Telemedicine Core

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The Telemedicine Core Facility is designed to carry out community-based research. The greatest needs that this community faced were education and consultation. The first network we developed was an educational program called Pediatric Physician Learning and Collaborative Education (Peds PLACE). We began with an effort to speed translational research in pediatrics from the academic bedside to the community. The Core includes 25 telemedicine units (high resolution monitor, computer, camera, scanning capacity, etc.) linked by T1 lines capable of carrying two simultaneous real-time conferences that connect hospitals statewide. The network is controlled by a media site that switches all video to the person who is speaking at a site, managing real-time interaction and allowing for educational videos to be reviewed at a later date by community providers. Each session addresses the diagnosis and treatment of a common disorder, and 10 consensus guidelines are developed annually by the participants. We typically have ~20 sites tuning into each conference, which can now be accessed via website utilizing Jabber software on private computers directly from physicians' offices with real-time conversation for web viewers. Community providers can submit questions which can be addressed during the session either directly using the software or online. Some presenters are located remotely and our programs are now viewed from as far away as Puerto Rico, Germany and India. With this program in place, we began the research component, "Tele-nursery", initially to address regionalization of neonatal intensive care. Although regionalization is associated with lower mortality, implementation has been difficult, especially in rural states like Arkansas. The CTN Telemedicine Core has been used to modify patterns of delivery in an established state network with great success. The sickest babies, in consultation with the Core, are now transferred to those sites most able to address the complex needs of Very Low Birth Weight (VLBW, <1500 grams) neonates, but those that can be cared for locally remain, maintaining closer family and support structures. This has resulted in widespread satisfaction (assessed in questionnaires) among staff and patients. More importantly, infant mortality was lowered from 8.5/1000 births to 7/1000, closer to the U.S. level of ~6/1000. In addition to these innovations, other programs in this Core include the development of a telelaryngoscope for intubating babies under remote video control from our hospital. Intubation is a critical skill because of the need to establish an ainway in preterm neonates with surfactant deficient lungs. Unfortunately, current training is often inadequate as 1/3 of pediatric residents at the end of their training cannot intubate a VLBW neonate after 3 tries, and skills deteriorate even more after training. The inability to intubate likely is a key factor in the increased incidence of intraventricular hemorrhage in neonates who inadvertently deliver in smaller community nurseries without neonatologists. We now have four of these units around the state, making them available to each region of the state. Another outreach program is the implementation of the "Helping Babies Breathe" program in partnership with the American Academy of Pediatrics, which we took to Zambia, and carried out training and provided supplies for three delivery sites (the CTN provided logistical support). The Core Facility also developed a network of sites at emergency departments (EDs) around the state. Since rural hospitals admit patients through the EDs rather than clinics as in large urban hospitals, the ED is an ideal location for research in rural and underserved communities. We thus developed the Emergency Department Physician Learning and Collaborative Education (EDs PLACE) program as an educational and consultation platform, and will soon begin the research program; Six units were placed at sites not already covered by the stroke program that has 9 locations, for a total of 19 units in EDs in AR. Additional units have been placed at other EDs by separate funding. In addition to eariy diagnosis and treatment of stroke, topics targeted trauma since our hospital recently became a Level 1 Trauma Center, and expanded to a range of topics including emergency medical services, acute cardiovascular care, disaster preparedness, rehabilitation and outcomes.