Kourosh Parsapour

Telemedicine Consultations and Medication Errors in Rural Emergency Departments

OBJECTIVE: To compare the frequency of physician-related medication errors among seriously ill and injured children receiving telemedicine consultations, similar children receiving telephone consultations, and similar children receiving no consultations in rural emergency departments (EDs). METHODS: We conducted retrospective chart reviews on seriously ill and injured children presenting to 8 rural EDs with access to pediatric critical care physicians from an academic children’s hospital. Physician-related ED medication errors were independently identified by 2 pediatric pharmacists by using a previously published instrument. The unit of analysis was medication administered. The association of telemedicine consultations with ED medication errors was modeled by using hierarchical logistic regression adjusting for covariates (age, risk of admission, year of consultation, and hospital) and clustering at the patient level. RESULTS: Among the 234 patients in the study, 73 received telemedicine consultations, 85 received telephone consultations, and 76 received no specialist consultations. Medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations or no consultations (3.4% vs 10.8% and 12.5%, respectively; P < .05). In hierarchical logistic regression analysis, medications for patients who received telemedicine consultations had a lower odds of physician-related errors than medications for patients who received telephone consultations (odds ratio: 0.19, P < .05) or no consultations (odds ratio: 0.13, P < .05). CONCLUSIONS: Pediatric critical care telemedicine consultations were associated with a significantly reduced risk of physician-related ED medication errors among seriously ill and injured children in rural EDs.

Cranial computed tomographic findings in a large group of children with drowning: diagnostic, prognostic, and forensic implications.

Objectives: The primary aim of this study is to better define both the type and incidence of cranial computed tomography (CT) abnormalities in children following submersion injury. Design: This is a retrospective chart review; patients were selected from a drowning registry that extends from January 1989 to April 2006. Setting: Children’s Hospital, San Diego. Patients: Patients were included if they were admitted to the hospital with a diagnosis of drowning and had a cranial CT within 24 hrs of submersion. Of 961 patients in the registry, 156 were included. Interventions: None. Measurements and Main Results: Eighteen percent (28 of 156) of children had an abnormal initial head CT, 82% (128 of 156) had a normal CT. Fifteen percent (24 of 156) of patients initially had a normal head CT and later had an abnormal CT. Abnormal CT findings were remarkable for diffuse loss of gray-white differentiation (75% on presentation) and bilateral basal ganglia edema/infarct (50% on presentation). There was no evidence of intra- or extra-axial blood nor were there any unilateral findings in any of the abnormal CTs. Presenting Glasgow Coma Scale was significantly lower in those who presented with an abnormal versus a normal head CT (p < 0.001). All patients with an abnormal initial CT presented with a Glasgow Coma Scale of 3, and all eventually died. Outcome was also very poor in those with a normal first CT and an abnormal second CT; 54% died and 42% remained in a persistent vegetative state. Conclusions: These data from the largest study of CT findings in pediatric drowning clearly illustrate that following submersion injury, intra- or extra-axial bleeding is not seen on cranial CT. Furthermore, an abnormal CT scan at any time was associated with a poor outcome (death or persistent vegetative state). The CT findings and the presenting Glasgow Coma Scale of patients with drowning differ from those of patients who have suffered abusive head trauma.

Type B lactic acidosis and insulin-resistant hyperglycemia in an adolescent following cardiac surgery.

Objective: To report the presence of type B lactic acidosis and insulin-resistant hyperglycemia following cardiopulmonary bypass in a pediatric patient. Design: Case report. Setting: Tertiary referral children’s hospital pediatric intensive care unit. Patient: Fourteen-year-old child with hyperlactatemia and hyperglycemia following cardiac surgery. Interventions and Results: We report a patient who following cardiopulmonary bypass for repair of his congenital heart disease developed type B lactic acidosis and hyperglycemia resistant to insulin therapy. Resolution of his hyperlactatemia and hyperglycemia occurred approximately 24 hrs postoperatively without apparent ill effect. Conclusions: Type B lactic acidosis is a phenomenon that may occur in the pediatric population in conjunction with insulin-resistant hyperglycemia. We observed that its resolution corresponded to improvement in the patient’s hyperglycemia.

Videoconferencing to Reduce Stress Among Hospitalized Children

OBJECTIVES: Family-Link is a videoconferencing program that allows hospitalized children and their parents to virtually visit family members and friends using laptops, webcams, and a secure Wi-Fi connection. We evaluated the association of Family-Link use on the reduction in stress experienced by children during hospitalization. METHODS: We offered Family-Link to pediatric patients who had an expected length of hospitalization equal to or greater than 4 days. We measured the stress levels of hospitalized children at admission and discharge using the previously published Parental Stress Survey. We used propensity score matching and multivariable linear regression methods to evaluate the relationship between the use of Family-Link and stress experienced by children during hospitalization. RESULTS: We included a total of 367 children in the study: 232 Family-Link users and 135 non–Family-Link users. Using the propensity score matching method, we found that the use of Family-Link was significantly associated with a greater reduction in overall mean stress compared with non–Family-Link users among the cohort of patients who lived closer to the hospital and had shorter lengths of hospitalization (β = 0.23; 95% confidence interval, 0.03 to 0.43; P < .05). In this cohort, the reduction in overall mean stress was 37% greater among Family-Link users than non–Family-Link users. CONCLUSIONS: The use of videoconferencing by some hospitalized children and families to conduct virtual visits with family and friends outside of the hospital was associated with a greater reduction in stress during hospitalization than those who did not use videoconferencing.

