Expanding the Circle of Influence With Neonatal Telehealth

Expanding the Circle of Influence With Neonatal Telehealth

If there is one area of Neonatology that is experiencing rapid growth it would be in telemedicine.  Each month I come across new reports of centers utilizing this strategy whether to connect families and their infants (televisitation) when they cannot be present or to connect medical teams with other centres lacking the local expertise to care for newborns with certain conditions.

I am fortunate to work in a centre that has an established telehealth program. The city of Winnipeg in Manitoba, Canada covers a exceptionally large geographic area.  On average we transport between 280 – 300 patients per year from as far as the Arctic Circle to North Western Ontario.    To put this in perspective, I had the pleasure of presenting our work at a conference in Ireland in 2013.Untitled  Superimposing the country of Ireland over a map of our catchment area provides some perspective of distances I am talking about.

The topic in this case was the impact of using Telehealth to reduce Neonatal transports by supporting care providers in families in their home cities and towns.  As care providers, if we have a strategy that can in some cases keep babies together with their families and support networks in their own communities, how can we not explore that possibility?  We commonly talk about the importance of family centred care and if you ask me it should begin with doing what is best for the family unit which is minimize the trauma to the family unit after delivery.  I thought it was worth sharing as it gives the people of Manitoba and beyond an idea of how dramatic an impact Telehealth can have when used in a clinical manner.  Telehealth of course is valuable for televisitation and allowing remote meetings but there is so much more. To our knowledge this is the first such use of telehealth in Canada and was awarded a leading practice designation by Accreditation Canada in 2013.  The effectiveness of this strategy has paid for the cost of implementation many times over and I would strongly urge other centres to explore with their Telehealth services whether it would be right for their centre.

How effective was the strategy?  In the year following May 2012 implementation an estimated 4 air and 12 ground transports were averted. Using an average cost of $10000 per air and $5000 per ground transport it is estimated that the total health care savings is $100000.

The Leading Practice can be found using this link which describes in detail what we accomplished and how it benefited the people of Manitoba.

Dare to Dream

The use of telehealth need not stop at the assistance of other care providers in caring for sick neonates.  As the field is developing I see the a larger benefit to long distance education.  How many non-tertiary care centres would benefit from linking to centres with more expertise in the neonatal field and being walked through new procedures or equipment that they are unfamiliar with.  The time and cost to travel to these remote locations can be avoided by the use of a high definition camera and regular scheduling of sessions.  If we want the best for the babies in our catchment areas, education can not be limited to the walls of the hospital we work in.  Prevention of adverse outcomes must start with providing proper care to the newborns in the place of birth rather than having the transport team address the issues that have already arisen.

As the technology becomes more available and at a lower cost I have no doubt we will see expansion of services.  Retcams exist already which are capable of avoiding transfer of discharged infants back for ROP screening.  Retcam__2This in fact has been recently reviewed by Fierson et al in January of this past year.  Alternatively, breastfeeding support is possible by connecting those with expertise in lactation support to rural centres without such training.  Why should breastfeeding success rates in rural communities be any different than in urban centres when the education can be brought to them?  Such an opportunity was highlighted recently by Friesen et al in 2015.

Are there other telehealth modalities that you know of out there that could help improve the care we provide to these vulnerable infants? The field of telehealth is exploding and with it opportunities to improve our care and ideally outcomes.  I encourage everyone whenever possible to ask the question “Can we link up so we can see a patient?”.  All too often what has been described and what is actually present in terms of signs and symptoms may be quite different.

To see the presentation click on the link below

Ireland

Can we prevent atopic dermatitis in susceptible patients?

atopic_dermatitis_3_080322-e1362868660632

When I was growing up it was quite the rare thing to hear that someone had a food allergy. I knew of a few children with eczema or asthma but these days one can’t help but notice the warnings everywhere at schools, camps etc to avoid bringing high risk allergens into close proximity with potentially susceptible children.  As a Neonatologist I don’t profess to be an expert in the area of Atopic conditions but I do believe as others have suggested that society’s obsession with antibacterial soaps and not playing the sandbox so to speak has led to an over development of the allergic response of our immune system due to lack of stimulation on the “infection fighting side” during our infant and toddler years.  As a Pediatric resident I recall treating many children in clinic for atopic conditions and certainly atopic dermatitis was extremely common and incredibly frustrating for parents not to mention the children.

