Women’s and Children’s

For more than 30 years, we have been a leading provider of outsourced women's and children's services, specializing in acute inpatient care and treatment of infants and children. We continue to expand our services into pediatric intensive care, pediatric hospitalist programs and pediatric emergency medicine.

Through our demonstrated commitment to clinical excellence, we are also motivated to be an integral part of your community. We develop collaborative working relationships with community obstetricians, pediatricians, hospital nursing staffs and administration.

PremiEHR™, our proprietary EMR, captures medical information relevant to care provided in the NICU, nursery and delivery room. We also offer a turnkey, universal newborn hearing screening program called Healthy Hearing™.

Led by our dedicated on-site medical director, our locally based teams are comprised of full-time, board-certified or board-eligible physicians and ARNPs. Learn more about our women's and children's services management.

Read our posts related to women's and children's:

28 March2017

Northside Team Saves Mother, Baby in Complicated Delivery

Air Force major Jerry Gay and his pregnant wife, Mary, were looking forward to the expected February 9 arrival of their new daughter. Mary was at home in Georgia and Jerry was deployed in Qatar, in the Middle East. But the couple’s joy became tempered with fear when Mary’s ob-gyn, Dr. Alex Eaccarino, noticed a spot that didn’t look quite normal during Mary’s 30-week checkup, per a recent story on Fox 5 Atlanta

The spot turned out to be uterine scarring from Mary’s prior cesarean-section deliveries. The scarring increased her risk for a placenta accreta, a potentially life-threatening obstetric condition that occurs when part or all of the placenta invades the uterine wall and is inseparable from it, preventing the placenta from detaching as it should during birth. "The biggest risk factor to the mom would be the risk of post-partum hemorrhage or uncontrollable bleeding," Dr. Eaccarino told Fox 5 Atlanta. Mary was told that she would need a C-section and that it was likely she also would need a hysterectomy to remove all or part of her uterus. Jerry immediately rushed home from the Middle East on emergency leave and was with Mary at Northside Hospital’s Forsyth campus on January 4 for her surgery.

Mary’s three surgeons and the anesthesia team from Sheridan practice Northside Anesthesiology Consultants (NAC) were extremely experienced in dealing with this type of complicated, high-risk delivery. Northside has the busiest obstetric practice in the country, delivering more than 25,000 babies and performing roughly 7,000–8,000 C-sections each year, according to John Kimbell, CAA, MMSC, NAC’s administrative chief anesthetist. 

Anticipating the possibility of hemorrhage, the anesthesia team placed invasive monitoring lines pre-operatively, and a large supply of blood products had already been cross-matched and were available, if needed—preparations that helped saved Mary’s and her unborn daughter’s lives.

The C-section went better than expected, with minimal bleeding, and it appeared that the placenta accreta was not as extensive as the surgeons had originally thought, Dr. Eaccarino told Fox 5. At that point, he said, they agreed it would be best to preserve Mary’s uterus and decided against performing a hysterectomy. Jerry told the reporter that while he was in the NICU with newborn daughter Sinclair, he was ecstatic to receive a call from Mary's surgical nurse, who told him that she was doing well and was being moved to the recovery area.

Unfortunately, this best-case scenario didn’t last long. When Mary woke up from the anesthesia, she was in severe pain and her nurse quickly realized Mary was bleeding excessively. The nurse "got my doctor back in there really quickly and the anesthesiologist back into the OR,” she recalled to the reporter. By then, Mary was hemorrhaging and needed more than 30 units of blood to replace the blood she was losing.

The anesthesia team, which included Stephen Grice, MD, Jeff Mims, CAA, Jeff Thomas, CAA and Patty Flaherty, CAA, among others, activated its Massive Transfusion Protocol that allows quick coordination with the blood bank and enables predetermined packages of different blood products to be delivered quickly and constantly. Thanks to that team’s prior preparations and the Massive Transfusion Protocol, the surgeons were able to stop the bleeding and remove part of Mary's uterus. Jerry told Fox 5 that it "the longest hour and a half of my life." 

When Mary woke up in the ICU, on a ventilator, she immediately asked to see her baby, Sinclair. "I don't think you can go through things like that and have it not change you,” she told the reporter. “I appreciate things a lot more."

