In Australia, specialist care for newborn infants is highly regionalised. Intensive care nurseries in tertiary hospitals provide care for the most unwell infants. In Queensland, there are three such nurseries, with two of them being located in the state capital of Brisbane and the third being 1,400km to the north in Townsville. There are a number of primary and secondary facilities able to care for healthly or moderately unwell newborns throughout the state.
Annually, around 75% of high-risk infants are delivered close to tertiary care in Queensland. The health system has three responses:
In cases were risks are indentifed prior to delivery in utero transfer to a tertiary facility is preferred. However, not all risks are predictable and many infants are born some distance from the level of care that they need.
For these infants, aeromedical or road ambulance retrieval of the infant to an appropriate level of care is carried out. Retrieval services are staffed by the tertiary nurseries.
Advice is provided by the tertiary nurseries by telephone
For some infants, large distances mean that retrieval can be very time consuming. For a proportion of these infants (up to 25% of high-risk infants) rapid access to specialist care is simply not feasible because of distance and time impediments.
The potential role of real-time telemedicine
While use of the telephone is the established standard for consultation between the tertiary and referring nurseries, telemedicine may have useful supporting roles to play within the existing model of neonatal care, including:
supporting clinical decision making for retrieval by allowing a remote visual assessment of infants and their X-rays
for providing remote advice to support the management of infants in the lead-time while the retrieval time is en route from the tertiary centre
supporting staff at referring hospitals by providing otherwise unavailable educational and upskillng opportunities at a distance
Our work aims to examine the circumstances in which real-time telemedicine may have benefits to neonatal care. In particular, the work aims to examine aspects of feasiblity, efficacy, clinical effectiveness, clinican acceptability and economics.
The research team of COH researchers and clinicians have designed and developed a system for neonatal teleconsultation known as NEMO (Neonatal Examination and Management Online). The system has two components: (i) a wireless, mobile trolley that can be positioned adjacent to an infant’s cot at the referring hospital and (ii) an easy to use PC-based interface for specialist clinicians at the tertiary nursery. NEMO is available 24 hours a day and provides a live video and audio link between clinicians at the Grantley Stable Neonatal Unit at the Royal Brisbane Hospital (RBWH) and four referring nurseries. During the teleconsultations, specialists at the RBWH can view high quality images of the infant, their X-rays and monitors while discussing the infant’s care with the referring hospital clinicians.
Following development, NEMO formed a research platform for a range of clinically focussed studies.
To assess feasiblity and efficacy, a method comparison study was designed to compare infant assessments (and reading X-rays, patient monitor and ventilator) via telemedicine with those carried out in person. The study was conducted within the controlled environment of the neonatal intensive care nursery at the Royal Brisbane and Women’s Hospital (RBWH). The study demonstarted the efficacy of using telemedicine for neonatal assessments.
Subsequently, a multicentre exploratory study (four referring sites, one tertiary site) has allowed a preliminary assessment of the clincal effectiveness, economics and the acceptability to clinicians of using NEMO for neonatal advice and retrieval consultations at a distance.
The results of this study, currently being prepared for publication, suggest that that telemedicine can enhance the outreach activities of a tertiary intensive care nursery in ways that would not be possible by the use of the telephone alone. The study found that telemedicine provides new clinically useful information, allows changes in diagnosis and management and, in some cases, allows retrieval to be avoided. In circumstances where retrieval is avoided, the infant may remain close to their family and cost savings are to the health system are realised through prevented transport and tertiary nursery admission.
NEMO remains in clinical use between the RBWH and the four referring hospitals (planned to increase to five hospitals in early 2011). Based on preliminary results, further work is planned to formally assess the clinical effectiveness of telemedicine for neonatal consultation and to assess its usefulness for providing neonatal nusring educational outreach.
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