Telemedicine Resuscitation & Arrest Trials (TreAT)

SUMR Intern: Karole Collier

Mentor: Dr. Brendan Carr & Dr. Anish Agarwal

Telemedicine within the ED for treating Severe Sepsis:

A Hub and Spoke Telemedicine pilot

Agenda:

1.What is sepsis?

2.How do you treat it?

3.Uptake of best practices?

4.Telemedicine Pilot - Literature review - Database development - Chart review & data entry - Feasibility pilot

5.Next steps = TRIAL

6.Lessons learned

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Sepsis

Early Goal Directed Therapy (EGDT)

Telemedicine

What is Sepsis?

▪ WHAT: Sepsis is a deadly medical condition characterized by a whole-body inflammatory state ; or in laymen’s term a severe full body infection

i. There is often confusion between sepsis, septicemia, and bacteremia

ii. To keep consistency, think of the aforementioned as a spectrum of medically relatedly medical conditions

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Sepsis

Bacteremia Septicemia SIRS

Prevalence: Severe Sepsis in the US

Sepsis is the 11th leading cause of death in the US, affecting over 750,000 patients per year ($17

billion/year) ▪ Its estimated that one patient present to an

emergency dept. in the US with severe sepsis or septic shock every minute

▪ Mortality [or incidence of death] ranges from 25%-50%”

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Imagine Your Sick? What’s the progression

In the same way that you recognize sickness, physicians are trained specially to notice key vital or

clinical encounters that allow them to diagnose disease

• Reason or clinical encounter

Infection

•A clinical response fulfilling certain criteria

How You Know • What infection

tells you about what is wrong.

Diagnosis

• Body Dysfunction,

SICK • Person may be

at the brink of serious damage or death

REALLY SICK!

Identification of Sepsis in the ED

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• Reason or clinical encounter

Infection/ Trauma

•A clinical response arising from a nonspecific resulting in ≥ 2 of the following :

SIRS Criteria • ≥ 2 SIRS

Criteria met + Source of Infection

Sepsis

•Organ Dysfunction, hypotension, or Hypoperfusion

Severe Sepsis •Severe Sepsis

w. hypotension, despite fluid resuscitation

Septic Shock

To understand how the problem of Sepsis can be solved one has to understand the process by which it develops and is diagnosed within a clinical setting.

Heart Rate: > 90 Respiratory Rate: >20 or

PaCO2 > 32 mmHg Temperature: <98.6°F

or>100.4°F WBC >12,000/mm3>,

< 4,000/mm3>, or Bands >10%

How do you treat it?

Early assessment on the basis of physical findings, vital signs, central venous pressure, and urinary output fails to detect persistent global tissue hypoxia. Global tissue hypoxia is an indicator of serious illness, and a key development preceding multi-

organ failure and death.

▪ Early Goal Directed Therapy [EGDT] = a more definitive resuscitation strategy to detect persistent global tissue hypoxia ▪ Resuscitation End Points: End points used to confirm the balance between oxygen delivery and

oxygen demand. ▪ Arterial Lactate Concentration

▪ Base Deficit

▪ Mixed Venous Oxygen Saturation

▪ pH

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Sepsis

EGDT

During the first 6 hr in the ED, the EGDT patients receive significantly more fluid therapy, red-cell transfusion, and inotropic agent (dobutamine) prior to ICU Admission

Sepsis

Sepsis

Relative risk of in-hospital, 28 day, and 60 day mortality was substantially reduced (roughly a third)

in Rivers 2001.

EGDT+ ED & Sepsis Mortality

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Despite the many proven prehospital and hospital based therapies for resuscitation care, multiple commentaries,

uptake remains poor. WHY? •Questions about how to develop hospital protocols, • The time window •Hospitals with inter-facility transport after initial stabilization Specifically for EGDT & Sepsis

Increasing the adherence to evidence based guidelines throughout the country

is a slow and arduous task

Even HERE!

▪Using the most liberal definition – “do you perform

goal directed therapy for patient with severe sepsis

more often than not?”, 66% of Pennsylvania EDs said

yes. (Carr 2013)

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The Study: USING REAL-TIME TELEMEDICINE TO IMPROVE QUALITY AND OUTCOMES

Aims…

▪ Telemedicine has been shown to improve the odds of appropriate treatment decision-making by nearly 11-fold for acute ischemic

stroke proving telemedical consultation to be an effective and feasible option.

Given that Sepsis: +Time Sensitive +Missed too often +Would Benefit from examination from an onsite expert

= may aid in narrowing the observed variation in survival and in the improvement of patient outcomes by utilizing TELEmedicine.

