A retrospective review of telehealth services for children referred to a paediatric nephrologist.

BACKGROUND: Telemedicine has emerged as an alternative mode of health care delivery over the last decade. To date, there is very limited published information in the field of telehealth and paediatric nephrology. The aim of this study was to review our experience with paediatric telenephrology in Queensland, Australia. METHODS: A retrospective audit of paediatric nephrology telehealth consultations to determine the nature of the telehealth activity, reasons for referral to telehealth, and to compare costs and potential savings of the telehealth service. RESULTS: During a ten-year period (2004 - 2013), 318 paediatric telenephrology consultations occurred for 168 patients (95 male) with the median age of 8 years (range 3 weeks to 24 years). Congenital anomalies of the kidney and urinary tract (30 %), followed by nephrotic syndrome (16 %), kidney transplant (12 %), and urinary tract infection (9 %) were the most common diagnoses. The estimated cost savings associated with telehealth were $31,837 in 2013 (average saving of $505 per consultation). CONCLUSIONS: Our study suggests that paediatric telenephrology is a viable and economic method for patient assessment and follow up. The benefits include improved access to paediatric nephrology services for patients and their families, educational opportunity for the regional medical teams, and a substantial cost saving for the health care system.

Challenges of the capacity evaluation for the consultation-liaison psychiatrist.

Assessing medical decision-making capacity is a clinical skill required of all medical professionals, but it is particularly essential for consultation- liaison psychiatrists. Medical decision-making capacity, often confused with competency, is evaluated by assessing 4 standards, which include whether a patient (1) can understand his or her medical situation, (2) can manipulate the information, (3) can evidence a choice about the proposed treatment, and (4) can appreciate the situation and its consequences. Multiple myths and pitfalls may be encountered during capacity evaluations; many of these can be avoided by proper education and training. We discuss the case of a 71-year-old man who presented to the emergency department by ambulance and was refusing non-emergent neurosurgery after a self-inflicted gunshot wound to the head. He was evaluated for medical decision-making capacity, specifically on whether he had the capacity to refuse neurosurgery and accept intravenous antibiotic treatment. In discussing this case, which illustrates the elements, challenges, and ethical dilemmas of the capacity evaluation, we review several mental illnesses that may prevent individuals from having medical decision-making capacity. Myths and pitfalls of capacity evaluations and possible methods for avoiding them are proposed. Specifically, we emphasize the importance of communication between the primary team and the consultationliaison psychiatry service and describe possible solutions to common communication problems that may arise between services. It is hoped that this case presentation and review will help educate psychiatry residents and other physicians so that they are well prepared to perform a medical decision-making capacity evaluation.

Multi-site videoconference tutorials for medical students in Australia.

BACKGROUND: About two-thirds of medical students are distributed among the major metropolitan tertiary teaching hospitals in Queensland, while the remainder are sent to regional hospitals up to 500 km away. The aim of this study was to investigate the feasibility and effectiveness of conducting surgical tutorials via videoconferencing (VC) for medical students undertaking at remote hospitals. METHODS: Surgical tutorials were offered to final-year medical students at the Royal Children's Hospital (RCH) in Brisbane and shared by VC to students undertaking clinical placement at nine remotely located hospitals in Queensland. We have conducted a retrospective review of service activity, student satisfaction and subject scores from 2008 to 2010. The main outcome measures were VC activity, medical students' satisfaction and student exam results pre- and post-introduction of the surgical tutorial programme. RESULTS: Between March 2009 and November 2010, a total of 57 VC tutorials were conducted during nine rotations for a total of 669 students. Approximately, 35% of students (236) attended tutorials face-to-face at the RCH while the remainder (including those at the Mater Children's Hospital in Brisbane and eight regional sites) participated via VC. A snapshot survey to measure satisfaction of both groups of students showed that overall satisfaction was very high. A total of 299 students completed the paediatrics and child health multiple-station assessment task exam in 2008, 326 in 2009 and 382 in 2010. The pre-intervention (tutorials not delivered by VC) median scores (interquartile range) of surgical and non-surgical questions were 5 (4-6) and 23 (21-25). Post-intervention, surgical scores increased significantly to 6 (5-7) (P < 0.001), while non-surgical scores remained similar at 23 (21-25) (P = 0.64). CONCLUSIONS: Our study demonstrates that VC is a feasible and effective method of engaging medical students regardless of their location. VC provides equitable access to medical teaching for medical students undertaking remote clinical placements.

Humour sans frontieres: the feasibility of providing clown care at a distance.

