Although emergency physicians are in short supply, pediatric emergency specialists are even harder to come by. Most work at tertiary care pediatric centers where they treat young patients with complex emergency care needs, many of whom have been transferred to these facilities from community hospitals. However, what if young pediatric patients in community hospitals could be evaluated by physicians who specialize in pediatric emergency medicine without the need for a transfer?

It’s an approach that is just getting started in the Robert Wood Johnson University Hospital (RWJUH) system, based in New Brunswick, NJ. Bristol-Myers Squibb Children’s Hospital (BMSCH) has established a secure, remote hookup with the ED at RWJUH’s Somerset, NJ, campus, and plans are in place to eventually expand the approach so that other community hospitals in the region can take advantage of the pediatric emergency medicine expertise at BMSCH as well.

“Telemedicine services have been going on for the past couple of years, mostly in the realm of tele-psychiatry and tele-neurology, but they have also been used in critical care ... to bring scarce expertise to locations where there can’t always be that presence,” explains Richard Brodsky, MD, director of pediatric telemedicine at BMSCH. “And that is almost a direct translation of what we want to do for pediatric emergency medicine.”

Brodsky explains that the EDs at community hospitals generally are staffed by adult emergency physicians, or there may be pediatricians who are taking care of pediatric patients in the ED. “Most of the time those physicians are excellent and can provide excellent care, but occasionally you are going to want someone who has a more sophisticated understanding and greater expertise in this particular field of pediatric emergency medicine,” he says.

The physicians at BMSCH and many other tertiary care children’s hospitals are fellowship-trained pediatric emergency medicine physicians, Brodsky observes. “We can do a remote examination and offer the advice of an expert without having the expert travel to the community hospital or the patient transferred to [our] tertiary care facility,” he says.

Use for Middle-ground Patients

The types of cases that tend to prompt telemedicine encounters with a BMSCH pediatric emergency physician encompass the uncertain middle ground, Brodsky observes. “The very simple things like rash, runny nose, cough, and fever are not the things that should require an expert, but at the same time, we do not provide services for things like codes, heart failure, or cases where children are obviously in very severe distress and need timely care,” he says. Adult emergency physicians generally are experts at handling codes and instances of severe distress, he says.

“The area where [community hospital EDs] generally need someone who is more specially trained is in the gray zone in between these two areas,” Brodsky says. These patients tend to present with more complex issues, but there is no obvious, immediate need for transfer, he says.

“For example, it might involve a patient with significant abdominal pain where the emergency physician is not quite sure whether this is something he or she needs to investigate for appendicitis, constipation, or something along those lines,” Brodsky explains.

Alternatively, it could be a patient who has just recovered from a seizure, and the emergency physician is not sure whether this patient should undergo more testing or whether follow-up testing can be conducted as an outpatient, Brodsky notes. “It could also involve a child who has a fever, but that fever is hitting this child very hard, and they look more ill than their exams or their tests indicate,” he says. “In these types of middle-ground patients, some more experienced judgment might be necessary to help with the disposition,” he says.

Fine-tune Operations

Currently, the telemedicine encounters are available from 8 a.m. until 8 p.m., but administrators hope to make the service available on a 24/7 basis soon. The physician who is charge of the ED at BMSCH handles the calls. “We have a command center that is inside our ED, and [the physician] will go to the command center to take the call,” Brodsky explains. “However, we do have someone on backup to handle any issues if we get very busy.” For instance, the backup physician would step in if the ED at BMSCH is handling something severe at the same time a call comes in for a telemedicine encounter, Brodsky notes.

These are still early days for the program, leaving time and space to work out operational issues as the telemedicine service expands to more hospitals in the region. “I am expecting that when we have our service fully up and running to multiple hospitals in the area, we will be receiving a volume of several calls a day,” Brodsky predicts. “That is a good volume to expect with a very robust service.”

For now, BMSCH is working closely with Somerset Hospital to fine-tune the telemedicine approach. “We have such a good relationship with [the providers at Somerset] that it is very easy to start our first partnership with them,” Brodsky observes. These early efforts will help ensure a smooth rollout to other facilities, he says.

While the financial incentives are not aligned perfectly to provide remote pediatric emergency medicine expertise to hospitals in the region, it is a logical next step for telemedicine, Brodsky shares. “It is a needed [service] because of the scarcity of the expertise,” he says. “Normally, a significant expert in pediatric emergency medicine only practices at a tertiary care pediatric institution.”

To be able to provide this level of expertise for the community makes sense for both providers and patients, Brodsky observes. The alternative involves an expensive transfer process whereby the patient is brought to BMSCH and potentially admitted there rather than in his or her own community, closer to family. “If we can avoid even one or two of those transfers in a brief period of time, then it saves medical dollars and it saves the system money in general,” he says. “It is not only good for the patient, family, and community, it is good for the outside ED because they are able to provide better care for their patients.” Brodsky adds that the service works to the advantage of BMSCH as well because it enables the hospital to preserve its resources for children who are in greater need.

There is a bill making its way through the New Jersey legislature that would enable telemedicine encounters to be reimbursed the same as in-person consultations, and there is talk of even more comprehensive federal legislation, Brodsky notes. Changes of this nature would fuel the creation of more telemedicine programs, but Brodsky says BMSCH intends to proceed with its plans regardless. “The benefits to the system far outweigh any individual reimbursement we would get,” he says. “There is no need to wait for reimbursement.”

SOURCE

  • Richard Brodsky, MD, Director of Pediatric Telemedicine, Bristol-Myers Squibb Children’s Hospital, New Brunswick, NJ. Email: brodskyri@rwjms.rutgers.edu.