In their interview with Fox 5 Atlanta, Mary and Jerry expressed their gratitude for Dr. Eaccarino and the entire Northside team, whose skill and alertness helped save both Mary’s and Sinclair’s lives, and for the dozens of strangers whose blood donations helped make the life-saving surgery possible.

21 March2017

Three Breakthrough Technologies That Will Change Medicine

The Massachusetts Institute of Technology (MIT) publishes an annual list of 10 Breakthrough Technologies. Three innovations from this year’s list promise to have a dramatic impact on the future of medicine.

Brain Implants that Reverse the Effects of Paralysis

In recent years, brain implants have enabled lab animals and even a few people to use thoughts to control computer cursors or robotic arms. According to the 2017 MIT report,  researchers are “taking a significant next step toward reversing paralysis once and for all” using what French neuroscientist Grégoire Courtine calls a “neural bypass.” Wireless implants transmit electrical impulses from brain to spinal cord, bypassing damaged parts of the central nervous system and enabling movement of limbs once paralyzed due to spinal cord injuries. Courtine and a team of researchers at a Swiss university have used the implanted electronics to restore mobility of a partially paralyzed macaque monkey in hopes of future applications with humans.

A team at Cleveland’s Case Western Reserve University placed two of the same type of implants used in the Swiss experiment in the brain of a middle-aged quadriplegic volunteer who, on his own, could not move any part of his body other than his head and a shoulder. The implants are smaller than a postage stamp and “bristle with a hundred hair-size metal probes that can ‘listen’ as neurons fire off commands.” The Case team also inserted more than 16 fine electrodes into the muscles of the volunteer’s arm and hand. According to the MIT report, in videos of the experiment, “the volunteer can be seen slowly raising his arm with the help of a spring-loaded arm rest, and willing his hand to open and close. He even raises a cup with a straw to his lips.” This transformational technology is expected to be available in 10 to 15 years.

Next-generation Gene Therapy

For decades, researchers have been pursuing the idea of gene therapy—what the MIT report calls the use of “an engineered virus to deliver healthy copies of a gene into patients with defective versions”—with mostly disappointing results. Now, researchers have solved some of the puzzles that caused many earlier gene therapies to fail. Scientists are “using viruses that are more efficient at transporting new genetic material into cells” to develop the next generation of gene therapies—or “gene therapy 2.0”—to treat patients with rare hereditary diseases. 

European regulators have approved two of the treatments. One is Strimvelis, for treating children with severe combined immunodeficiency due to adenosine deaminase deficiency (ADA-SCID). The other is Glybera, for treating patients with lipoprotein lipase deficiency (LPLD), a rare disease that causes fat to accumulate in the blood and increases the risk of acute and recurrent pancreatitis. 

In the United States, one of Spark Therapeutics’ gene therapies for inherited retinal diseases (IRDs) is in phase III clinical trials. The company’s hemophilia B therapy, SPK-9001, is currently in an ongoing phase i/ii clinical trial and recently received breakthrough therapy and orphan product designations from the U.S. Food and Drug Administration. Another promising gene therapy in development could lead to a cure for hemophilia and enhance healing in patients suffering from epidermolysis bullosa, an excruciatingly painful and sometimes fatal hereditary skin disease. 

According to the MIT report, researchers are conducting clinical trials for gene therapies for some 40 to 50 diseases. “Fixing rare diseases, impressive in its own right, could be just the start.” 

The Human Cell Atlas

An international consortium of scientists is being assembled to develop the first comprehensive map of human cells. Biologists, clinicians, technologists, physicists, computational scientists, software engineers and mathematicians from the U.S., U.K., Sweden, Israel, the Netherlands, and Japan will be collaborating on the construction of what the MIT report calls “biology’s next mega-project”—a “cell atlas” that catalogs and maps the 37.2 trillion cells of the human body. 

The Human Cell Atlas website explains the significance of this massive, ambitious and unprecedented undertaking. “A complete Human Cell Atlas would give us a unique ID card for each cell type, a three-dimensional map of how cell types work together to form tissues, knowledge of how all body systems are connected, and insights into how changes in the map underlie health and disease. It would allow us to identify which genes associated with disease are active in our bodies and where, and analyze the regulatory mechanisms that govern the production of different cell types.”

