1. Can Telemedicine Improve Adherence to Resuscitation
Guidelines for Critically Ill Children at Community Hospitals?
A Randomized Controlled Trial Using High
Fidelity Simulation
CHRIS P. YANG1,2, ELIZABETH A. HUNT1,2, NICOLE SHILKOFSKI1,2, ROBERT DUDAS2, JAMIE MCELRATH SCHWARTZ1,2
DEPARTMENTS OF 1ANESTHESIOLOGY AND CRITICAL CARE MEDICINE AND 2PEDIATRICS
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE, BALTIMORE, MD
2. Disclosure Statement
• I have no relevant financial relationships with the
manufacturer of any commercial product and/or
provider of commercial services discussed in this
CME activity.
• I do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation.
3. Background
• Children with life threatening illness present to
community hospitals that lack access to
specialized pediatric care.
• Children transferred from community hospitals are
‘sicker.’ They have greater need for pressors,
mechanical ventilation, and longer PICU stays
than those presenting to pediatric care centers.1
1. Pediatrics 2008; 121:e906-e911.
4. Background
• When physicians without specialized training
adhered to ACCM-PALS resuscitation guidelines,
mortality decreased from 38% to 8%.2
• Telemedicine virtual presence was as effective as
physical presence in resuscitation education, and
both were superior to telephone education.3
• However, little research exists to determine if
telemedicine can improve adherence to
guidelines. 2. Pediatrics 2003; 112:793-799.
3. Journal of Telemedicine and Telecare 1999; 5:242-245.
5. OBJECTIVE
To evaluate the impact of telemedicine on
community hospital adherence to
guidelines through mock scenarios with
high fidelity simulation of critically ill
children comparing pediatric critical care
medicine (PCCM) consultation via
telemedicine vs. telephone.
6. Methods
• We are conducting a randomized
controlled trial of in-situ mock scenarios
using high-fidelity simulation of critically
ill children presenting to a community
hospital
• Different vignettes are presented that
result in cardiopulmonary arrest (CPA)
8. Methods
• Community hospital team members are participants
and PCCM fellows serve remotely as consultants.
• Scenarios are randomized to PCCM consultation via:
Telemedicine Telephone
(intervention) OR (control)
10. Outcome Measures
• Primary outcome • Secondary outcome
measure measures
– Time to verbalize – Time to recognition of
intent to defibrillate PVT
pulseless ventricular
tachycardia (PVT) – Proportion of
scenarios with correct
compression to
ventilation ratio during
cardiopulmonary
resuscitation (CPR)
11. Results
• 8 scenarios were completed at the time
of this analysis
• Data was obtained from video-
recordings of each mock scenario and
debriefing logs from the high-fidelity
simulation mannequin software
12. Time to Recognition of
Pulseless Ventricular Tachycardia
60 53
Time in Seconds 50
Median for entire 40
group: 9.5 seconds
(IQR:4.5-25) 30
Control:21.5 seconds 21.5 17 Median
20
(IQR:6-43)
Intervention:8 seconds 10 8
(IQR:4.5-13)
0
p value=0.31
Control Intervention
13. Time to Verbalize Intent to Defibrillate
Pulseless Ventricular Tachycardia
70 65
60
Time in Seconds
Median for entire group:
50 47.5 44
26 seconds (IQR:8-52.5)
Control:47.5 seconds
40
(IQR:19-63) 30
Intervention:13.5 seconds
Median
(IQR:8-31)
20
13.5
p value=0.39 10
0
Control Intervention
14. Compression to Ventilation
Ratio during Scenarios
Correct Ratio Incorrect Ratio
100%
90%
Proportion of Scenarios
80%
Correct ratio for entire 70%
group:4/8 scenarios (50%) 60%
Intervention:3/4 scenarios 50%
(75%) 40%
Control:1/4 scenarios (25%) 30%
20%
p value=0.49
10%
0%
Control Intervention
15. CONCLUSIONS
•These preliminary results suggest that PCCM virtual presence
through telemedicine may positively affect the community
hospital team performance during simulation of CPA
•A trend toward improvements in recognition and treatment of
PVT and better adherence to CPR guidelines were observed
•We plan to complete a total of 38 mock scenarios to
demonstrate that this difference is statistically significant
