Evaluating the feasibility of a multicenter teleneonatology clinical effectiveness trial.

BACKGROUND: Our research consortium is preparing for a prospective multicenter trial evaluating the impact of teleneonatology on the health outcomes of at-risk neonates born in community hospitals. We completed a 6-month pilot study to determine the feasibility of the trial protocol. METHODS: Four neonatal intensive care units ("hubs") and four community hospitals ("spokes") participated in the pilot-forming four hub-spoke dyads. Two hub-spoke dyads implemented synchronous, audio-video telemedicine consultations with a neonatologist ("teleneonatology"). The primary outcome was a composite feasibility score that included one point for each of the following: site retention, on-time screening log completion, no eligibility errors, on-time data submission, and sponsor site-dyad meeting attendance (score range 0-5). RESULTS: For the 20 hub-spoke dyad months, the mean (range) composite feasibility score was 4.6 (4, 5). All sites were retained during the pilot. Ninety percent (18/20) of screening logs were completed on time. The eligibility error rate was 0.2% (3/1809). On-time data submission rate was 88.4% (84/95 case report forms). Eighty-five percent (17/20) of sponsor site-dyad meetings were attended by both hub and spoke site staff. CONCLUSIONS: A multicenter teleneonatology clinical effectiveness trial is feasible. Learnings from the pilot study may improve the likelihood of success of the main trial. IMPACT: A prospective, multicenter clinical trial evaluating the impact of teleneonatology on the early health outcomes of at-risk neonates born in community hospitals is feasible. A multidimensional composite feasibility score, which includes processes and procedures fundamental to completing a clinical trial, is useful for quantitatively measuring pilot study success. A pilot study allows the investigative team to test trial methods and materials to identify what works well or requires modification. Learnings from a pilot study may improve the quality and efficiency of the main effectiveness trial.

Medical Marijuana Legalization in Oklahoma: Effects on Neonatal Exposure to Opiates.

OBJECTIVE: The U.S. opioid epidemic has been characterized by increases in opioid misuse, overdose deaths, and neonatal opioid withdrawal syndrome. Research suggests that marijuana legalization has contributed to decreased use of opiates, although many studies had methodological weaknesses and failed to address the pregnant population. Implementation of medical cannabis laws has the potential to reduce maternal opioid use and, therefore, neonatal exposure to the drugs. This study aimed to examine the association between Oklahoma's implementation of state medical marijuana laws and the neonatal exposure to opioids. STUDY DESIGN: Electronic medical records at two sites (Oklahoma City and Lawton) were searched for results of cord, urine, and meconium screens to detect amphetamines, barbiturates, benzodiazepines, cocaine, ethanol, opiates, phencyclidine, and tetrahydrocannabinol (THC). Two study periods were compared: 19 months before Oklahoma's medical marijuana law took effect and 19 months after legalization began. RESULTS: A total of 16,804 babies were born alive at the two sites during the study period. The rate of positive THC tests per 1,000 liveborn infants significantly increased from 16.2 per 1,000 during the prelaw period to 22.2 per 1,000 during the postlaw period (p = 0.004). Neonatal opioid exposure incidence showed a nonsignificant decrease from 7.6 positive tests per 1,000 liveborn infants to 6.8 per 1,000 from prelaw to postlaw period (p = 0.542). The number of positive tests for THC and concomitant use of opioids doubled from the prelaw period (n = 4) to postlaw (n = 9), but there were too few cases for statistical significance. Infants at the more rural site had significantly higher rates for amphetamines, benzodiazepines, and THC, with a trend toward higher rates for opiates. CONCLUSION: Marijuana legalization was related to significant increases in positive test rates for THC, but no significant change/association was noted for neonatal exposure to opioids. KEY POINTS: · Prior studies have not examined neonatal exposure to opioids following marijuana legalization.. · Oklahoma's new law led to higher neonatal marijuana exposure.. · Legalization of medical marijuana did not change Oklahoma's neonatal opioid positivity rate..

Validation and Feasibility of the Postnatal Growth and Retinopathy of Prematurity Retinal Screening Criteria at a Level IV Tertiary Care Neonatal Intensive Care Unit.