The MIT report calls the future genomic reference map “a technological marvel that should comprehensively reveal, for the first time, what human bodies are actually made of and provide scientists a sophisticated new model of biology that could speed the search for drugs.”

According to the report, this new type of mapping is possible thanks to the confluence of three technologies: 

  • Drop-Seq—described in the abstract of a 2015 Cell article by Evan Z. Macosko and his colleagues as “a strategy for quickly profiling thousands of individual cells by separating them into nanoliter-sized aqueous droplets, associating a different barcode with each cell’s RNAs, and sequencing them all together.” 

  • Ultra-fast, extremely efficient sequencing machines that can decode and identify the genes active in single cells “at a cost of just a few cents per cell. One scientist can now process 10,000 cells in a single day.”

  • Innovative labeling and staining techniques that “can locate each type of cell—on the basis of its gene activity—at a specific zip code in a human organ or tissue.”

Among the key supporters of this project are the U.K.’s Wellcome Trust Sanger Institute, the Broad Institute of MIT and Harvard in Massachusetts, and the new Chan Zuckerberg Biohub in California funded by Facebook CEO Mark Zuckerberg and his wife, Priscilla Chan. Zuckerberg and Chan made the Human Cell Atlas project “the inaugural target of a $3 billion donation to medical research,” according to the MIT report. The human cell atlas should be available in five years.

14 March2017

Newly ID’d Genomic Features of Cervical Cancer May Allow Targeted Therapies

Once known as the leading cause of cancer deaths for women in the United States, cervical cancer has been on the decline due to advances in detection technology and medical treatments over the last four decades. The latest example of this trend is a recent study by investigators with The Cancer Genome Atlas (TCGA) Research Network, which has identified novel genomic and molecular characteristics of cervical cancer that may aid in the creation of more targeted, effective drug therapies.

Through an analysis of the genomes of 178 primary cervical cancers, TCGA researchers found that more than 70 percent of cervical tumors had genomic alterations in one or both of two important cell signaling pathway. Further, researchers identified a unique set of eight cervical cancer tumors that demonstrated molecular similarities with endometrial cancers and had high frequencies of mutations in the KRAS, ARID1A and PTEN genes. Researchers unexpectedly discovered that all the tumors with genomic alterations and most of the endometrial-like tumors did not show evidence of human papillomavirus (HPV) infection, the leading cause of nearly all cervical cancer incidents.

The discovery of HPV-negative tumors with endometrial characteristics is significant in the pursuit of effective cervical cancer treatments. While current preventive vaccines are effective against the most oncogenic forms of HPV, most women who will develop cervical cancer are older than the recommended age for vaccination and will not be protected. The TCGA findings confirm that a notable portion of cervical cancers are formed from other factors not related to HPV. This signals the need for new cervical cancer treatments that specifically target genomic alterations and are effective for women regardless of age.  

TCGA researchers have already begun looking at the potential applications of the research for cervical cancer treatment. During the same study, researchers examined the tumors with genomic alterations to discover whether any alterations were particularly amplified. Amplification can predict genetic responsiveness to immunotherapy, a treatment which is becoming an increasingly important component of general cancer treatments. Ultimately, several of the alterations were amplified enough to be considered effective potential immunotherapy agents, including some alterations involving the gene BCAR4, which has been shown to respond to certain breast cancer immunotherapies

9 March2017

NICU Clinical Trial Studies Probiotics Use to Prevent NEC

Sheridan Clinical Research is participating in a multicentered, randomized, double-blind clinical trial using an Investigational probiotic for the prevention of necrotizing enterocolitis (NEC) in premature infants. The research is sponsored by Sigma-Tau Pharmaceuticals, Inc.  Sheridan’s NICU Medical Director Mitchell Stern, MD, is the Principal Investigator for the Phase Ib/IIa trial being conducted at Plantation General Hospital in Plantation, Florida, to study the safety and efficacy of once-daily dosing of STP206 in premature very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates to decrease the incidence of NEC.

