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telemedicine control room

Telehealth and AI reduce cardiac arrest in the cardiac ICU

telemedicine control room

The telehealth command center located a few steps away from the cardiac ICU at Children’s National Hospital.

The cardiac critical care team at Children’s National Hospital has developed an innovative Tele-Cardiac Critical Care model aiming to keep constant watch over the most fragile children with critical heart disease in the cardiac ICU. The system combines traditional remote monitoring and video surveillance with an artificial intelligence algorithm trained to flag early warning signs that a critically ill infant may suffer a serious event like cardiac arrest while recovering from complex cardiac surgery. This second set of eyes helps bedside teams improve patient safety and quality of care.

These high risk post-operative patients are often neonates or small infants born with the most complex and critical congenital heart diseases that require surgery or interventional cardiac catheterization in their first days or weeks of life. At these early stages after crucial cardiac surgery, these patients can decompensate dangerously fast with few outward physical symptoms.

The AI algorithm (T3) monitors miniscule changes in oxygen delivery and identifies any mismatch with a child’s oxygen needs. It also tracks and displays small changes in vital sign trends that could lead to a serious complication. The cardiac ICU command center staff then analyzes additional patient data and alerts the bedside team whenever needed.

The Tele-Cardiac Critical Care program started two years ago. In that time, the program has contributed to a significant decrease in post-operative cardiac arrest for this patient population.

“It’s easy to see how a model  like this could be adapted to other critical care scenarios, including our other intensive care units and even to adult units,” says Ricardo Munoz, M.D., chief of Cardiac Critical Care and executive director of Telehealth. It allows the physicians and nurses to keep constant watch over these fragile patients without requiring a physician to monitor every heartbeat in person for every patient at every hour of the day to maintain optimal outcomes for all of them.”

Dr. Munoz and Alejandro Lopez-Magallon, M.D., medical director of Telehealth and cardiac critical care specialist, presented data from the pilot program at the American Telemedicine Association’s virtual Annual Meeting on June 26, 2020.

telemedicine control room

Telehealth connects pediatric heart experts about critical COVID-19 details

telemedicine control room

Telehealth is more than a doctor-to-patient tool during COVID-19. Experts in congenital heart disease meet weekly to share details about how it affects their vulnerable patients.

During the COVID-19 pandemic, telehealth has been crucial in allowing doctors to maintain safe contact with patients who require ongoing medical care without an office visit. Just as important is the role that telehealth is playing to connect care providers with each other to ensure that everyone around the world has the information they need to provide the best care possible for this swift-moving disease.

One good example of this specialist-to-specialist thought leadership connection is the ongoing weekly meeting hosted by the Children’s National Hospital cardiac critical care specialists. Since early in the spread of COVID-19, the Cardiac-ICU team, led by cardiovascular specialists including Ricardo Munoz, M.D., chief of cardiac critical care medicine and executive director of telehealth at Children’s National, have connected pediatric clinicians around the world to discuss how best to care for particularly vulnerable patients with pre-existing heart diseases, and to discuss breaking news in epidemiology of the disease and the effectiveness of various treatment approaches.

The video conference attracts hundreds of physicians and nurses who specialize in pediatric cardiac care from countries all over the world. In the last week of April, the meeting featured a late-breaking session to discuss new pediatric intensive care observations of inflammatory symptoms similar to Kawasaki disease, which were being detected in the United Kingdom, Paris and the United States. While more information is needed about this discovery, the ability of these experts to gather and compare disease phenotypes from country to country facilitates both the additional classification of pediatric-related symptoms and improves how all centers, no matter their location, can prepare to treat children who present locally with these symptoms.

In recent weeks, cardiac physicians and nurses from some of the world’s hardest hit regions, including Italy and Spain, have shared detailed information about their on-the-ground experiences to help colleagues in the U.S. and elsewhere better prepare for new developments.

“This new disease is a moving target, especially when it comes to understanding how it might impact children and adults with existing cardiac disease, particularly those with congenital heart disease,” says Dr. Munoz. “It is extremely important that we learn from each other, especially when we are able to connect with our colleagues in the epicenters of the most serious outbreaks of COVID-19. We are happy to host this important weekly meeting with the goal of helping every specialist keep as many patients with cardiac diseases as safe as possible throughout the global health emergency.”

If you would like to join these weekly telehealth meetings, please send your request to COVIDMultiCICUResponse@childrensnational.org.

covers of books edited by Children's National faculty

We wrote the book

Children’s National Hospital is proud to have a number of faculty members who literally wrote the books on pediatric cardiology, neonatology, neurology and pulmonology. These texts, edited by experts Gil Wernovsky, M.D., Gordon Avery, M.D., Ricardo Munoz, M.D., Anastassios Koumbourlis, M.D., MPH, Robert Keating, M.D. and Roger Packer, M.D., have become the definitive references for medical students everywhere.