OBJECTIVE: Retinopathy of prematurity (ROP) is detected in preterm infants by standardized screening programs, but in general, they have poor sensitivity. The Postnatal Growth and Retinopathy of Prematurity (G-ROP) algorithm uses weight gain to predict ROP superior reported sensitivity. Our objectives are to (1) independently validate the sensitivity of G-ROP criteria for the detection of ROP in infants born at >28 weeks' gestation in a tertiary care unit in the United States and (2) to calculate the cost savings associated with a potential reduction in examinations. STUDY DESIGN: This is a retrospective analysis of retinal screening examination data, with post-hoc application of G-ROP criteria to determine whether G-ROP criteria had acceptable sensitivity and specificity in diagnosing Type 1 and Type 2 ROP. All infants born at >28 weeks who were screened by current American Academy of Pediatric Ophthalmologists/American Academy of Pediatrics guidelines at Oklahoma Children's Hospital at the University of Oklahoma Health Sciences Center, between 2014 and 2019, were included. Subset analysis of infants screened by second tier criteria was also performed. Potential cost savings were estimated by analyzing frequency of billing codes. And by calculating the number of infants who could have potentially been spared examination. RESULTS: The G-ROP criteria had 100% sensitivity in detecting type 1 and 87.6% sensitivity in detecting type 2 ROP, which would have reduced infants screened by 50%. All infants in the second tier who would require treatment were detected. A cost saving of 49% was projected. CONCLUSION: The G-ROP criteria are easy to apply in real-world setting, thus establishing feasibility. The algorithm identified all cases of type 1 ROP; however, some cases of type 2 ROP were not detected. The annual savings in hospital examination cost by using these criteria would be 50%. Therefore, G-ROP criteria can safely be used to screen for ROP and may reduce the number of unnecessary examinations. KEY POINTS: · The G-ROP screening criteria are safe and predict 100% of treatment warranted ROP.. · Adoption of G-ROP criteria is feasible for level IV NICUs.. · Adoption of G-ROP screening guidelines will result in significant cost savings..

Provider Perspectives on the Acceptability, Appropriateness, and Feasibility of Teleneonatology.

OBJECTIVE: We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals. STUDY DESIGN: Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models. RESULTS: The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries. CONCLUSION: Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable. KEY POINTS: · Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

A 360 Evaluation of Neonatal Care Quality at a Level II Neonatal Intensive Care Unit when Delivered Using a Hybrid Telemedicine Service.

OBJECTIVE: In 2013, the Section of Neonatal and Perinatal Medicine at the University of Oklahoma's Children's Hospital began providing advanced care to a regional level II neonatal intensive care unit (NICU), using a hybrid telemedicine program. This project compares health care providers' and parents' assessments of health care quality using this program. STUDY DESIGN: This is a prospective, anonymous, nonrandomized survey of health care providers and parents of neonates using our hybrid telemedicine services. Physicians, neonatal nurse practitioners (NNPs), nurses, and parents completed pencil-and-paper surveys based on their participatory roles. Institutional Review Board approval was obtained at OU Medical Center and Comanche County Memorial Hospital. Surveys consisted of 5-point Likert's scale questions. Descriptive statistics compared the level of agreement with each question across participant groups. A service quality (SQ) composite score was created by summing responses from six SQ questions. Between-group analysis was done on the SQ score using the Mann-Whitney U-test. RESULTS: Nine physicians, 10 NNPs, 12 nurses, and 40 parents completed the survey. Providers agreed (90%) that telemedicine can effectively deliver advanced neonatal care; the care patients receive is comparable to direct patient care (87%); telemedicine enhanced overall patient care quality (90%); providers can effectively interact with each other and families using telemedicine (90.3%), and overall telemedicine experience was good (90%). In total, 61% of providers reported telemedicine improves physician-patient interaction. Parents of newborns agreed that they were well informed about telemedicine use for their child's care (88%), were able to communicate routinely with neonatologists (85%), and were comfortable with their child's physical examinations (93%). Provider's versus family's (SQ) score was not significantly different. CONCLUSION: All survey participants, including neonatologists, NNPs, nurses, and patient families, reported high levels of satisfaction with the hybrid telemedicine model developed and implemented at this institution which may be comparable to in-person direct patient care. KEY POINTS: · Implementation of a hybrid telemedicine system provides an alternative to the transfer of newborns needing advanced care to tertiary care facilities.. · In this study, both health care providers and patient family members were satisfied with the quality of care using hybrid telemedicine.. · In this study, families of newborns could fully participate in their child's care using the hybrid telemedicine system..