NEC is the most common serious acquired disease of the gastrointestinal tract in preterm infants. The majority of NEC occurs in infants weighing less than 1500 g at birth. It affects the bowel of premature infants in the first few weeks of life and has been reported to occur in approximately 10 percent of VLBW infants, although the incidence varies among countries and neonatal centers. The mortality rate of VLBW infants with NEC is approximately 20 percent. In addition, infants with NEC often require surgical intervention, have an increased rate of complications related to total parenteral nutrition (TPN) and require extended hospitalizations. In a study by National Institute of Child Health and Human Development Network (NICHD) published in JAMA in 2004, researchers also found an increase in neurodevelopmental impairment rates among infants with NEC and sepsis.

A 2010 analysis of previous clinical trials, published in Evidence-Based Child Health, found that the use of probiotics, dietary supplements containing potentially beneficial bacteria or yeast, reduces the occurrence of NEC and death in VLBW premature infants, but that there was insufficient data on the benefits and potential adverse effects in ELBW neonates.

The four-year Phase Ib/IIa clinical trial is intended primarily to assess the safety and tolerability of once-daily dosing of two dose levels of an investigational probiotic versus control in four different birth weight strata in premature neonates. Plantation General Hospital’s NICU has historically been involved in multiple trials with Dr. Stern as the Principal Investigator. For the current probiotic trial, Dr. Stern has had the highest enrollment for cohort 3b, which closed in May 2016, and was one of the highest enrollers for newly closed cohort 4a.

As Jessy Tharakan, NNP, knows very well, obtaining informed consent for clinical trials in the NICU setting is particularly challenging, because the patient population is both delicate and vulnerable. As the authors of the 2014 Pediatrics Perspectives article “Honesty, Trust and Respect During Consent Discussions in Neonatal Clinical Trials” wrote, “Participation in neonatal clinical trials is often viewed as risky, ethically challenging, burdensome for parents, and a favor that altruistic families are performing for future generations of babies.” But they pointed out that the consent process also can empower and reassure families, as long as certain conditions are met. For example, the investigators and clinicians must believe that the research is both safe and important and must agree that participation in the proposed research would be meaningful and safe for each prospective participant. And the research team should strive for an open, trusting relationship with the parents and enable them to make an informed decision about what is best for their baby, rather than focusing on getting the consent form signed. 

 

 

 

 

 

 

 

 

 

Kochuthresia (Jessy) Tharakan, NNP with Mitchell Stern, MD 

 

21 February2017

Research Recommends Continued Breast Cancer Screening Mammography for Older Women

New research about the appropriate age limit for breast cancer mammography screenings, presented at the Radiological Society of North America’s annual meeting late last year, challenges current conventional recommendations. While the U.S. Preventive Services Task Force (USPSTF) recommends that women undergo screenings every two years until age 74, researchers from the University of California at San Francisco assert this age limit may be arbitrary after finding that the precision of breast cancer mammography screening, and thus the rate of cancer detection, increases significantly as women age.

Pulling from the American College of Radiology National Mammography Database, the research team examined 5.7 million mammography screenings from 2.6 million women 40 years or older. The team found the average national cancer detection rate to be 3.74 per 1000 screenings, while the average recall rate of screenings leading to a call-back for additional workup was 10 percent. Further, the rate of cancers found in cases recommended for biopsy was 20 percent, and the rate of cancers found in women who underwent biopsy was 29 percent.

Next, researchers stratified the data into five-year age groups to identify any trends. They found that the recall rate decreased progressively every decade and that detection rates increased progressively with age. The team concluded that doctors should continue to recommend mammography screenings for women 75 years and older if it is medically appropriate based on preexisting conditions and life expectancy.

This conclusion coincides with growing evidence of high breast cancer incidents in older women. A similar study published in the May 2015 edition of the American Journal of Roentgenology found a significant detection of carcinomic and invasive breast cancer tumors in women 75 years and older at a rate of 5.9 per 1000 screenings. While detection rates for older women seem to have recently decreased, as the American Cancer Society states in its 2015-2016 report, almost 58 percent of all breast cancer deaths occur in women older than 65. Within this same group, women 80 years or older make up 46 percent of all deaths. 
 
