By Jennifer L. Fang, MD, FAAP1; Beth L. Kreofsky, MBA2; Matt Bushman, BS1; Lisa A. Stubert, PMP2; Hussain Mohammed3; Kathleen D. Stuart3; Joan K. Broers, MS, RN2; Robert V. Johnson, MD, FAAP1; Christopher E. Colby, MD, FAAP1
Minnesota’s current regionalized perinatal care system is designed to ensure that high-risk deliveries occur in tertiary care centers in order to optimize neonatal outcomes. However, an expectant mother’s access to these advanced-level services may be limited due to various factors including geography, transportation, or unanticipated need. When high-risk deliveries occur in community hospitals, the local providers may have limited expertise and resources to optimally respond to these newborn emergencies.
To address this issue, Mayo Clinic’s Division of Neonatal Medicine and Center for Connected Care have implemented telemedicine for high-risk neonatal resuscitations in six community-based health system sites over the last 24 months. This includes hospitals located in Blue Earth, Freeborn, Goodhue, Martin, Mower and Olmsted counties. To date, this video telemedicine service has been activated 70 times for a variety of cases, such as resuscitation of the extremely preterm infant, management of meconium aspiration syndrome, and identification of congenital anomalies.
Initially, this emergent, synchronous video telemedicine consult service was provided using HIPAA compliant video conferencing software on a wireless tablet device. However, with this technology, both the local care team and the consulting neonatologist experienced issues with reliability of connection and audio and video quality. At baseline, we experienced a 10-15 percent failure to connect rate, with 20-25 percent of users reporting poor or very poor audio and video quality (N=50). Image and audio quality issues included slow frame rates, lack of high-definition video, lack of audio when users spoke simultaneously, and insufficient volume.
With the Connect 2 Care grant provided by the MNAAP, our team was able to test various technologies to determine what would best meet the needs of video consultations for newborn resuscitations. During the initial discovery tests (N=12), the efficacy of various network connections, devices, and video platforms were evaluated at two health system sites. While network topology, bandwidth, and routing could potentially affect the video and audio experience, this was not found to be a significant contributor to the quality problems. An alternate tablet running a different operating system was also tested; however this tablet performed more poorly in all metrics and was deemed an unacceptable alternative. Our team evaluated a cloud-hosted video conferencing service, which underperformed when compared to our institutional video conferencing infrastructure and was not a viable alternative. Finally, a wired, mobile telemedicine cart was tested and found to be superior to the consumer grade devices used in the health system. Use of the wired telemedicine cart improved both connection reliability and audio/video quality. From this discovery testing, we concluded that due to multiple factors including the unpredictability associated with wireless connectivity, tablets were not recommended for use in emergent situations requiring reliable video connectivity.
Based on the results of the discovery testing, a wired video telemedicine cart is being evaluated as a short-term solution to provide consults for neonatal resuscitations. The first phase of testing will use the cart for simulated neonatal resuscitations at a single, higher volume health system site. Four of the anticipated twelve mock calls have been completed.
Thus far, these calls have demonstrated that the wired telemedicine cart is feasible, reliable, and provides higher quality audio and video during newborn emergencies. With respect to feasibility, the local care team rated the cart highly with respect to ease of retrieval, set-up, and ease of use during the consultation. Mobility and position of the cart during the simulated resuscitations will be further evaluated using various workflows during subsequent testing. Reliability of the connection was also improved with no failures to connect. All connections were successfully established by the consulting neonatologist on the first call attempt.
Both the local care teams and the neonatologist ranked the audio and video quality of the telemedicine cart as very good or excellent. Audio quality for the current tablet-based system had an average score of 2.9 on a scale of 1 (poor) to 5 (excellent). Comparatively, the telemedicine cart with its integrated noise cancelling, full-duplex microphone and speaker set provided improved audio quality and clarity with an average score of 3.9. Even greater improvements were seen in the video quality. Overall video quality scores improved from an average of 3.1 with the wireless tablet technology to 4.75 with the telemedicine cart. The wired cart is equipped with a high definition camera with pan/tilt/zoom capabilities that can be remotely controlled by the neonatologist.
If the remaining simulated neonatal resuscitations continue to demonstrate that the wired telemedicine cart provides a feasible, more reliable, higher quality video telemedicine experience, then the generous grant support from MNAAP will help move this technology into the clinical setting.
1 Division of Neonatal Medicine, Mayo Clinic, Rochester, MN
2 Center for Connected Care, Mayo Clinic, Rochester, MN
3 Media Support Services, Mayo Clinic, Rochester, MN