Accuracy of Simulated Research Tasks by Community Hospitals Participating in a Multicenter Telemedicine Trial.

Background/Aims: Clinical trials evaluating facility-to-facility telemedicine may include sites that have limited research experience. For the trial to be successful, these sites must correctly perform research-related tasks. This study aimed to determine whether health care professionals at community hospitals could accurately identify simulated study eligible patients and submit data to a research coordinating center. Methods: Twenty-seven community hospitals in the United States and Canada participated in this study. An electronic survey was sent to one designated health care professional at each site. The survey included a description of trial eligibility criteria and five written neonatal resuscitation scenarios. For each scenario, the participant determined whether the neonate was study eligible. One scenario required participants to submit 14 data elements to the coordinating center. Accuracy of study eligibility and data submission was summarized using standard descriptive statistics. Results: The survey response rate was 100% (27/27). Overall accuracy in determining study eligibility was 89% (120/135), and accuracy varied across the five scenarios (range 82-93%). Overall accuracy of data submission was 92% (310/336). Data were >95% accurate for 9 of the 14 data elements, with 100% accuracy achieved for 6 data elements. These results were used to clarify eligibility criteria, inform database design, and improve training materials for the subsequent clinical trial. Conclusions: Health care professionals at community hospitals accurately determined trial eligibility and submitted study data based on written clinical scenarios. Research teams conducting telemedicine trials with community hospitals should consider completing pre-trial simulation activities to identify opportunities for improving trial processes and materials.

Tele-Echocardiography for Congenital Heart Disease Screening in a Level II Neonatal Intensive Care Unit with Hybrid Telemedicine System.

Introduction: The nationwide shortage of pediatric cardiologists in medically underserved areas poses a challenge to congenital heart disease (CHD) screening requiring echocardiography, resulting in transfer of neonates to regional Level III/IV Neonatal Intensive Care Units (NICUs). This study aimed to evaluate the accuracy, safety, and cost-effectiveness of tele-echocardiography for advanced CHD screening at a Level II NICU managed by a hybrid telemedicine system. Methods: Retrospective chart review of infants requiring tele-echocardiography at a Level II NICU. Patient demographics, echocardiography indications, and findings were analyzed. Agreement between tele-echocardiography and conventional echocardiography findings was assessed. Transport cost savings were calculated based on preventable transfers to Level IV NICU. Descriptive statistics were computed for demographic and clinical variables. Results: Over 5 years, 52 infants were screened for CHD. Thirty-two infants (62%) had findings consistent with minor CHD or normal neonatal transitional physiology. Twenty infants (38%) had abnormal findings requiring follow-up with either a conventional echocardiography as inpatient at the regional Level IV NICU or as outpatient after discharge. Only 5 infants (10%) required transfer to a Level IV NICU for CHD management, whereas 15 infants (29%) were scheduled for outpatient follow-up. Strong agreement was noted between tele-echocardiography and conventional echocardiography findings. No case of critical congenital heart disease (CCHD) was missed. Tele-echocardiography saved $260,000 in transport costs. Conclusions: Tele-echocardiography can be accurate, safe, and effective in CHD screening, preventing unnecessary transfer of most infants to regional Level III/IV NICUs, saving transfer costs.

Evaluation of Neonatal Services Provided in a Level II NICU Utilizing Hybrid Telemedicine: A Prospective Study.