Ultimately, at a time when the medical community is questioning the effectiveness of screening mammography, research still supports the necessity of continued, quality preemptive care for all – and especially older – women.

16 February2017

No Link Between Maternal Influenza and Increased Autism Risk for Children

Current research by the Center for Disease Control and Prevention estimates that autism spectrum disorder (ASD) affects about 1 in 68 children in the United States. While the exact causes for ASD are not yet known, previous and now widely discredited scientific research contributed to the popular belief that vaccinations can cause the disorder. Despite new research that increasingly disproves any potential link, this belief continues to linger. To further investigate a possible connection, a recent study published in JAMA Pediatrics examined the association between maternal influenza vaccination during pregnancy and an increased risk of ASD for children.

For this cohort study, researchers from Kaiser Permanente Northern California examined the mothers of 196,929 children born at Kaiser Permanente between Jan. 1, 2000 and Dec. 31, 2010. Influenza was diagnosed in 0.7 percent of the women with a gestational age of at least 24 weeks, and 23 percent of these women received an influenza vaccination during the remainder of their pregnancy. After adjusting for covariates, the team found there to be no substantial link between a mother’s vaccination for influenza during her pregnancy and the subsequent development of autism in her child. 

Overall, only 1.6 percent of children in the study were diagnosed with ASD. However, in a trimester-specific analysis, there was a slight correlation between first trimester influenza vaccination and an increased risk of ASD for children. While the researchers ultimately determined that this correlation could be due to chance, the possible increased risk in the first trimester suggests additional research is needed. 

Based on their findings, the research team has not called for any changes to influenza vaccine policy or practice for pregnant women. Their research supports current medical recommendations that all women receive the influenza vaccine when pregnant, as the weakened state of a pregnant woman’s immune system increases a child’s susceptibility to short- and long-term risks such as premature birth, low birth weight and illness in early life. Further, studies show that maternal infections that occur and are not treated during pregnancy can increase the risk of ASD for children. 

7 February2017

Grand Strand Medical Center Adds Neonatology Program

Grand Stand Medical Center in Myrtle Beach, South Carolina has launched a new neonatology program that has been in the works for about a year. The hospital is working to recruit two permanent, local neonatologists. Until those positions can be filled, neonatologists from other counties in South Carolina are working at the hospital, making Grand Stand Medical Center the only hospital in Horry County to have a neonatologist either in the hospital or on-call at all times.

Dr. Art Shepard, the Sheridan neonatologist who worked on staff at the hospital during the first week of the new program, told local ABC News affiliate WPDE that the hospital delivers about 1,000 babies a year, and that 8-10 percent of all babies need specialty neonatal care. “If babies need respiratory support or prolonged tube feeding, for example, because they're early those babies would ordinarily have to go to [a NICU in] Charleston or Florence, and so that's about a hundred babies a year that have to leave just for those reasons," Shepard said. Because Grand Strand has a level II nursery and not a NICU, he explained, some seriously ill babies will still need to be transported to either the Florence or Charleston NICUs.

"We can take care of babies as young as 32 weeks gestational, so about 8 weeks early, we can take babies that are as small as 1500 grams at birth, which is about 3 1/2 pounds, and we can maintain babies on mechanical ventilation for as long as 24 hours,” he continued. “If babies are smaller than that, less mature than that, or require more respiratory therapy than that, they still need to go to the regional perinatal center."

Both Shepard and OB/GYN Dr. Tracey Golden are excited that more babies will be able to be treated locally, near their mothers and families. "We are looking forward to the opportunity to keep those babies here. Keeping babies and moms together is so important. It's important to facilitate breast feeding, we want to encourage that. And keeping families together is the best way to get a family off to a healthy start," Shepard said. Golden added, "It's priceless, because unfortunately the NICUS are at least an hour and a half to two hours from this local region, and for many families that means they're taken away from their other children or their support network."

