A Lifeline for Newborns in Need
Erika*, an obstetrics nurse for just over a year, received the call around 3:00 am: An ambulance was on its way to her rural Northern New England hospital with a woman in preterm labor. Up until that point it had been a typical night, with a bare-bones labor and delivery (L&D) staff of one other obstetrics nurse on the floor and a third nurse on-call. When the patient arrived on a stretcher, bearing down and pushing, the hospital’s midwife, obstetrician, and pediatrician were all still en route. Erika examined the patient and saw the baby’s head.
“At that point I thought that there was going to be a baby born right into my hands,” Erika says. “Which would have been my first delivery.”
Then the patient’s contractions stopped, and the baby’s head was no longer visible. Erika had a window of opportunity, and she used it to call into Dartmouth Hitchcock Medical Center’s TeleIntensive Care Nursery (TeleICN).
Filling a growing need
The Children’s Hospital at Dartmouth Hitchcock Medical Center (CHaD) is New Hampshire’s only comprehensive, full-service children’s hospital. In its intensive care nursery (ICN) critically ill infants from throughout the region receive expert, high-quality care. But what happens when babies need urgent, expert care before they’re at Dartmouth Hitchcock Medical Center (DHMC)?
Since 2018, DHMC has been offering TeleICN services to critical access and community hospitals throughout Northern New England. Using a secure app that ensures patient privacy, board-certified DHMC neonatologists are able to join local bedside teams from their phones, tablets, or computers to provide around-the-clock, real-time assessment and treatment recommendations through telemedicine. Today, nine sites in New Hampshire and Vermont are either utilizing the service or in the process of implementing it. TeleICN is one of eight telemedicine services offered by DHMC's Connected Care.
TeleICN fills a growing need in the region. In New Hampshire, where birth rates are declining, Medicaid reimbursement rates are low, and obstetricians are scarce, 10 hospitals have closed their L&D units since 2000. That means pregnant women are traveling farther from home for their care and, in some cases, giving birth in the closest emergency room. To address these challenges, TeleICN is available to L&D units and to emergency departments.
Michelle Tyler, MD, a neonatologist at CHaD and an assistant professor of pediatrics at the Geisel School of Medicine, says, “This service is so helpful to local providers who could use support and assistance with sick newborns. It takes a long time to travel places in such a rural region and the TeleICN connection allows us to better manage patients until our team can get to them.”
Cheshire Medical Center in Keene, N.H., was the first site to utilize DHMC’s TeleICN services in 2018. Pictured here are pediatrician Deborah Hansen, MD, and Logan F., RN. Photo by Mark Washburn
The power of teamwork
In Erika’s case, early contact with DHMC TeleICN allowed her team to prepare for the birth of an extremely preterm infant. “We knew the DHMC neonatologist would lead the resuscitation and the respiratory therapist, pediatrician, and I would be filling various roles,” she says.
They set up the operating room with micro-preemie equipment and positioned an iPad so that the neonatologist would be able to visualize the infant during resuscitation. “We received great feedback in real time. Having a provider more experienced with premature babies was reassuring for us, and helped us be more comfortable with the resuscitation.”
Steve Ringer, MD, PhD, section chief of neonatology and a professor of pediatrics at Geisel, says, “We embarked on TeleICN so we could provide the best possible support. And one of the things that makes this better than we ever imagined is that the neonatologist is in a position of team leader who’s able to look at everything that’s going on. It allows everybody else to focus on taking care of the baby.”
The baby Erika helped deliver was stabilized and transferred to CHaD’s ICN by the Dartmouth Hitchcock Advanced Response Team (DHART) neonatal transport crew. DHART can be looped in to all TeleICN calls, so the team knows what to expect when it gets to a hospital, and local providers know exactly when the helicopter or ambulance will arrive.
Michelle Tyler, MD, neonatologist, trains local providers in the use of telehealth technology through practice calls. Photo by Mark Washburn
Keeping care local
One of the benefits of TeleICN is that it prevents unnecessary transfers. While extremely preterm newborns and other critically ill infants need the life-saving care provided at CHaD, some babies have conditions that can be monitored and treated right where they are. Video capabilities also allow neonatologists to help local providers rule out problems like neonatal encephalopathy—a syndrome in which neurological function is disturbed—that would require treatment in the ICN.
“Before telemedicine, when we provided consults by phone, newborns with suspected encephalopathy were sent to us automatically, which was traumatic for families,” Tyler explains. “It’s so much easier now that we can walk through a neurological exam together with a pediatrician and get a clear sense of what’s going on with a baby. We can reassure providers and families that these babies look perfect and don’t have to come to us.”
And that’s one of the primary goals of TeleICN and all the telemedicine services offered by DHMC: To bring the expertise of an academic medical center to families throughout the region, regardless of where they are. CHaD neonatologists are committed to helping any sick infant anywhere—especially when their involvement means a baby gets to stay in its community and a family avoids the stress and expense of travel to DHMC.
The most important piece for us is just figuring out how best we can help the providers on the ground with that baby. It’s our job to be flexible and to help in whatever capacity they need.”
Accessibility and flexibility
To that end, DHMC has made implementation of TeleICN easy for regional hospitals. Tyler says, “With some telemedicine services you have to outfit an entire room with cameras and other expensive equipment because there’s so much interaction needed. For us, instead of fancy, large equipment, the best solution is an iPad that can be placed right up to the baby.”
While regional providers like Erika hope they never have to use the TeleICN service, they’re grateful to have it. “We took full advantage of the CHaD neonatologist’s experience and will do so again in the future,” she says.
“The most important piece for us is just figuring out how best we can help the providers on the ground with that baby,” Tyler says. “Whether they want us to lead resuscitation, be a second set of eyes, talk with a family, or mobilize a transport team, it’s our job to be flexible and to help in whatever capacity they need."
*Names and some details about this case have been changed to protect patient privacy.
With your help, CHaD's ICN can offer even more to the families in our region. Please contact Polly Antol, Director of Development for Child Health Initiatives, at 603-646-5316 or Polly.Antol@hitchcock.org for more information.