Objective: To evaluate the safety and efficacy of premature infant treatment managed by hybrid telemedicine versus conventional care. Methods: Prospective, noninferiority study comparing outcomes of premature infants at Comanche County Memorial Hospital's (CCMH) Level II neonatal intensive care unit (NICU) with outcomes at OU Medical Center's (OUMC) Level IV NICU. All 32-35 weeks gestational age (GA) infants admitted between May 2015 and October 2017 were included. Infants requiring mechanical ventilation >24 h or advanced subspecialty care were excluded. Outcome variables were: length of stay (LOS), respiratory support, and time to full per oral (PO) feeds. Parents at both centers were surveyed about their satisfaction with the care provided. Between-group comparisons were performed by using Chi-square or Fisher's exact test. LOS was assessed for normality by using the Shapiro-Wilk test, and robust regression was used to construct a multivariable regression model to test the independent effect of location on LOS. All analyses were performed by using SAS v. 9.3 (SAS Institute, Cary, NC). Results: Data from 85 CCMH and 70 OUMC neonates were analyzed. CCMH neonates had significantly shorter LOS, reached full PO feeds sooner, and had fewer noninvasive ventilation support days. Location had a significant independent effect (p = 0.001) on LOS while controlling for GA, gender, race, surfactant use, inborn/outborn status, and 5-min APGAR scores. CCMH patients had reduced LOS of 3.01 days (95% confidence interval 1.1-4.8) than OUMC patients. Eighty-five surveys at CCMH and 66 at OUMC were analyzed. Compared with CCMH, OUMC parents reported more travel distance difficulties. 92.5% reported telemedicine experience as good or excellent, whereas 1.5% reported it as poor. Conclusion(s): Hybrid telemedicine is a safe and effective way to extend intensive neonatal care to medically underserved areas. Parental satisfaction with use of hybrid telemedicine is high and comparable to conventional care.

Scope of telemedicine in neonatology.

There is a widespread shortage of physicians worldwide, especially in rural areas. This shortage is more prevalent when it comes to subspecialty care, even in developed countries. One way to provide access to specialty care is using technology via telemedicine. Telemedicine has evolved over the last two decades, and its use is becoming widespread in developed countries. However, its use in the neonatal population is still limited and practiced only in some centers. It is now apparent that telemedicine can be successfully used in the neonatal population for screening premature infants for retinopathy of prematurity, congenital heart disease, bedside clinical rounds, neonatal resuscitation with the support of a tertiary care hospital, and family support. This avoids unnecessary transfer and appears to provide the same quality of care that the baby would have received at the tertiary care facility. This approach also improves family satisfaction, as the baby and the mother are kept together, and reduces the cost of care. This review focuses on the use of telemedicine in neonatal care, concentrating on the main areas where telemedicine has been shown to be successful and effective, including the status of telemedicine in China.

A Hybrid Form of Telemedicine: A Unique Way to Extend Intensive Care Service to Neonates in Medically Underserved Areas.

BACKGROUND: More than 90% of neonatal intensive care units (NICUs) in the United States are in urban areas, denying rural residents' easy NICU access. Telemedicine use for patient contact and management, although studied in adults and children, is understudied in neonates. A hybrid telemedicine system, with 24/7 neonatal nurse practitioner coverage and with a neonatologist physically present 3 days per week and telemedicine coverage the remaining days, was recently implemented at Comanche County Memorial Hospital's (CCMH) Level II NICU. OBJECTIVE: To compare outcomes of moderately ill infants between 32-35 weeks gestational age (GA) managed by our hybrid telemedicine program with outcomes of similar neonates receiving standard care in a Level IV NICU at Oklahoma University Medical Center (OUMC). DESIGN/METHODS: This was a retrospective, noninferiority study comparing outcomes of neonates receiving hybrid telemedicine versus standard care. All 32-35 weeks GA infants admitted between July 2013 and June 2015 were included. OUMC infants came from areas geographically comparable with CCMH. Infants requiring prolonged mechanical ventilation or advanced subspecialty services were excluded. Outcome variables were length of stay, type and duration of respiratory support, length of antibiotic therapy, and time to full enteral feedings. RESULTS: Eighty-seven neonates at CCMH and 56 neonates at OUMC were included in the analysis. Compared with neonates at OUMC, neonates at CCMH had shorter hospitalizations, fewer days of supplemental oxygen, and fewer noninvasive ventilation support days, and reached full enteral feeds sooner. CONCLUSIONS: The hybrid telemedicine system is a safe and effective strategy for extending intensive care to neonates in medically underserved areas.

THE OPIOID-EXPOSED NEONATE: A REVIEW OF THE OKLAHOMA EXPERIENCE.