Emerald Rabon, who has a high-risk, complicated pregnancy, is comforted by the availability of a neonatologist at the hospital. “I'm going to be delivering really early, and she's going to be super small and not as developed, so that's even more scary," she told WPDE. After meeting with Dr. Shepard, she was reassured to learn that even if her baby girl arrives weeks early, there’s a good change she will be able to remain in Myrtle Beach. "You think of a pregnancy and the baby just pops out and they're doing great and mine is going to be hooked up to machine and tubes going in and out of her. It's scary," she said. 

31 January2017

Learning Health System (LHS) Pilot Saved Nationwide Children’s Hospital $1.36 Million in 12 Months

Researchers from Nationwide Children's Hospital and The Ohio State University (OSU) found that a learning health system (LHS) pilot program at Nationwide combining tailored electronic health records system entry, care coordinators and evidence-based clinical data and research reduced total inpatient days by 43%, reduced inpatient admission by 27%, reduced ER visits by 30% and reduced urgent care visits by 29% during the first year. Per a recent article in HealthLeaders Media, those reductions generated an impressive $1.36 million savings in health care costs during the 12-month period in 2010 and 2011.

The National Academy of Medicine’s Learning Health System Series defines a learning health system (LHS) as a system in which “science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience.”

The findings by the team of Nationwide and OSU researchers were published by the journal Developmental Medicine and Child Neurology. The study authors said they “developed, implemented, and evaluated a model of EHR-supported care in a cohort of 131 children with cerebral palsy that integrated clinical care, quality improvement, and research, entitled ‘Learn From Every Patient’ (LFEP).“ A multidisciplinary team of key stakeholders was recruited for this pilot program, which was designed to fully integrate research, clinical care and quality improvement. 

The findings were also cited in an editorial published in JAMA, which said the LFEP pilot included initial standardized care for all patients, both evidence-and expert opinion-based; routine clinical data collected in the EHR as discrete data fields and data elements (categories and choices within those categories, respectively); physician-inspired research data collection in the EHR; content-specific quality control of EHR data entry; and provision of standard care coordination. Per the HealthLeaders Media article, special data entered into the patients' EHRs was used to coordinate care, with the goal of reducing treatment duplication and errors. LFEP data were extracted into an Epic Clarity enterprise data warehouse, which also housed billing information, and providers used clinical documentation templates created in Epic that presented them with a prioritized list of research questions designed to drive specific improvements in clinical care.
 
The HealthLeaders Media article also said the total cost of implementing the pilot program, including care coordination services, was about $225,000 during the first year; but since that represented only 16% of the reduced health care costs during that same year, the program yielded savings of roughly $6 for every $1 invested. And the study authors believe that similar programs could yield even greater potential healthcare system savings in adult patients, since the chronic conditions of the children with CP resemble those of chronic multi-symptom conditions in adults.
 
For hospitals and health systems considering investing in learning health systems, the National Academy of Medicine discussion paper “Generating Knowledge from Best Care: Advancing the Continuously Learning Health System” provides strategies and examples of operational and research collaborations within U.S. delivery system settings.

24 January2017

Strategies to Provide Neuroprotection for Preterm Infants

Neuroprotection for preterm infants can be one of the most important aspects of care provided to preterm neonates, yet it is sometimes overlooked because the providers are focused on other health issues. It is also essential that neuroprotection for preterm infants be done correctly to avoid causing lifelong struggles for both the babies and their families. A recent article in Neonatal Network, “Neuroprotection of the Preterm Infant,” co-authored by Sheridan Doctor of Nursing Practice (DNP) and Neonatal Nurse Practitioner (NNP) Abby Kaspar, offers simple strategies that providers and nurses can use to provide effective neuroprotection for premature infants.

The article defines neuroprotection as “strategies or interventions…used to prevent cell death and promote normal development.” This is done by supporting the developing brain or by facilitating the development of new connections and pathways for functionality and by decreasing neuronal death. These strategies are necessary to prevent intraventricular hemorrhage (IVH) and other brain injuries in very small, immature infants who are born preterm. Preterm infants who develop a severe IVH have an increased chance of mental retardation, cerebral palsy, seizures and/or hydrocephalus, and even preterm infants with milder IVH can have developmental difficulties. Since most IVHs occur within the first 24-48 hours of life, neuroprotection should be provided as soon after birth as possible. 

