct the rest of the team, enabling them to see the whole picture.4
BACKGROUND
Evaluation of the literature on the general topic of patient safety related to critical events outlines the need for effective teamwork and leadership during these events. Research by Yates and colleagues5 and Thomas and colleagues3 supports the consensus that enhancing teamwork is an important strategy to help improve the overall quality of health care and support the hypothesis that NRP will be improved by the elimination of the detriment of task saturation. Research by Yates and colleagues5 for the Joint Commission yielded a thorough look at human factors as they relate to emergency situations and describes the need for excellent communication and clear leadership for effective teamwork during these high-risk, critical events. Few would argue the benefit of frequent real-world exposure to reinforce, cement, and improve technical and leadership skills, in any worker, in any workplace. Having a team leader for neonatal resuscitation who uses the algorithm and specialized skills on a frequent basis, such as an NNP based in a NICU, could potentially improve the outcome of the resuscitation because their clinical leadership hones effective communication and efficient teamwork.
The issues related to effective neonatal resuscitation are multitudinous and include such things as effective skills training, building muscle memory, communication skill development, and task saturation.6 Use of the American Academy of Pediatrics/American Heart Association’s Neonatal Resuscitation Program training and algorithm for these events is a community standard in the United States, but training is often only required every two years. Few nurses or clinicians receive enough exposure to these critical patient events, either in training or in practice, to become proficient at timely implementation of the algorithm. Because these stressful events are rare, there is not enough exposure to and experience with advanced procedures such as chest compressions, umbilical vein intravenous access, and endotracheal intubation. In one study, the average Neonatal Resuscitation Index (knowledge) score was low (69 percent). Many skills needed for full resuscitation are not performed very often, not even yearly, and low levels of comfort with the skills needed for full resuscitation are reported by staff and resuscitation team members.7 Hermansen and Hermansen6 report that errors in neonatal resuscitation related to the skills of the resuscitation team continue to occur. Knowledge and skills deteriorate after initial NRP training, even with newer teaching modalities such as computer-based, student-led learning and simulation with debriefing training.8,9 In a study by Thomas and colleagues,10 the mean NRP algorithm noncompliance rate ranged from 15.9 percent for preparation for the resuscitation event and the initial steps of NRP to 54.5 percent for instances where infants requiring airway support experienced multiple attempts before being successfully intubated. Compounding the neonatal resuscitation leadership and execution problem is the issue of community pediatricians becoming less comfortable responding to and leading neonatal resuscitations. Gaies and colleagues11 studied pediatric residents and their experience with performing procedures and leading neonatal resuscitations during their pediatric residencies. Interviews of the pediatric residency program directors yielded reports about their graduates’ competence. These levels of perceived competence ranged from 56 percent for umbilical line placement, to 60 percent for endotracheal intubation, to 55 percent for leadership of the resuscitation team. Recently, pediatric medicine has become more subspecialized with a defined split between inpatient/outpatient medicine. This has led to a concentration of neonatal expertise at tertiary centers with NICU.12 Low-risk maternity/delivery services have staff trained in neonatal resuscitation (a biannual class) but will never have a volume of events equal to that of a NICU. Employing an on-site expert around the clock would be expensive and a questionable use of health care resources. Leadership and clear communication are integral to team function during resuscitation events.4,10 Thomas and colleagues10 describe that leadership style and skill related to the
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emergency event were significantly correlated with the nurse team members’ rating of overall quality of the care provided during the resuscitation. Teamwork behaviors were associated with shorter resuscitation duration and higher performance scores in a study of the quality of simulated resuscitation training by Katakam and colleagues.13 In addition, task saturation can occur when the leaders must perform procedures; they then lose focus on the process and team performance.14 Team leaders can become task saturated when managing airway and intravenous access and directing and monitoring the rest of the team.14 The introduction of this new remote leader via technology would reduce leader task saturation and could increase neonatal resuscitation team members’ confidence in their skills and team response. This could have a significant impact on key issues that hospitals consider, such as staff acceptance, provider recruitment, and quality of care.