Neonatal abstinence syndrome from opioids (NAS-O) is a multisystem disorder resulting in neurological and gastrointestinal symptoms from the abrupt discontinuation of chronic fetal exposure to opioids. Increasing opioid use during pregnancy has led to a five-fold increase in NAS-O nationally over the past decade. Several knowledge gaps in our experiences with opioid-exposed neonates have been identified: 1) universal maternal screening; 2) diagnostic tools for newborn abstinence syndrome; 3) optimal treatment protocols; and 4) long-term neurodevelopmental effects of fetal opioid exposure. This review article gives a broad overview of the issues associated with screening, diagnosis, and management of opioid exposure in newborns as well as the issues with collecting accurate outcomes data to monitor efforts aimed at curbing opioid exposure in children and NAS-O. Data specific to Oklahoma is provided, when available.

Establishing level II neonatal services in southwestern Oklahoma.

Historically, Neonatal Services in Oklahoma have relied upon Level III and IV NICUs within the largest metropolitan areas to provide services for premature and other sick newborns. Smaller, regional Level II nurseries have delivered care according to previous American Academy of Pediatrics (AAP) Guidelines for Levels of Care. With changing guidelines in perinatal and neonatal care, there has been the need to add to available neonatal resources to continue to allow infants to remain in their home. This article is a description of a partnership between Comanche County Memorial Hospital (CCMH) and the Department of Pediatrics, Neonatal-Perinatal Medicine Section at OU Health Sciences Center (OUHSC) to establish a regional Level II NICU and the planning and implementation required to meet local, state, and national standards. The process, which involved neonatologists, nurse practitioners, nurses, laboratory services, pharmacy services, radiology, and respiratory therapy, resulted in a fully-functioning 8-bed Level II NICU.

A clinical consensus guideline for nutrition in infants with congenital diaphragmatic hernia from birth through discharge.

OBJECTIVE: To develop a consensus guideline to meet nutritional challenges faced by infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN: The CDH Focus Group utilized a modified Delphi method to develop these clinical consensus guidelines (CCG). Topic leaders drafted recommendations after literature review and group discussion. Each recommendation was sent to focus group members via a REDCap survey tool, and members scored on a Likert scale of 0-100. A score of > 85 with no more than 25% outliers was designated a priori as demonstrating consensus among the group. RESULTS: In the first survey 24/25 recommendations received a median score > 90 and after discussion and second round of surveys all 25 recommendations received a median score of 100. CONCLUSIONS: We present a consensus evidence-based framework for managing parenteral and enteral nutrition, somatic growth, gastroesophageal reflux disease, chylothorax, and long-term follow-up of infants with CDH.

Human botfly (Dermatobia hominis) larva in a child's scalp mimicking osteomyelitis.

Furuncular myiasis caused by Dermatobia hominis is endemic throughout Central and South America. However, because of widespread travel, furuncular myiasis has become more common in North America. Misdiagnosis and mismanagement can occur owing to limited awareness of the condition outside endemic areas. We report a case of furuncular myiasis in an immigrant from El Salvador with magnetic resonance imaging findings. The case is unique because neuroimaging was obtained upon the clinical suspicion of calvarial osteomyelitis. Parasitic infestation should be included in the differential diagnosis of a new skin lesion in patients who have traveled to endemic areas.

Multicenter study assessing physicians' and transport teams' attitudes and expectations about utilizing telemedicine to manage critical neonatal transports.