Fetal and Neonatal Neuroprotection Strategies

Neuroprotection strategies, which can be implemented during the prenatal or postnatal period and include organizational, therapeutic and environment-modifying measures, may protect fetuses and newborns from developing IVHs and cerebral ischemia.

One fetal neuroprotection strategy the authors recommend is administration of betamethasone to the mother at least 24 hours before preterm delivery. Betamethasone is a corticosteroid that protects the development of blood vessels in the germinal matrix of the infant’s brain or inhibits prostaglandin synthesis. It also helps an infant’s lungs mature, which can reduce the incidence of respiratory distress syndrome (RDS). If the mother tolerates it, continuous magnesium sulfate infusion during the same can decrease the likelihood that the infant will have an IVH.

Routine caregiving activities (e.g., diaper changes, endotracheal tube repositioning, other minor manipulations) performed on critically ill preterm infants has been shown to be associated with major circulatory fluctuations that can lead to IVH. The authors recommend supine positioning of preterm neonates and midline positioning of their heads, a position that favors cerebral venous drainage, prevents an elevation of cerebral blood pressure and increased flow, and may increase cerebral oxygenation. Another recommendation is keeping the head of the bed either flat or slightly elevated and keeping the infant’s head midline, which has been shown to decrease intracranial pressure.

Other recommendations for neuroprotection of preterm infants:

  • Keep the baby’s hips and legs lower than his or her head during diaper changes to avoid increasing intracranial pressure and maintaining a neutral thermal environment, since hypothermia has been associated with IVH.
  • Keep lighting and noise levels low and handle the infant as little as possible to minimize stress and overstimulation, which can increase blood pressure and, consequently, cerebral blood flow, which can lead to IVH.
  • Provide swaddling and pain medication to minimize crying, which can impede blood return from the brain, increase cerebral blood flow and decrease cerebral oxygenation.
  • Infuse fluid boluses or hyperosmolar solutions slowly or dilute the solution to avoid potential swelling, thinning and/or fluid reduction in the vessels in the fragile germinal matrix that can cause them to rupture, eventually leading to IVH.
  • Limit endotracheal tube suctioning, which can increase cerebral blood flow and intracranial pressure and has been associated with increased incidence of IVH.
  • Maintain a partial pressure of carbon dioxide (PC02) greater than 30 mmHg, keep peak inspiratory pressures (PIP) less than 30 cm H20 and keep the mean airway pressure (MAP) less than 12.5 cm H20.

19 January2017

Integrating Telemedicine Responsibly

Providers and patients alike view telemedicine as an increasingly important healthcare delivery modality. Per a recent article in Medical Economics, “How to balance telemedicine advances with ethics,” the American Telemedicine Association (ATA) reports that more than half of all U.S. hospitals use some form of telemedicine; and IHS Technology predicts the number of patients using telehealth services will jump from fewer than 350,000 in 2013 to 7 million in 2018.

But this modality can also be challenging to implement responsibly.

Telehealth Benefits

The dramatic growth of telemedicine is driven by its ability to further the goals of the “quadruple aim” framework for value-based care.

More Efficient Care

The recent American Hospital Association (AHA) issue brief on telehealth cited several examples of significant telehealth-driven savings, including the Veterans Health Administration’s “nearly $1 billion in system-wide savings associated with the use of telehealth in 2012.” A major contributor was the dramatic decrease in hospitalizations.

In addition, doctors who offer telehealth services can spend more time caring for additional patients – time that otherwise would have been spent traveling between offices or facilities.

Better Outcomes

The AHA brief also describes the efficiencies and improved outcomes resulting from the innovative Hospital at Home (HaH) care model developed by Johns Hopkins researchers. HaH is being used effectively to provide hospital-level care at home in place of acute hospital care for older adults. Per the brief, “When a patient is treated at home, clinical staff travel to the home as needed to provide treatment, while telehealth is used to monitor the patient’s condition and enable daily meetings with the physician.” According to the program’s website, HaH patients experience better clinical outcomes, higher patient and family satisfaction, reduced caregiver stress and better functional outcomes compared to similar hospitalized patients.

