Transcription:
Saving Lives Virtually Using TeleCooling

Caitlin Whyte (Host): Welcome. You're listening to Pediatric Insights, Advances and Innovations with Children's Health. I'm Caitlin Whyte. In 2013, Children's Health launched Texas's first and only dedicated NICU Telemedicine service. The program connects neonatologists at your hospital's level II or level III NICU with UT Southwestern Neonatologists and 150 Clinical and Surgical sub-specialists.

Today, we're going to talk about TeleCooling, which is one treatment method offered as part of this program.

Caitlin Whyte (Host): Director of NICU Transport and Outreach at Children's Health, as well as an Assistant Professor of Pediatrics at UT Southwestern. So, Doctor to start us off, can you give us a background on the NICU TeleTransport Program that is offered at Children's?

Vedanta Dariya, MD (Guest): So, the past year with the pandemic, we've seen an exponential growth in all things virtual. Changes to the way we do things. It's touched each of our lives. And for some of us in more ways than one. We find ourselves adapting to this changing paradigm. And we're just doing more remotely and kids are learning remotely. We go to the gym remotely. We even see the doctor remotely now, and Telemedicine in general, has grown pretty rapidly this past year. However, for us at Children's Health, in collaboration with UT Southwestern, our TeleNICU program has been around for a long time, in fact, since 2013. We were one of the first in the nation with this comprehensive service.

And the guiding principle was quite simple. Texas is a huge state. And what is it 14 hours to drive from the Northern parts to the Southern part of the state. And we needed an effective, safe way to provide that highest quality of medical care to our patients across the state, without having to transport them long distances into our level IV NICU.

And that's essentially how our TeleNICU program came into being. We developed a network of regional NICUs that referred patients to us through our TeleNICU Program. And it benefited patients and families when we were able to keep them at that referring facility and also decrease the cost of medical care. And once we established the TeleNICU Program, the almost logical natural progression of that concept was a TeleTransport Program for the NICU. Because when babies, the neonates, when infants are ill, time is of the essence. Right? And that's why we're proud to be one of the nation's first hospitals to launch a neonatal TeleTransport program which enables our experts to evaluate patients and guide their care, even when they're miles away and using TeleTransport, our UT Southwestern neonatologists, with the expertise and the capabilities of level IV neonatal care that we can provide, combined with our extremely capable transport team at the outside hospital, we're able to assess patients, their imaging, their test results, speak with the referring doctors and parents and help optimize the baby's condition even before they get transported to us. And more importantly, this virtual connection continues right throughout the transport. The physicians can monitor patients in real time. We're able to provide minute by minute care to keep them stable right through this process.

So, the way we see it, TeleTransport allows us to bring our level IV expertise to the patient's bedside at the earliest possible moment. And while we've been doing this, we've found that we're actually helping guide other large children's hospitals create their TeleTransport and Telemedicine programs as well.

Host: Now, as part of this program, you offer TeleCooling. Can you explain what that is and which patients benefit from this treatment?

Dr. Dariya: Of Course. Before we talk about TeleCooling, you know, I think it's imperative to just spend a few minutes talking about hypoxic ischemic encephalopathy, or HIE. Hypoxic means, not enough oxygen. Ischemic means it's not enough blood flow and encephalopathy is a brain disorder. So, essentially HIE or hypoxic ischemic encephalopathy is a type of brain dysfunction that occurs when the brain doesn't receive enough oxygen or blood flow for a period of time. Now HIE can develop during pregnancy, the latter part of pregnancy, during the process of labor and delivery or sometimes even in the immediate postnatal or afterbirth stage of life. And there's a number of different causes, and it's, it's a spectrum of sorts that ranges from mild all the way to severe. So, some children with the more mild form of HIE may experience no health issues from HIE, but the others, those with moderate or severe HIE can actually develop severe permanent disabilities. And when we talk about disabilities, now we're talking about potential developmental delays, cerebral palsy, or CP, epilepsy or seizures and cognitive impairment. And these are serious, long lasting, potentially neurologically devastating effects of the disease process of HIE.