Connecting hospitalized patients with their families: case series and commentary

The overall aim of this project was to ascertain the utilization of a custom-designed telemedicine service for patients to maintain close contact (via videoconference) with family and friends during hospitalization. We conducted a retrospective chart review of hospitalized patients (primarily children) with extended hospital length of stays. Telecommunication equipment was used to provide videoconference links from the patients bedside to friends and family in the community. Thirty-six cases were managed during a five-year period (2006 to 2010). The most common reasons for using Family-Link were related to the logistical challenges of traveling to and from the hospital—principally due to distance, time, family commitments, and/or personal cost. We conclude that videoconferencing provides a solution to some barriers that may limit family presence and participation in care for hospitalized patients, and as a patient-centered innovation is likely to enhance patient and family satisfaction.

Inaugural paediatric telehealth colloquium

The regionalization of children’s hospitals has led to higher quality of care and improved outcomes among paediatric patients. However, children living in non-urban areas are often excluded from paediatric specialty care. Telemedicine is a new way of providing children in rural communities with access to subspecialists. The inaugural Pediatric Telehealth Colloquium was held in October 2006 in order to provide a forum for national and international experts to share their experiences in this field. This would also assist other groups who were considering setting up new telepaediatric programmes. The conference was held at a hotel in San Francisco and was sold out. There were 73 attendees from the USA and international attendees from the Caribbean and Australia. The backgrounds of those attending ranged from children’s hospital specialists to rural physicians and nurses, as well as health-care administrators seeking information on implementing and sustaining a telemedicine network. Eight companies were also present to discuss products ranging from infrastructure support to telemedicine robotics. The colloquium topics were structured into four themes: inpatient telemedicine, outpatient telemedicine, telehealth administration and alternative applications of telemedicine. Dr Tom Nesbitt provided the introduction and overview of telemedicine, with historical and future perspectives. After this, a general telehealth technology lecture was given by Dan Kurywchak, who has spent more than 17 years working with telemedicine technologies. He provided the basic definitions and an overview that were discussed over the three days. The keynote speaker on the first day was the Governor of the State of California, Arnold Schwarzenneger. Governor Schwarzenneger spoke about the ‘ylife changing benefits of broadbandy and the incredibly important work that can be done with these high speed and high performance technologies’. Governor Schwarzenegger was connected via videoconference to an 11-year-old girl with leukaemia and multiple other medical problems hospitalized in the Pediatric Intensive Care Unit (PICU) at the University of California, Davis Children’s Hospital in Sacramento (150 km away, Figure 1). Finally, the Governor signed an executive order to help develop broadband networks that would assist government agencies in gaining access to the best available technologies to serve the people of California. He also called for the creation of a task force that would enable government and business experts to work together to improve broadband Internet access across the state and the rest of the USA. After the Governor’s appearance, the conference’s first major topic on inpatient telemedicine was introduced by Dr Kourosh Parsapour. Dr Randall Wetzell provided an overview of the applications of inpatient telemedicine along with a discussion regarding the advancement of the virtual PICU project at the Children’s Hospital in Los Angeles. The UC Davis experience in providing inpatient consultations by telemedicine was discussed by Dr James Marcin. Dr Marcin presented data from research studies evaluating the effect of telemedicine on patients and families in rural facilities who received paediatric emergency and critical care consultations. Following this discussion, two of the practitioners from remote facilities (Drs Steve Struve and Mark Satterfield) described their perspectives and provided lessons learned from their experience in a telemedicine relationship with tertiary centres. Finally, Dr Karen Rheuban (University of Virginia) concluded by discussing the vast use of paediatric telemedicine in the State of Virginia. In particular, she described the successful use of real-time and store-andforward telecardiology. The second part of the day focused on some of the administrative components of a telemedicine programme. Ms Anna Orlowski, Chief Counsel for the UC Davis Health System, discussed the legal and regulatory issues that surround many of the current telemedicine programmes in the USA. Ms Kathy Chorba, from the Health Systems Center for Health and Technology, discussed the implementation of a telemedicine programme and the requirements for sustaining the programme after it had started. These topics were very popular with conference attendees who were in the early stages of developing a programme, as well as being of interest to those from institutions that had well-established telemedicine networks. The day concluded with an opportunity for conference participants to try out various technologies and demonstrations. The second day of the colloquium focused on telemedicine applications for the delivery of outpatient services to rural and remote areas. The delivery of teleeducation was also addressed later in the session programme. Speakers from UC Davis and from other institutions described their experiences with outpatient telemedicine services. Dr Javeed Siddiqui (Center for Health and Technology, UC Davis) began with a general synopsis of outpatient telemedicine applications in the USA and summarized the results of various satisfaction studies conducted at UC Davis and elsewhere. The applications of telemedicine at the UC Davis Children’s Hospital included assisting with evidence collection and appropriate examinations for suspected victims of child abuse, facilitating multidisciplinary collaboration for treatment regimens in paediatric oncology, distance

Inhaled nitric oxide and sildenafil therapy for a pediatric patient with multiple pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations may result in intrapulmonary shunting and hypoxemia, and often are treated by embolization or surgical resection. Previous reports have demonstrated effective treatment of hypoxia with inhaled nitric oxide in the acute setting. In this report, we describe a child with severe hypoxemia secondary to an inoperable pulmonary arteriovenous malformation that was initially managed with the use of nitric oxide followed by long term management with the phosphodiesterase-5 inhibitor, sildenafil.