Pediatric traumatic brain injury is the leading cause of injury related mortality and morbidity in the United States. However, the management and outcomes of these patients can vary significantly based on where the injury occurs and where it is treated (Greene et al. Arch Phys Med Rehabil. 2014;95:1148-1155). One reason for this may be related to the time it takes to obtain emergent neurosurgical treatment from a pediatric neurosurgeon, most likely in a tertiary care center. Although reports are inconsistent, there are some data in adults suggesting that intracranial hematomas evacuated within 4 hours improves mortality compared with those evacuated after 4 hours (Kim YJ et al. Int Emerg Nurs. 2014;22:214-219; Matsushima et al. J Trauma Acute Care Surg. 2015;79:838-842). Although there are no such data in children, it is likely that early intervention by a specialist would improve outcomes in the pediatric population as well.
Telemedicine refers to medical information exchanged between one site and another via electronic communication to improve a patient’s outcome. It is typically used when the distance between the referring hospital and accepting hospital is a barrier. The use of telemedicine in pediatrics has been slowly increasing as physicians realize that the technology used for mobile devices has improved. Currently it is being used in pediatric cardiology, emergency medicine, and pediatric surgery, among others (Burke BL Jr, et al. Pediatrics. 2015;136:e293-e308).
Jackson et al (Ped Crit Care Med. 2018;19:1033-1038) conducted a retrospective chart review to compare outcomes in children who needed operative management of an intracranial hemorrhage (ICH) before and after the pediatric transport service implemented a telemedicine program. In the cases for which telemedicine was used, a consult with the medical control physician (MCP) at the receiving hospital was triggered by a neuroimaging interpretation, either by the referring hospital or by the transport team. The MCP would then review the case (including de-identified images) with the on-call pediatric neurosurgeon, who would then decide on the need for time-sensitive surgery. If early neurosurgery was needed, the transport would be expedited, the emergency medicine physicians would have a more focused evaluation, and the surgical and anesthesia staff would be mobilized more quickly. The objective of this study was to analyze the impact telemedicine had on time to surgery in children with ICH.
Outcomes were compared between children with operative ICH before January 2014 (pre-telemedicine) and after January 2014 (telemedicine period). Operative ICH was defined as any intracranial bleed requiring surgery for evacuation or decompression less than 2 hours from presentation to the trauma bay. The authors then compared variables including demographics, time to the operating room, pediatric ICU and hospital lengths of stay, and number of patients discharged home.
In all, the study looked at only 8 patients in the telemedicine group and 7 in the non-telemedicine group. While there were no statistically significant differences in any of the values studied, some of the trends were interesting. Patients in the telemedicine group had higher Glasgow Coma Scale scores in the trauma bay, decreased repeat neuroimaging, decreased time from trauma bay to operating room, decreased pediatric ICU and hospital lengths of stay, and a higher number of patients discharged home compared to the non-telemedicine group.
This study has significant limitations because of its very small sample size and retrospective nature. In addition, the authors comment on the many obstacles the development and use of a telemedicine-based transport system carries (e.g., reimbursement, feasibility) However, telemedicine may be particularly useful in the U.S. system of regionalized healthcare, and the addition of any positive studies may help it become more widespread. Clearly, larger and more definitive studies are needed.
Author of this installment of Concise Critical Appraisal:
Daniel E. Sloniewsky, MD, is an associate professor in the Division of Pediatric Critical Care Medicine in the Department of Pediatrics at Stony Brook Long Island Children’s Hospital. Dr. Sloniewsky is an editor of Concise Critical Appraisal.