TELEMEDICINE APPLICATIONS
The socioeconomic implications of telemedicine as a methodology to improve access to health care while using limited resources efficiently are vast. Technology supports health care in a myriad of ways ranging from image transfer for specialist interpretation (e.g., tele-ophthalmology), to guiding interventions for high-risk illnesses (e.g., tele-stroke), to intensive care rounding (e.g., tele-ICU), to follow-up home care (e.g., pulmonary care), to patient education (e.g., diabetic teaching) and staff training (e.g., newborn stabilization training).15–19 Telemedicine can reduce time and money spent on travel and brings specialty care to places devoid of providers. In the neonatal care realm, reports of cost savings by reducing the expense of transferring neonatal patients has been reported by Armfield and colleagues. 20 Teamwork between centers with regionalized levels of care can occur with things such as tele-ICU rounding, and the use of telemedicine for NRP is an extension of that model: critical care support where you need it, when you need it.21 This process can leverage technology to build interdisciplinary, interfacility teams, bridging miles to bring tertiary care expertise to the bedside at rural or other low-risk care provision institutions. Studies of telemedicine are increasingly being published such as the one by Thomas and colleagues,19 who conducted a large observational study with 2,034 patients in six intensive care units (ICUs) of five hospitals in a large American health care system. The study validated the use of tele-ICU for patient rounding to expand the reach and availability of intensivist specialty expertise. In a recent review of the literature, Lewis and colleagues22 validated telemedicine’s ability to enhance continuity of care and increase access to specialized consultants in medically underserved and rural areas. Telemedicine has become increasingly common for many clinical situations, such as enabling intensive care specialists (intensivists) to monitor ICU patients from an off-site location.23 There are reports of telemedicine programs that
enable consultations with neonatologists and pediatric cardiology specialists via real-time live video teleconferencing and tele-echocardiography, allowing specialists to examine radiographic images and visually examine neonates remotely.21,24 Although this is not research per se, nor is it specific to neonatal resuscitation, it supports the idea that video visualization is of high enough quality to support the application of this technology to neonatal resuscitation. Garingo and colleagues25 used remote telemedicine technology in a prospective study using 304 patient encounters on 46 preterm and term neonates in an ICU. A neonatologist located remotely and an on-site neonatologist evaluated the same neonates, and the results were compared. The researchers found telemedicine to be feasible because the remote neonatologist was able to identify and assess the patients accurately and comparably to the on-site neonatologist’s findings. They also concluded that studies are needed on the use of telemedicine for the provision of clinical care in the NICU to assess impacts on clinical outcomes and health care costs. Areas to be studied might include the technology aspects such as security, the interpersonal aspects such as provider and patient acceptance, and the organizational aspects such as culture change.26
PRACTICAL APPLICATION, OUTCOMES, AND IMPLICATIONS
In addition to leading the team through the NRP algorithm during an acute event, prebriefing for role assignment and contingency planning as well as postevent debriefing can be performed via the telemedicine link. The use of a debriefing provides rapid input about processes and programmatic issues as well as emotional support of the team. These team “huddles” often include the directly involved staff—NICU resuscitation nurse, and pediatrician; as well as charge nurses, nursing supervisors, RTs, and any other team members who desire to provide feedback—and serve as a chance to describe the team’s performance (positive and negative) as well as other issues such as equipment and processes that team members would like to see worked on. New processes to review related to the adjunctive telemedicine aspect include any delays to the NICU remote provider “arriving on the scene” as well as the telemedicine equipment functionality from the perspective of both the Level I site and the NICU personnel. Because extensive neonatal resuscitation is only needed at approximately 1 percent of deliveries, it may be desirable to track the measurement of processes and outcomes with every telemedicine event.27
OUR TELEMEDICINE RESUSCITATION PROGRAM
In Portland, Oregon, the Level IV unit at Randall Children’s Hospital at Legacy Emanuel has partnered with five low-risk maternity centers to provide remote coverage