BACKGROUND: Managing critically ill neonates has unique challenges, and the transport team plays an important role in stabilizing and facilitating the transfer of these neonates from lower-level nurseries to tertiary centers, and the use of telemedicine in transport (tele-transport) can potentially benefit patient care. We conducted a multicenter study to assess the readiness for utilizing telemedicine as an adjunct to guide the care of critically ill neonates among physicians and transport team members (TTMs). This is the first multicenter study that explored physicians' and TTMs' perceptions of telemedicine usage and its value in neonatal transport. METHODS: A confidential, voluntary survey on pre-implementation attitudes toward telemedicine usage during neonatal transport was conducted as part of a quality improvement initiative. This survey involved physicians and TTMs from four academic institutions whose responses were entered into an online survey using REDCap®. The survey inquired about satisfaction with the current practice of phone consultation and the perception of using telemedicine to optimize the management of neonates during transport. RESULTS : The overall response rate for the survey was 60.1%; 82 of 127 (64.6%) physicians and 64 of 116 (55.2%) TTMs responded to the surveys. Half of the physicians and less than one-fourth of the TTMs had prior experience with telemedicine other than that used on neonatal transport. TTMs expressed greater concern about the inconvenience of video (55% vs. physicians 35% agree or strongly agree) and its time consumption (84% vs. physicians 50%). More than 70% of physicians and less than half of TTMs endorsed the potential for added value and quality improvement with video capability. Almost half of TTMs reported concern about video calls reducing their autonomy in patient care. Physicians expressed confidence in management decisions they would make after video calls (72% confident or very confident) and less confidence (49%) about both the phone assessment by TTMs and their decisions based on phone assessment. In contrast, TTMs were confident or very confident (94%) in both sharing their assessment over the phone and executing patient management after a phone call, compared with 70% for decisions made after video calls. CONCLUSIONS : Physicians and TTMs had distinct opinions on the use of telemedicine during neonatal transport. Physicians were more likely than TTMs to agree with statements about the potential for improving quality of care, while TTMs were more likely than physicians to say video calls would be time-consuming and inconvenient. We speculate some differences may stem from the TTMs' concern about losing their autonomy. Therefore, during implementation, it is critical for physicians and TTMs to agree on a shared mental model of indications for telemedicine during transport and its value to the patient care.

Placental Neutrophil Infiltration Associated with Tobacco Exposure but Not Development of Bronchopulmonary Dysplasia.

Objective: In utero inflammation is associated with bronchopulmonary dysplasia (BPD) in preterm infants. We hypothesized that maternal tobacco exposure (TE) might induce placental neutrophil infiltration, increasing the risk for BPD. Study design: We compared the composite outcome of BPD and death in a prospective pilot study of TE and no-TE mothers and their infants born <32 weeks. Placental neutrophil infiltration was approximated by neutrophil gelatinase-associated lipocalin (NGAL) ELISA, and total RNA expression was analyzed via NanoString© (Seattle, WA, USA). Result: Of 39 enrolled patients, 44% were classified as tobacco exposure. No significant difference was noted in the infant's composite outcome of BPD or death based on maternal tobacco exposure. NGAL was higher in placentas of TE vs. non-TE mothers (p < 0.05). Placental RNA analysis identified the upregulation of key inflammatory genes associated with maternal tobacco exposure. Conclusion: Tobacco exposure during pregnancy was associated with increased placental neutrophil markers and upregulated inflammatory gene expression. These findings were not associated with BPD.

Utility of telemedicine to extend neonatal intensive care support in the community.

Moderately ill preterm infants residing in medically underserved areas are frequently transferred to tertiary care NICUs that are mostly located in urban areas, resulting in mother-infant separation, high transportation costs, and the emotional costs of limited infant visitation. In 2012, The American Academy of Pediatrics revised neonatal care guidelines, adding in-house neonatal services to the scope of Level II NICUs. Limited availability of neonatologists in medically underserved areas has prompted innovative solutions like telemedicine to meet this requirement. Telemedicine consultations for pediatric transports have demonstrated improved patient outcomes compared with phone consultation, but evidence regarding telemedicine use for neonatal transport is mostly limited to simulation settings. Also, there are limited data on telemedicine use as a primary means to provide intensive care to neonates in Level I/II NICUs. Recently, two groups demonstrated the feasibility and safety of synchronous telemedicine to guide care for premature infants at lower level NICUs. This approach prevented unnecessary transfer and appeared to provide the same quality of care that the baby would have received at the tertiary care facility. As current evidence regarding the use of telemedicine to extend intensive care is based on single-center experiences, additional research and evaluation of the effectiveness of telemedicine for this application is required. This chapter describes the use of telemedicine to support physicians at lower level nurseries and the transport team with management of critical neonates, utility as primary means to provide care at lower level NICUs, barriers for implementation, and future opportunities to enhance telemedicine's impact in NICU settings.

Use of Telemedicine for subspecialty support in the NICU setting.

