Reaching Babies before They Reach the NICU: Launching one of the Nation’s First Neonatal TeleTransport Programs
When neonates and infants are ill, time is of the essence. That’s why Children’s Health℠, Children’s Medical Center Dallas in collaboration with UT Southwestern recently became one of the nation’s first hospitals to launch a neonatal TeleTransport program, enabling our experts to evaluate patients and guide their care, even when they are miles away.
Using TeleTransport, UT Southwestern neonatologists with expertise in Level IV neonatal care can work with the transport team at the outside hospital to assess the patient and their imaging and test results, speak with the referring doctors and parents, and help optimize the baby’s condition before transport. Importantly, the virtual connection continues during transport, where the physicians can monitor the patients in real-time and provide minute-by-minute care to keep them as stable as possible.
“TeleTransport allows us to bring Level IV expertise to the patient's bedside at the earliest possible moment,” says Rashmin Savani, M.D., Division Director of Neonatal-Perinatal Medicine at Children’s Health and Professor of Pediatrics at UT Southwestern. “That’s going to help more babies survive and thrive, and our experience building the program could be informative to other hospitals who want to create one of their own.”
Tailoring Technology for the Mobile NICU
Vedanta Dariya, M.D., Neonatologist, Director of NICU Transport at Children’s Health and Assistant Professor at UT Southwestern, has observed the ever-growing need for technology in NICU care. He recalls one recent case where a critically ill newborn with huge pneumothoraces was being resuscitated at a freestanding ER and then transported to Children’s Health.
“I stayed on the phone with the transport team for about 45 minutes,” says Dr. Dariya. “And every one of those minutes, I was thinking, ‘If I could look at this baby, I wouldn't need to have the transport team telling me what's happening while they're trying to resuscitate the baby.’”
Important hurdles had to be overcome to establish the program. Putting telemedicine on wheels requires light, mobile equipment that doesn’t delay transport teams. The technology for both the NICU team and transport nurses has to be extremely user friendly. And TeleTransport equipment has to transmit clear video, audio and telemetry data from medical devices without interruption, even as connectivity fluctuates in rural and urban areas and inside hospitals.
To solve these puzzles, the transport team is equipped with a cellular-enabled tablet, routers in ambulances to provide Wi-Fi hotspots, and software that is simple and intuitive.
“The platform was designed so that, no matter what needs to be done, the nurses and doctors can get to the solution with the smallest number of clicks,” says Eric McKenney, I. S. Architect at Children’s Health.
To pilot the project, transport nurses were trained to use the equipment and incorporate it into their teamwork and their emergency procedures. Early cases showed the difference that the remote connection could make.
The first baby to benefit from TeleTransport had “an initial blood gas that was near death,” relates Dr. Savani. “The pH was 6.89, and CO2 was unrecordably high.”
He visually assessed the baby, watched the monitors relaying its vital signs, and collaborated with the transport nurses to change ventilator settings and administer medications – including blood pressure support and nitric oxide – to stabilize the baby’s critical condition.
“I was able to do almost exactly what I would have done if I was there physically, and when the baby showed up in our NICU four or five hours later, the blood gas was pH 7.40 and PCO2 42, both completely in the normal range,” says Dr. Savani. “All the interventions that were made during the transport improved the baby’s physiological condition, and the baby’s life was saved.”
TeleTransport also allows the physicians and the transport nurses to “meet” the parents virtually. “The transport nurses can engage with the family so that they can understand the specialty care being provided and also meet our physicians who are caring for their baby early in the process,” says Scotti Floyd Edgar, Director of Transport Services at Children’s Health.
With the first baby TeleTransported, Dr. Savani was able to counsel the parents as to the critical nature of the baby’s condition and keep them updated about the progress being made.
“If parents are able to meet the neonatologist and team virtually before transport,” says Kristin Carlton, Program Director for Telespecialty and Clinical Outreach, “when they arrive at Children’s Health, they see familiar faces, adding some level of comfort to a very stressful time.”
Jumpstarting Therapeutic Cooling
TeleTransport allows Level IV care to start before the babies reach the NICU. One important example is therapeutic hypothermia for babies with hypoxic-ischemic encephalopathy.
“When babies have been severely depressed at birth and deprived of oxygen or blood flow to the brain, their brain is at risk. Hypothermia is the only treatment currently shown to reduce death or disability but only if the encephalopathy is recognized immediately and treatment is initiated in the first six hours after birth – the sooner, the better. Literally speaking, time is brain.” says Dr. Lina Chalak, Neonatologist, Director of the Neonatal NeuroNICU Program and Professor at UT Southwestern Medical Center. “We have invested in a Tecotherm Neo device, the only FDA-approved method for cooling on transport, and trained the team on using this fast implementation cooling device as part of the TeleTransport program.
The sooner the cooling begins, the better the baby’s chances.
“To determine what babies qualify for this intervention, we need to be able to examine them remotely,” says Dr. Dariya. “Then, with certainty, we can tell our transport team, ‘Start cooling this baby now.’” The baby can then be actively cooled during transport, starting this critical therapy sooner.
Imagining the Future of TeleTransport
TeleTransport marks the latest milestone in our push to extend Level IV care to babies across our region. In partnership with UT Southwestern, we developed one of the nation’s most comprehensive TeleNICU programs in 2013. We’ve virtually examined more than 200 neonates so far, and more than half of those patients have been able to remain in their home hospitals. Now we’re looking for ways to virtually connect with more patients and more providers.
“The underlying principle is that we want to extend the reach of our level of care, while collaborating with doctors at referring hospitals to enhance treatment,” Dr. Savani says.
The next goal is to provide TeleTransport capability on “any and every transport,” says Dr. Dariya. “And not just for the NICU. My hope is that our colleagues in the ER, Pediatric ICU and CVICU all find benefit doing this. Any service within this hospital should have the ability to evaluate a sick patient – before they get here.”
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