In October of 2014, in the Journal of Allergy and Clinical Immunology Simpson et al reported a pilot study that could change the approach from treatment to prevention for many children if the results hold true in larger studies. The article abstract can be found here with the full article being free as well: http://1.usa.gov/1BR1typ

In this pilot randomized control trial emolients were used in the treatment arm once a day for the first 6 months of life and had to be started within three weeks of life.  All of these children were deemed to be high risk by having a first degree relative with allergic disease.  The emolients used in the US group were sunflower oil, cetaphil cream and aquafor ointment and were applied to all skin surface except for the head.  The theory was that skin breaks in newborns and infants allow allergens to reach the subcutaneous tissue and elicit an immune response thus creating allergic skin disease no different than an exposure to peanuts, tree nuts, dust mites etc can later trigger the immune system to cause allergic rhinitis or food allergy (Fig 1 from quoted paper below).  Previous observational studies had yielded some support to this theory so the RCT was an attempt to answer the question as to whether keeping the skin smooth without breaks could prevent atopic eczema from happening.

gr1

The study was not powered to show a difference but the results of the study make this comment irrelevant.  If a study is underpowered and no difference is seen between two groups one cannot say with certainty if no effect is seen that there was in fact no effect.  If a difference is seen in even the smallest study between two groups in the primary outcome this is in fact significant as it was in this study.

The study found that the treatment group incidence of atopic dermatitis at 6 months was 22% vs a 43% incidence in controls.  This corresponds to a 50% reduction in risk with a number needed to treat to prevent 1 case of atopic dermatitis of about 6 but with wide confidence intervals due to the small size of the study (3-1138).  This speaks to the issue with small studies.  Although the results seem impressive at first when you examine how confident you are with the estimate of the benefit it may be much less than originally thought.  One thing to note though is that about 20% of families did not adhere to the daily application of emolient so one has to wonder if the results would have been even more impressive had the use been more consistent.

That all being said, applying a cream or ointment once a day to keep your newborns’ skin smooth and free of cracks seems to me to be something that many parents (especially those of us who live in the North) do anyway. Atopic dermatitis is a terrible condition that causes a lot of stress and discomfort for children and their families.  If applying a cream or ointment once a day for the first 6 months of life was able to achieve such dramatic results and avoid such a condition I see very little harm in trying.  Of course a larger study will now need to be done to confirm the cited paper here but I think this is a potentially exciting simple treatment to prevent a terrible condition!

I am a fan of simple treatments and even more so of simple interventions to prevent children from ever experiencing a condition at all.  Might early use of emolients be one of these strategies?

A world wide response!

Flags of the world

I have been reminded this past week of the ability of the internet to connect people who would otherwise never be able to meet or at least write to one and other.  Not surprisingly the first responses to the blog came from Canada but within a day viewers in the US were soon added and to them many countries in the Middle East, Great Britain, Spain, Senegal, Turkey and Laos just to name a few.

I have been greatly encouraged by the feedback on the site and topics and your comments have led me to explore other websites and initiatives that I was naive to myself.  I see an incredible potential to disseminate ideas and in the future even collaborate on projects that people may be inspired to create.  There are approaches and technologies that are in practice all over the world that through sharing we may bring to our own shores.

I really just wanted to say thank you to the readers for your participation and I look forward to exploring the neonatal universe with you as we move along. I have received a few suggestions for topics and will be releasing the next post in the morning.  Until then I thought I would leave you with a tease of what is to come by congratulating the University Maternal Hospital Limerick for their accomplishment which was certainly newsworthy this week and I hope is replicated more and more throughout the world.  http://bit.ly/1AGYkPh

Have a great weekend everyone!