Through these books, generations of children worldwide will benefit from the expertise at Children’s National:

  • Anderson’s Pediatric Cardiology. Wernovsky, G., Anderson, R.H., Kumar, K., Mussatto, K.A., Redington, A.N., Tweddell, J.S., Tretter, J.T. (Eds.). (2019). Philadelphia, PA: Elsevier Publishing.
  • Avery’s Neonatology: Pathophysiology and Management of the Newborn. MacDonald, M.G., and Seshia, M.M.K. (Eds.) (2015). Philadelphia, PA: Lippincott Williams & Wilkins.
  • Critical Care of Children with Heart Disease: Basic Medical and Surgical Concepts. Munoz, R.A., More, V.O., da Cruz, E.M., Vetterly, C.G., da Silva, J.P. (Eds.). (2010) London, UK: Springer-Verlag London Ltd.
  • Diagnostic Tests in Pediatric Pulmonology. Davis, S.D., Koumbourlis, A.C., and Eber, E. (Eds.). (2015) London, UK: Springer-Verlag London Ltd.
  • Pulmonary Complications of Non-Pulmonary Pediatric Koumbourlis, A.C., and Nevin, M. (Eds.). (2018) London, UK: Springer-Verlag London Ltd.
  • Tumors of the Pediatric Central Nervous system. Keating, R.F., Goodrich, J.T., and Packer, R.J. (Eds.). (2013) New York, NY: Thieme Medical Publishers.

covers of books edited by Children's National faculty

Dr. Bear Bot

Advances in telemedicine start with new cardiac critical care robot

Dr. Bear Bot

Dr. Bear Bot’s “robot-only” parking space in the Cardiac ICU. Alejandro Lopez-Magallon, M.D., is featured on the robot display screen, where he drives the robot from his location in the command center, in order to visit patient rooms and capture additional medical information and connect with patients, parents, and attending nurses and physicians.

The telemedicine robot at Children’s National arrived in late August 2018 and recently completed a 90-day test period in the tele-cardiac intensive care unit (cardiac ICU) at Children’s National. The bot travels between rooms as a virtual liaison connecting patients and attending nurses and physicians with Ricardo Munoz, M.D., executive director of the telemedicine program and the division chief of critical cardiac care, and Alejandro Lopez-Magallon, M.D., a cardiologist and medical director of the telemedicine program.

Drs. Munoz and Lopez-Magallon use a nine-screen virtual command center to remotely monitor patient vitals, especially for infants and children who are recovering from congenital heart surgery, flown in for an emergency diagnostic procedure, such as a catheterization, or who are in the process of receiving a heart or kidney transplant. Instead of traveling to individual rooms to check in on the status of one patient, the doctors can now monitor multiple patients simultaneously, enhancing their ability to diagnose, care for and intervene during critical events.

If Drs. Munoz or Lopez-Magallon need to take an X-ray or further examine a patient, they drive the robot from its ‘robot-only’ parking space adjacent to the nurse’s station, and connect with attending doctors and nurses in the teaming area. The onsite clinicians accompany one of the telemedicine doctors, both of whom remain in the command center but appear virtually on the robot’s display screen, to the patient’s room to capture additional medical information and to connect with patients and families.

Over time, the telemedicine team will measure models of efficiency in the tele-cardiac ICU, such as through-put, care coordination, and standards of safety, quality and care, measured by quality of life and short- and long-term patient health outcomes. This test run will serve as a model for future command centers offering remote critical care.

Ricardo Munoz and Alejandro Lopez-Magallon

(R) Ricardo Munoz, M.D., executive director of the telemedicine program and the division chief of critical cardiac care, and Alejandro Lopez-Magallon, M.D., a cardiologist and the associate medical director of the telemedicine program in the tele-cardiac ICU command center.

“As technology and medicine advance, so do our models of telemedicine, which we call virtual care,” says Shireen Atabaki, M.D., M.P.H., an emergency medicine physician at Children’s National, who manages an ambulatory virtual health program, which enables patients to use virtual health platforms to connect with doctors, but from the comfort of their home. “We find the patient-centered platforms and this new technology saves families’ time and we’re looking forward to studying internal models to see how this can help our doctors, enabling us to do even more.”

The ongoing virtual connection program that Dr. Atabaki references launched in spring 2016 and has enabled 900 children to connect to a doctor from a computer, tablet or smart phone, which has saved families 1,600 driving hours and more than 41,000 miles over a two-year period. Through this program, virtual care is provided to children in our region by 20 subspecialists, including cardiologists, dermatologists, neurologists, urgent care doctors, geneticists, gastroenterologists and endocrinologists.

To extend the benefits of virtual communication, while saving mileage and time, Dr. Atabaki and the telemedicine team at Children’s National will partner with K-12 school systems, local hospitals and health centers and global health systems.

The Children’s National robot was named Dr. Bear Bot after a 21-day voting period with patients and staff, beating 14 other child-selected names, including SMARTy (Special Medical Access to Remote Technology), Dr. Bot and Rosie. Dr. Bear Bot celebrated with an official reveal party on Valentine’s Day, which was streamed to over 220 patients through the hospital’s closed-circuit television and radio station.