Clown care has been shown to have health-related benefits and is a well-established part of the routine in many children's hospitals. However, children who have been admitted to general hospitals or who are being cared for at home cannot usually enjoy visits by Clown Doctors. Therefore, the aim of this work was to investigate whether an existing telemedicine network could be used to improve equity of access to humor for sick children, specifically those who are hospitalized away from the nearest clown-enabled hospital or who are being cared for at home. Using videoconferencing, we conducted regular clown outreach links from The Royal Children's Hospital in Brisbane, Australia, to children in regional hospitals and to sick children in their homes. Using a program of performance, which was modified for delivery by videoconference, teleclowning was found to be feasible. Further work is required to determine whether the health-related benefits that accrue from in-person clowning are successfully translated to the video-based modality.

Clinical services and professional support: a review of mobile telepaediatric services in Queensland.

In Queensland, the majority of rural hospitals and some regional hospitals lack paediatricians or paediatric sub-specialists. Many specialist referrals result in a transfer to a tertiary paediatric hospital in Brisbane--up to 3000 km away. Travel is difficult, time-consuming and expensive, especially from rural and remote areas in Queensland. The telepaediatric service managed by the Centre for Online Health (COH) at the Royal Children's Hospital (RCH) in Brisbane, delivers general and specialist paediatric support directly into selected neonatal and paediatric wards in a convenient and child-friendly manner. We conducted a review of telepaediatric service records to determine which clinical and educational services had been delivered through the mobile videoconference systems. Telepaediatric service activity records for all consultations conducted between January 2005 and July 2010 were summarised.Since 2005, seven mobile telepaediatric systems have been established in selected regional hospitals throughout Queensland. For some hospitals, the service was used mainly for consultations with specialists based at the RCH or at The Townsville Hospital (TTH) in north Queensland. During a 67 month period, a total of 966 consultations were conducted during 465 videoconference sessions, totaling about 228 hours of activity. In addition, 39 education sessions were delivered to regional staff through the mobile robot systems by specialists based at the RCH in Brisbane. The telepaediatric robots have proven useful for general paediatric support for hospitals without a local paediatrician; sub-specialist paediatric support and professional education and support for regional clinicians. Our service model provided a streamlined method of delivering specialist health services to children and families living in rural and remote regions of Queensland.

Improving heart failure symptom recognition: a diary analysis.

BACKGROUND: Heart failure (HF) is a costly and highly disabling syndrome affecting nearly 5 million individuals yearly. Lifestyle changes are crucial to the successful management of HF, and daily weight monitoring is an essential component of self-care. Daily weights provide an objective indicator of fluid volume status in patients with HF. However, the practice of performing daily weights is underappreciated and infrequently implemented by patients. This may contribute to an inability to recognize worsening HF and, ultimately, delay in seeking medical care. OBJECTIVE: The aim of this study was to evaluate weight monitoring diaries for adherence to daily weight monitoring, reasons for nonadherence, prevalence of weight gain of 3 lb or more in 1 day, and medical advice-seeking behavior after weight gain in a sample of patients with documented HF. METHODS: A cohort study design was used to analyze data from 20 HF patients who participated in a tailored, one-on-one educational intervention. The analysis is part of a parent pilot study designed to improve symptom recognition and response to symptoms of fluid overload. Diary data were collected for 3 months after the intervention. The diaries provided information regarding symptoms that participants experienced, daily weights, and a record of unplanned hospital visits or contacts with their physician. RESULTS: Of 20 participants in the study, 16 returned diaries for analysis. Two participants withdrew participation before the conclusion of the study and 2 participants who claimed to have completed their diary never returned the diary despite repeated reminders and telephone calls. Sixteen participant diaries were therefore available for analysis. The mean adherence score for these 16 participants was 79.4%. Seventy-five percent had weight gains of 3 lb or more in 1 day and only 1 person contacted his/her physician for weight gain. Vacation time was the most common reason for weighing nonadherence. CONCLUSION: This study revealed high adherence to daily weights in patients receiving an education session focused on fluid weight management. However, behavior related to daily weights did not lead to more appropriate use of physician or provider consultation. Diaries offer promise for symptom management and an opportunity for patients to engage in self-care; however, clinicians need to encourage patients to use the diary data to seek prompt medical care.

Psychosocial impact of the implantable cardioverter defibrillator: nursing implications.

Sudden cardiac death (SCD) remains a significant problem despite an overall reduction in other cardiac related deaths in recent years. Research supports the use of the implantable cardioverter defibrillator (ICD) as an effective means of treating dangerous ventricular tachydysrhythmias to prevent SCD. The issue that demands increasing attention is the psychologic experience of ICD recipients. Although the ICD is clearly a technological success, there is evidence that recipients experience strong physical and emotional reactions to the device. Such quality of life issues are worthy of a multidisciplinary effort directed at facilitating patient acceptance and adaptation to technology that although potentially life-saving, may also be unpredictable and anxiety provoking.