The regionalization of neonatal care was implemented with an overarching goal to improve neonatal outcomes.1 This led to centralized neonatal care in urban settings that jeopardized the sustainability of the community level 2 and level 3 Neonatal Intensive Care Units (NICU) in medically underserved areas.2 Coupled with pediatric subspecialist and allied health professional workforce shortages, regionalization resulted in disparate and limited access to subspecialty care.3-6 Innovative telemedicine technologies may offer an alternative and powerful care model for infants in geographically isolated and underserved areas. This chapter describes how telemedicine offerings of remote pediatric subspecialty and specialized programs may bridge gaps of access to specialized care and maintain the clinical services in community NICUs.

Evaluating Patients' and Neonatologists' Satisfaction With the Use of Telemedicine for Neonatology Prenatal Consultations During the COVID-19 Pandemic.

Background: During the COVID-19 pandemic, telemedicine plays a critical role in providing safe, effective healthcare services, while reinforcing social distancing and optimizing the use of personal protective equipment. In this context, the Oklahoma Children's Hospital implemented virtual neonatology prenatal visits for pregnant women with a diagnosis of fetal anomalies. While tele-consultations have been broadly used with a high degree of acceptance in rural and remote areas, satisfaction has not been assessed in this particular scenario, where patients and physicians discussing sensitive healthcare information had to rapidly adjust to this new modality. Objectives: To evaluate patients' and neonatologists' satisfaction with virtual prenatal consultations in the context of the COVID-19 pandemic and to compare satisfaction levels of patients receiving virtual consultation with those receiving in-person consults. Methods: This cross-sectional study evaluated patients' and neonatologists' satisfaction with virtual consultations. Participants included pregnant women with diagnosis of fetal anomalies who received neonatology prenatal consultations at Oklahoma Children's Hospital, either in-person or through telemedicine, from May to mid-November 2020, and neonatologists providing virtual prenatal consultations in the same period. Virtual visits were delivered via Zoom Pro™. Patients and physicians who agreed to participate rated acceptability completing an anonymous 5-point Likert scale survey. Item frequencies and means for categories of items were computed by group (video-consult patients, in-person patients, physicians) and analyzed, using Welch's t for unequal sample size. Results: Overall consultation quality was rated good or excellent by 35 (100%) video-consult patients and 12 (100%) in-person patients. Patient group means computed on six 5-point Likert items about patient-physician communication did not differ significantly, video-consult: M = 28.71 (2.22); in-person consult: M = 28.92 (1.78) (p = 0.753263). All eight physicians (100%) agreed or strongly agreed that telemedicine was effective, using a 5-point Likert scale, and their combined consultation quality score computed on 10 survey questions was high: M = 46.4 (3.11). Conclusion: Despite patient inexperience with tele-consultations, the quick implementation of telemedicine, and the sensitive reason for the visit, patients and physicians were highly satisfied with virtual visits. Telemedicine is a safe, effective alternative for providing neonatology prenatal consultations for pregnant women with diagnosis of fetal anomalies during the pandemic.

Volume Targeted Ventilation and High Frequency Ventilation as the Primary Modes of Respiratory Support for ELBW Babies: What Does the Evidence Say?

Respiratory management of the extremely low birth weight (ELBW) newborn has evolved over time. Although non-invasive ventilation is being increasingly used for respiratory support in these ELBW infants, invasive ventilation still remains the primary mode in this population. Current ventilators are microprocessor driven and have revolutionized the respiratory support for these neonates synchronizing the baby's breath to ventilator breaths. High frequency ventilators with the delivery of tidal volumes less than the dead space have been introduced to minimize barotrauma and chronic lung disease. Despite these advances, the incidence of chronic lung disease has not decreased. There is still controversy regarding which mode is ideal as the primary mode of ventilation in ELBW infants. The most common modes seem to be pressure targeted conventional ventilation, volume targeted conventional ventilation and high frequency ventilation which includes high frequency oscillatory ventilation, high frequency jet ventilation and high frequency flow interrupter. In recent years, several randomized controlled trials and meta-analyses have compared volume vs. pressure targeted ventilation and high frequency ventilation. While volume targeted ventilation and high frequency ventilation does show promise, substantial practice variability among different centers persists. In this review, we weighed the evidence for each mode and evaluated which modes show promise as the primary support of ventilation in ELBW babies.