I．Introduction

Pediatric critical care is resource-intensive and demands meticulous process control. The complexity of pediatric intensive care unit（PICU） support has increased due to advances in surgical interventions and treatment modalities. The need for the PICU is continuously increasing, but the current number of pediatric intensive care physicians, nurses, and comedical staff in Japan is inadequate to meet the demand.

Intensive care unit telemedicine （tele-ICU, so called eICU） is technology-enabled care delivered from off-site locations and was developed to address the increasing complexity of patient care and the inadequate number of intensivists^［1］. Tele-ICU/eICU has rapidly expanded in adult ICU treatment, but has lagged behind in the PICU.

In this present study, we developed the first eICU system for children and aimed to evaluate the usefulness of eICU system in pediatric critical consultation.

II．Materials and methods

The first eICU system was developed as a collaborative effort between TMCMC and Tama- Hokubu Medical Center（THMC） using a public grant from the Tokyo Metropolitan government and was installed at Tokyo Metropolitan Children’s Medical Center（TMCMC） in 2010. A video conference unit was installed in the PICU at TMCMC using four monitors to display the patients’ appearance, biological information, radiological images, and selected information from the electronic medical records（data were restricted to protect patients’ personal information） （Fig. 1）. A mobile, pole-mounted telemedicine unit was placed in the pediatric ward at THMC（Fig. 2）.

This system was used to deal with 15 cases（22 events） during the project period（2011-2013）. We analyzed case backgrounds, purpose of usage and efficacy of this eICU system. Also we herein describe the typical case of one patient whose treatment clearly demonstrated the effectiveness of this eICU system. This is the first report describing the usefulness of the eICU system in pediatric critical care consultation in Japan. This study was approved by the ethics board of the Medical Research Committee of TMCMC. Publication of the study was approved by the Institutional Review Board of TMCMC.

III．Results

15 cases （22 events, 0 months-18 years, mean age 4 months） used eICU were observed during this project period（2011-2013）. Case background, purpose of usage and efficacy of eICU was summarized in Table 1. 6 cases（9 events, 41%） were consultation only, however, 7 cases（7 events, 32%） required interhospital transfer from pediatric general ward in THMC to PICU in TMCMC. Within 7 transferred cases, 4 cases were transferred in emergent fashion by the transfer team dispatched from TMCMC. 6 events were used for follow up rounds after the discharge from PICU/NICU in TMCMC to general ward in THMC. Typical case description was as below.

A 2-month-old boy was admitted to the pediatric general ward of THMC due to respiratory difficulty. Bronchiolitis caused by rspiratory syncytial virus infection was diagnosed. His respiratory condition deteriorated, and he was intubated by pediatricians at THMC. Consultation was later held via the eICU system in the PICU at TMCMC.

Since the patient had straightforward bronchiolitis, the THMC physicians initially opted to continue treatment at THMC; however, the intensivists at TMCMC decided that the patient should be transferred to the PICU at their institution due to his unstable, nonsynchronized respiratory pattern on the ventilator, which was visualized by the eICU system. A transport team was dispatched from TMCMC to receive the patient.

The patient’s chest X-ray images were transmitted via the eICU system, and the endotracheal tube（ETT） position was confirmed and adjusted. The dosage of sedative was increased, and the ventilator settings were adjusted to stabilize the patient. Serial changes in his respiratory pattern were monitored via the eICU system. Physicians at TMCMC were continuously updated on the patient’s status by the transport team during transit using a different communication modality.

Before the transport team arrived to receive the patient, his respiratory condition had improved, and preparation for PICU admission was complete. He was transported successfully and admitted to the PICU at TMCMC without further event.

IV．Discussion

ICU telemedicine programs now support 11% of critically ill adult patients in private hospitals worldwide. There is increasingly robust evidence of an association between the use of ICU telemedicine programs and lower ICU and hospital mortality and shorter ICU length of stay^［2］. The use of telemedicine is increasing and will eventually be common even in remote emergency departments, inpatient wards, and intensive care units for pediatric care^［3］.

Dharmar et al. reported that physician-rated qualityof- care for children was higher for patients who received consultations via telemedicine than for patients who received either telephone consultations or no consultation at all. Telemedicine consultations for sick children were associated with more frequent changes in diagnostic and therapeutic interventions and higher parent satisfaction than telephone consultations ^［4］.

In the present case, the referral decision was expedited, critical care management（ETT position, sedative dosage, ventilator settings, etc.） improved, and the time required for treatment was generally shortened（prompt dispatch of transport team, swift admission preparation, etc.） as a result of improved time management. The overall improvement in critical care management was remarkable.

Although many studies have supported the use of telemedicine/eICU, and the facts described in this case report underscore the findings of these studies, several obstacles to the further expansion of eICU remain. The high cost and technical difficulties with the use of the current system are examples of such barriers. However, the reduction in personnel expenses and the superior time-efficiency allowed by the eICU system compensate for its higher cost while the current technical difficulties will doubtless be resolved through improvements in the technology.

Network security and privacy protection are also frequently pointed out as potential problems, and are major obstacles to the expansion of this program in Japan. These issues need to be resolved for the future expansion of the telemedicine/eICU program in Japan.

Author contributions

NS conceived and designed the study, collected, analyzed, and interpreted the data. NS, TO, OS, and TI were involved in writing and reviewing the manuscript.

Acknowledgements

I would like to thank Mr. Yoshihiro Shindo for his assistance with developing eICU systems in TMCMC. I also would like to thank Mr. James Robert Valera for his assistance with editing the manuscript.

Conflict of interest

The authors declare that they have no conflicts of interest, either financial or non-financial, with the context of this article, except for the public grant from Tokyo Metropolitan.