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for newborn resuscitation. Over the last two years, the NNP team has supported 70 deliveries or 2% of births. The NNP serves as the team leader until the pediatric provider arrives on the scene from his or her office or home. Telephone initiation of the process allows nearly instantaneous communication with the NNP as she walks to the computer in her office in the NICU. She then logs in and remotely views the baby and team via the robotic camera at the birth center. The camera can zoom in and out, allowing for close viewing for procedural support as well as a broad view for prebriefing and debriefing with the group. The NNP can hand off to the pediatric provider, talk to family members, and arrange to transfer the baby. Based on 24 months of event tracking and debriefing of our program, overwhelmingly positive feedback has been received. All team members (as well as family members) feel supported; descriptions such as immediately feeling calmer to feeling empowered are common. In addition, two unintended, unpredicted, beneficial trends were identified. Because the previous process for transfer involved waiting for the pediatric provider to arrive to initiate the transfer of the baby to a higher level of care, this time interval has been shortened by having the receiving NICU involved in the care from the beginning. The entire transport process and handoff are streamlined because the receiving NICU provider is often the remote leader. In addition, the ability to immediately assess for encephalopathy and the need for neuroprotective cooling (a time-sensitive procedure) has enabled the time to initiation of (passive) cooling to be shortened dramatically .
FUTURE DIRECTIONS
The use of telemedicine for neonatal resuscitation holds potential for improved resource use in this age of health care reform. The expertise of NICU staff can be broadly shared via the remote leadership model. This could occur anywhere if there is the ability to transmit a visual image. Siegal describes how the innovative uses of information technology can provide global opportunities for better and more accessible health care in a “medical world-wide web.”28(p29) Cell phones and other smart devices could be used in making this type of support available to low-resource countries because of the border-free characteristic of Internet-based communication. Siegal 28 describes the anticipation of positive outcomes in countries such as India where the spending on health care is mismatched per capita, making telemedicine a promising way to provide medical care and public health education. The social, geographic, and economic implications related to the myriad of ways that NRP support via telemedicine could be implemented are far ranging, and no end is in sight. Telemedicine has socioeconomic impacts that could be far reaching not only in developed countries but also across country lines, as collaborations arise between developed and developing nations. This could effect social change; resources can be shared via telemedicine as opposed to the difficulty
and expense of sending a health care team or training enough health care providers for all. From an urban NICU hub, the spokes could reach across town to Level I hospital nurseries; to midwifery centers; to rural parts of the country; and to distant, low-resource countries. In order for telemedicine to continue to expand and improve access worldwide, work is being done entailing examination of a range of aspects, from streamlined credentialing via an endorsement process to a federal or even international process for licensure.28 The boundaries for any telemedicine program are limited by technology. The limits and quality of access would be based on the available technology, ranging from cameras designed for telemedicine that have encrypted audiovisual communication and stethoscope capability to smart cell phones from which images could be transmitted. It is reasonable to expect that this technology will continue to be enhanced like other technologies, and improvements may lower the price and add applications, as has been the case with computers and cell phones.
SUMMARY
In summary, the use of a remote neonatal resuscitation leader is an idea that is supported by an evaluation and extrapolation of the literature. Using telemedicine to augment the usual team composition by the addition of an expert neonatal care provider at a remote NICU location can potentially improve the teamwork and communication of low-risk maternity center resuscitation teams and thereby the outcomes of the inevitably stressful event of neonatal resuscitation. Experience has demonstrated acceptance by the teams and improvement in times to transfer to NICU care and neuroprotective cooling. The positive impact of remote NRP leadership could lead to broad use of telemedicine to support teams at community hospitals by tertiary centers not only throughout the United States but also around the world.
REFERENCES
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About the Author
Patricia Scheans, DNP, NNP-BC, provides clinical support for neonatal care at Legacy Health in Portland, Oregon. For further information, please contact: Patricia Scheans, DNP, NNP-BC 3935 NE Skidmore Street Portland, OR 97211 E-mail: [email protected]
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