Telemedicine: Within the ED

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We proposed to use real-time telemedicine to develop a novel care delivery system for

patients with Severe Sepsis

• It provides a way to replace or augment existing education and system design efforts for unplanned critical illnesses Dissemination Issues

• Could serve as a powerful model for improving care in other disease states and critical conditions. Innovation of the ED with “Man to Man coverage”

Overview:

Pre-Telemedicine (1) Telemedicine Intervention (2)

Post Intervention (3)

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What: • Decrease sepsis related mortality

How: • Establish a baseline (chart review) • Prove feasibility of an intervention (real time coaching via telemedicine) • Perform a large scale randomized trial

Methods

▪ Develop a network of hospitals arranged in a hub (typically an academic medical center) and spoke (typically smaller community hospitals) that will enable us to trial the virtual resuscitation of patients in need of critical care.

▪ UPHS Trial Hub & Spoke:

▪ Hospital of the University of Pennsylvania [HUB]

▪ PENN Presbyterian Medical Center

▪ Pennsylvania Hospital

Technology

(REACH Health) was used to build an internal telemedical network which included:

▪ mobile telemedical carts placed in each ED equipped with a laptop computer,

▪ hidefinition pan-tilt-zoom video camera, and

▪ high-speed wireless connectivity.

▪ Both hub and spoke providers could control the camera and

view/enter/edit patient information through HIPAA secure connections in

real-time.

Florida? HUP

Kids’ Baseball Game Center City

Severe Sepsis Management

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US guided IV placement

Carr @ Home (3 am)

Study Design:

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Pilot & Trial (1) Telemedicine Intervention (2)

Post Intervention (3)

Assess the practical and technologic feasibility of using a real-time video based telemedical consultation to treat and manage critically ill patients within the ED (i.e. severe

sepsis and post-cardiac arrest care).

1. Obtain all data on Sepsis Patient in UPHS Network in the last year

2. Create a database to organize the data obtained

3. Analyze the UPHS Sepsis mortality rate and utilization of EGDT comparatively within the 3 hospitals of UPHS

4. Obtain provider perceptions regarding telemedical platforms within the ED

1. Create and Utilize a network of resuscitation experts to take telemedicine consults.

2. Consult critically ill (i.e severe sepsis) patients and utilize EGDT via a telemedical platform

3. Continually assess and gather data on telemedicine intervened patients

1. Obtain data on all Sepsis patients in UPHS network during the study/

2. Utilize the created database to compare patients receiving telemedical platform and not.

3. Obtain provider perceptions & monitor use or uptake of EGDT

4. Gain funding to roll out intervention on large scale RT.

My Role within the Telemedicine Pilot

▪ Quantify and describe the epidemiology of severe sepsis within the UPHS spoke network

▪ Create a database and analyze a database of severe sepsis cases treated in the ED within the UPHS institutions

▪ 165 Chart Reviews & Data Abstraction

▪ Help in ease implementation of telemedicine consultation by creating a standardized entry system -Functional Data Dictionary.

▪ Ultimately help create the baseline for the larger Telemedicine & Sepsis Trial

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How I achieved these goals:

▪Red Cap?

▪Data Entry?

▪Medview – Chart review ▪Deciphering through the varying ways in which a

chart is completed in the ED

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How I made the Database: ▪ I had to learn the thought process of both clinicians and researchers to best design the

database and execute data entry. My database had to mirror the clinical process by which clinicians came to the conclusion of sepsis.

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Red Cap

Many, many , MANY Charts to read!

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Limitations?

▪ Understanding the extreme variety within healthcare – Standardization of Charts is not often not a very feasible solution. Though it would better reflect the patient information (particularly for this study) within the ED, as ED physicians , dept., and ED coding varies drastically even within the UPHS system.

▪ Telemedicine, though innovative is not quite at the point that it is readily available, or adequately compensated for.

▪ Technology : though innovative and quite exciting, the expectations of the technology used is not quite up to speed with the technology readily available to patients outside of healthcare (i.e Facetime & Skype but with clinical capabilites)

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The Surreal Experience – Lessons Learned

▪ My Father’s experience with Severe Sepsis after serious surgical complications in the SICU. Letter Specifically to PCORI

▪ My Hopes for Telemedicine and its capabilities in solving Patient Centeredness.

▪ Medical Abbreviations!!!

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Thank YOU! DR. CARR

DR. AGARWAL

KATIE!

JOANNE

SAFA & SHANAE

LDI COHORT ‘13