Expanded Access to Care

Traveling to medical facilities can be a hardship for people who are physically challenged/housebound, live far from the nearest medical center or cannot afford to take time off from work. The ability to meet with a clinician remotely via a secure audiovisual device or application can mean the difference between those patients seeking – and getting – the care they need versus going without.

More Convenient Care

While it’s early days yet, “virtual visits” are beginning to be offered for more and more types of medical care. For example, St. Vincent Heart Center in Indianapolis is piloting a telecardiology program, per a recent article in Cardiovascular Business.

There is also increasing demand by health care consumers for “at home” virtual visits. A recent ATA-WEGO Health survey of active health care users found that consumers are very interested in using telehealth to complement (or even replace) their in-person care, primarily because of convenience. Other commonly cited reasons included scheduling conflicts and issues with transportation. 

Expanded Access to Specialized Clinical Expertise

Many small or rural hospitals often don’t have the budget or volume to support staffing a range of staff specialists or subspecialists. Even hospitals that have the budget may be in areas that make it difficult to recruit those types of physicians.

Dr. Lynn Palmeri, National Medical Director of Telehealth for Sheridan’s Women’s and Children’s Division, explains that telehealth carts can allow doctors at these facilities to consult remotely with specialists or subspecialists as needed. For example, an obstetrician may see an expectant mother with high-risk findings that require her to be referred out to see a perinatologist. Rather than having the mother drive three or four hours to the nearest perinatologist – potentially putting her and her baby at even greater risk – the obstetrician could have a remote telehealth consult with the subspecialist to determine whether the mother can be given appropriate care locally with the help of follow-up telehealth consults with the perinatologist.

Telemedicine is equally valuable in emergency medicine. Physicians in the adult emergency department (ED) at Jupiter Medical Center consult remotely with neurologists at the Cleveland Clinic using a telehealth cart approximately 10–30 times per month, most often to expedite implementation of tissue plasminogen activator (tPA) therapy for stroke patients.

Sophisticated telemedicine robots can allow remote specialists and subspecialists to perform much more in-depth examinations. Dr. Palmeri says “there are robots with sensors that can, for example, allow a neonatologist to remotely inspect a patient, auscultate bowel, breath and heart sounds, examine a neonate’s eyes for retinal findings, and even palpate to see if there is abdominal pathology or edema. These patient care modalities augment the in-person physical examinations by the nurse and neonatal nurse practitioner at the bedside.”

Radiology’s many subspecialties make it a prime candidate for expanding access to highly specialized clinical expertise remotely while also increasing efficiency. For example, Sheridan’s distributed teleradiology network includes hundreds of the country’s best radiology subspecialists who can provide hospitals of any size with affordable, 24/7/365 coverage and faster turnaround times for final reads. 

Challenges to Responsible Implementation

The promise of telemedicine is exciting, and pertinent logistical and quality matters will be ensured prior to its implementation and expansion.

Protecting Patient Privacy

Maintaining patient confidentiality is a cornerstone of ethical medical practice. Telemedicine systems will be HIPAA-compliant and hospitals must make data security a top criterion when selecting robot cart and software options.

Maintaining Care Quality

The same standards of care must be maintained regardless of the delivery modality, and that’s a key challenge of telemedicine. The American Medical Association (AMA) released its Guidance for Ethical Practice in Telemedicine in June. In the policy announcement, AMA Board Member Jack Resneck, M.D. said, "Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions. The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians' fundamental ethical responsibilities do not change.” The AMA also released its Principles to Promote Safe, Effective mHealth Applications in November. 

Telemedicine can make continuity of care challenging, especially when patients seek care from doctors who are not affiliated with their primary care physicians or who use different EHRs. But in some situations telehealth can improve care continuity. “In a pediatric unit, for example, an attending physician might see the baby during morning rounds, but by the time the parents can come to the hospital that evening after work that physician’s shift may have ended and the parents may not speak directly to that same doctor,” explains Dr. Palmeri. “Telemedicine has the potential to overcome those types of scheduling conflicts so that parents can speak with the doctor ‘face-to-face’ through the telemedicine robot screen whenever needed.”

Telehealth will play an increasingly important role in care delivery and physicians will carefully adopt remote care technology in a manner that ensures patient safety and privacy.

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