HIE occurs in around one to one and a half per 1,000 live full term births. Okay, so you might think, well, that's not a lot, but when you think about how many patients are born every year in the United States, that's a sizeable number of patients. It involves this complex cascade of events that leads to two distinct phases of energy failure in the brain cells, which then leads to cell death.

Okay. So, while the advances in obstetric care, fetal monitoring and maternal care have helped our babies; for the longest time, we had no real treatment modality for this clinical entity other than supportive ICU care for the baby. But then about now, almost a couple of decades ago, therapeutic hypothermia, cooling was shown to reduce death or disability in patients with moderate to severe HIE.

It is the only treatment we have available to us at this time to reduce the severity effects of HIE but it's critical that the treatment is initiated within the first six hours of life. So, the sooner, the better and large landmark trials have demonstrated the life and brain saving effects of therapeutic hypothermia or cooling.

Now we are fortunate at UT Southwestern to work with one of the country's leading experts in neonatal brain injury. Dr. Chalak Is a Professor of Pediatrics here at UT Southwestern, the Director of our Neuro Neonatal ICU program. And she will say this all the time. Time is brain, literally speaking. Essentially because we have that tight window, that short window, we need to ensure that we are able to provide this intervention in a timely manner, because the sooner the cooling begins, like I said, the better the baby's chances. But to determine what babies qualify for HIE, because there are very, very strict criteria that are employed for us to determine if a patient is a candidate for therapeutic hypothermia or cooling.

So, for us to be able to determine what babies qualify for cooling, we have to be able to examine them, right. Now, like I said before, Texas is huge. So, in the time it takes for our transport team to get to a center far, far away and bring a baby back to us, we may have essentially timed out. We may have essentially lost that window of opportunity within those first six hours of life.

So, TeleCooling or cooling on transport, allows us to examine the baby remotely. And then we can direct our transport team to start the cooling process for these babies even before they have left the outside hospital. We can just tell them, yes, this baby qualifies. These are the criteria that are met. Start the cooling now. In that manner, we're able to get this critical therapy to the patient, even before they've left the outside facility.

Host: And what steps had to be taken to offer this cutting edge treatment virtually?

Dr. Dariya: Yeah, the truth is, I feel like this program is almost a perfect coming together of our wonderful virtual health team at Children's, the transport team at Children's, the NICU team, our UT Southwestern physicians. Dr. Savani is the Division Chief of Neonatal Perinatal Medicine at UT Southwestern. He was the one that led the charge, starting the TeleNICU program here at Children's, many, many years ago. And Dr. Jawahar Jagarapu is an Assistant Professor here and he's forging ahead with a lot of virtual health in the field of neonatology. We have Kristy Carlton, who's the Director of Telemedicine and Outreach. Joy Hicks who is the Manager of Virtual Health. Eric McKenny, Frank Milano, and Jimmy Puga who are managers and team leaders on transport. We've essentially drawn expertise from various realms in healthcare, here, all available here at Children's and UT Southwestern, and brought all of that together for this program.

And, and like I said before, the hard work had pretty much already been done when the TeleNICU program was created. So, we had the blueprint in place already, but we still, we collaborated with the medical, legal, compliance folks, technology experts in the field. Essentially, we had to have light mobile equipment that our transport team can carry with them, that doesn't delay them. It doesn't slow them down. We found the technology that worked for the NICU team and our transport nurses, and it had to be very user-friendly. TeleTransport equipment transmits this recording. We have continuous audio feeds. We have telemetry data from medical devices that's uninterrupted, because connectivity can fluctuate in different parts of the state. We could be, it could be in an area that doesn't have the ability to provide that quality of feed. The platform was designed so that no matter what needs to be done or where it needs to be done, our physicians at Children's can get to the solution.

Our transport team can make things work with the smallest and the fewest number of clicks. There was a lot of groundwork that went into it and it wouldn't have been possible without a number of these people and all their hard work, but we have something that we're extremely proud of and that works very well.

Host: So, what about the equipment? What is needed to make this possible?

Dr. Dariya: So, we invested some years ago in FDA approved technology that allows cooling or therapeutic hypothermia on transport. And then we had to train our entire transport team on the use of this cooling device. And then the transport team is equipped with actually it used to be these cellular enabled iPads. We've moved away from that. We now, they all have their i-Phones. There's routers that have been fitted in our ambulances to provide wifi hotspots. We employ a software that is simple, intuitive, so that's on the transport end of things.