Darren Klugman

Children’s National cardiac intensive care experts named to leadership of Pediatric Cardiac Intensive Care Society

Darren Klugman

Darren Klugman, M.D., medical director of the cardiac intensive care unit (ICU) at Children’s National Health System, has been re-elected to the executive board of the Pediatric Cardiac Intensive Care Society (PCICS).

Darren Klugman, M.D., medical director of the cardiac intensive care unit (ICU) at Children’s National Health System, has been re-elected to the executive board of the Pediatric Cardiac Intensive Care Society (PCICS). Klugman will serve a second term as secretary of the organization, which serves to promote excellence in pediatric critical care medicine.

Melissa B. Jones, CPNP-AC, a critical care nurse practitioner at Children’s National, received the honor of being elected Vice President of PCICS. She will take on this leadership role for two years before assuming the presidency of the society in 2020.  Another critical care nurse practitioner at Children’s National, Christine Riley, CPNP-AC, was elected to serve a two-year term on the board of directors.

Congenital heart disease (CHD) is the most common birth defect. There have been many advances in the treatment of children with cardiovascular disorders, leading to a reduction in mortality. However, the extreme complexity of this treatable disease requires specialized care from disciplines beyond cardiology, including critical care, cardiac surgery and anesthesia. PCICS was formed to provide an international professional forum for promoting excellence in pediatric cardiac critical care.

Children’s National has had a large role in PCICS since its inception in 2003. David Wessel, M.D., executive vice president and chief medical officer, Hospital and Specialty Services, was one of the founding members of the international society. Children’s National served as the host of the 13th Annual International Meeting of PCICS in December of 2017 with many experts including Richard Jonas, M.D., division chief of cardiac surgery and co-director of the Children’s National Heart Institute, and Ricardo Muñoz, M.D., division chief of cardiac critical care medicine and executive director of telemedicine, giving talks. Many Children’s National specialists again will lend their expertise to this year’s PCICS annual meeting in Miami, Fla., in December.

Ricardo Munoz

Ricardo Muñoz, M.D., joins Children’s National as Chief of Cardiac Critical Care Medicine, Executive Director of Telemedicine and Co-Director of Heart Institute

Ricardo Munoz

Children’s National Health System is pleased to announce Ricardo Muñoz, M.D., as chief of the Division of Cardiac Critical Care Medicine and co-director of the Children’s National Heart Institute. Dr. Muñoz also will serve as the executive director of Telemedicine Services at Children’s National, working to leverage advances in technology to improve access to health care for underserved communities and developing nations.

Within the new division of Cardiac Critical Care Medicine, Dr. Muñoz will oversee the work of a multidisciplinary team, including critical care nurse practitioners and nurses, respiratory and physical therapists, nutritionists, social workers and pharmacists, in addition to a medical staff with one of the highest rates of double-boarded specialists in cardiology and critical care.

“We are honored to welcome Dr. Ricardo Muñoz to Children’s National,” says David Wessel, M.D., executive vice president and chief medical officer of Hospital and Specialty Services. “He is a pioneer and innovator in the fields of cardiac critical care and telemedicine and will undoubtedly provide a huge benefit to our patients and their families along with our cardiac critical care and telemedicine teams.”

Dr. Muñoz comes to Children’s National from Children’s Hospital of Pittsburgh of UPMC. During his 15-year tenure there, he established the cardiac intensive care unit and co-led the Heart Center in a multidisciplinary effort to achieve some of the best outcomes in the nation. He also is credited with pioneering telemedicine for pediatric critical care, providing nearly 4,000 consultations globally.

“Children’s National has a longstanding reputation of excellence in cardiac critical care, and I am pleased to be able to join the team in our nation’s capital to not only deliver top-quality care to patients regionally, but also around the world,” says Dr. Muñoz. “The early identification and treatment of pediatric congenital heart disease patients has made rapid improvements in recent decades, but there is a shortage of intensivists to care for these children during what is often a complex recovery course.”

Dr. Muñoz attended medical school at the Universidad del Norte, Barranquilla, Colombia, and completed his residency in pediatrics at the Hospital Militar Central, Bógota, Colombia. He continued his training as a general pediatrics and pediatric critical care fellow at Massachusetts General Hospital, and as a pediatric cardiology fellow at Boston Children’s Hospital. He then joined the faculty at Harvard Medical School and served as an attending physician in the Cardiac Intensive Care Unit at Boston Children’s.

Dr. Muñoz is board certified in pediatrics, pediatric critical care and in pediatric cardiology. He is a fellow of the American Academy of Pediatrics, the American College of Critical Care Medicine and the American College of Cardiology. Additionally, he is the primary editor and co-author of multiple textbooks and award-winning handbooks in pediatric cardiac intensive care, including Spanish language editions.