And then in the NICU, we have this state of the art TeleNICU room that is equipped with large screens, audio devices with digital otoscopes, with stethoscopes, with high resolution cameras, video laryngoscope. So, essentially I was sitting in that room, have the ability, the capability to conduct a detailed physical exam ranging from skin rash to I can hear a heart murmur on a baby. I can hear their breath sounds. I could be doing all of this examining a baby virtually that's 650 miles away in El Paso or 300 some miles away in Galveston if I had to, all while sitting in that room in Dallas. So, I think it's, it's pretty incredible how we're able to do that.

And like I said, the transport team is equipped with the device they need to essentially record everything. We're constantly on the phone with them. We're talking them through a process, through our thought process, examining a patient together, while we do all these things, doing all of that to provide the best possible care to these babies.

Host: This of course is a stressful time for any family who needs to have their baby transported. How do you make the family feel comfortable during this critical time?

Dr. Dariya: Yeah, that's a really, really important question. And I'm glad you brought that up because when we talk about HIE, obviously, the focus for a lot of us is on the baby, right. And how do we get to the baby and do all the things that we need to, to help the baby? And often we might forget about what this means for the family. I mean, everybody goes into the hospital. I recently had six months ago I had, I had a baby myself and every, every family, every, every parent goes into the hospital wanting that birthing process to be something that is memorable.

And you want the least possible complications, obviously for your baby, for the people that are involved in the process. When we talk about HIE, it can very often be happening in an extremely stressful environment. We're often dealing with families that have had a pregnancy that is relatively unremarkable up until that point. And then all of a sudden, their world is turned upside down and inside out because this is happening in the setting of a baby that is suddenly showing signs of being in immense stress while they're inside mommy. So, you could have them having to rush the mom back for an emergent C-section or trying to get the baby out as quickly as possible.

And while all of this is happening, families are getting the information that maybe the baby's not breathing well, or the baby's starting to seize. The baby is floppy. I mean, that's the last thing that a parent wants to hear about when they've just had a baby. Right? So, it's like you said, it can be an extremely stressful time for families. One of the other advantages of our TeleTransport Program is that we have the ability for our physicians and transport team to meet these parents virtually. We could be engaging them. We could be talking to them as soon as our team gets to the bedside and explaining things to them in the best way possible. A lot of times these are the mother might still be in the OR and another parent is trying to make sense of all of this and what this means. And we have the ability to meet them face to face, virtually, albeit virtually we have the ability to kind of talk to them and explain the things that are happening and what we can do to help and what we're about to do to help their baby.

And I think that that's such an underappreciated facet of the service that we provide. Very often, we're able to counsel parents or even other family members who have no idea about exactly what's going on. We have the ability to kind of talk to them, explain things to them, hopefully reassure them about what we have available for that baby and how we're able to help them. Very often, when the family then finally does make their way into our Neonatal ICU in Dallas, they recognize faces. I imagine that that is in some way comforting because you're not moving into a place where you know nobody. Hopefully you've built some sort of relationship in an extremely stressful environment, but something that a parent or family member can kind of hold on to. And that hopefully that makes that transition process just a little bit better.

Host: Well, Doctor, like you said, just an incredible service you provide. Is there anything else you'd like to share?

Dr. Dariya: We're extremely proud of this service. We have, like I said, a team that has brought people in from such diametrically opposite ends of, of medical care and healthcare, and we've all come together to provide this service that I think is really fantastic. While we've talked about this in the Neonatal ICU, our hope is that this program grows beyond that, because to my mind, this service would be just as helpful for our emergency room physicians and for our pediatric ICU colleagues, our cardiothoracic ICU, CVI ICU, physician colleagues as well. So, I think the scope of this program is pretty immense. The opportunities for growth are fantastic. And the service that we provide is really incredible for our babies and for their families.

Host: Well, Doctor, thank you so much for joining us today and for all the work you do at Children's Health. And as always thank you for listening to Pediatric Insights. For more information, head on over to children's.com/teleNICU.

I'm your host, Caitlin Whyte. Stay well .