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Blog posted by: Simon Minford, 16 July 2020.

By Simon Minford
Clinical Innovation Consultant – Lead for telehealth, Alder Hey Children’s NHS FT

Making clinical decisions by telehealth

COVID-19 has caused innovation to happen at breakneck speed at Alder Hey. We have launched a telehealth service, working with a company called InTouch Health, which has transformed life for both patients and staff.

Long before lockdown became a thing or even a thought, we had already been thinking how we could employ telehealth for our neonates.  

On 2 March - two weeks before lockdown – we ran a virtual care symposium with Dr Jennifer Fang, a neonatologist from the Mayo Clinic in Rochester, USA, talking about how they developed telehealth with their new-borns. It is amazing! They have one central hub and are using telehealth to serve a geographical footprint almost as the big as the UK.

Sometimes babies have a problem which isn’t picked up at birth and they suddenly become very, very unwell. Mayo Clinic have a telehealth system set up in neonatal delivery rooms throughout the state. Clinicians in any hospital can instantly get advice and direction from a specialist tele-neonatologist for unexpected neonatal resuscitation – almost beaming into the room and being there!

Mayo inspired us to act

Thanks to an inspirational demonstration at our symposium, it gave us the courage to fast-track the project as the pressures from COVID-19 increased. So, just two weeks after the symposium we had telehealth up and running.

We got some equipment on loan and deployed a portable device at Alder Hey, and a more advanced version in Liverpool Women’s brand-new neonatal unit.

Initially, our business use case was to protect neonates from COVID; but we also know that Alder Hey surgeons, neurosurgeons and cardiologists are continually travelling over to the Women’s. So we said if we could cut down the footfall that would really help, especially if you cut out the travel time even just across town, to keep our staff on site in case they’re needed.

It started with a ward round once a day and an ad hoc consultation if needed, but it’s grown very quickly. We’ve gone from training the core team of three or four staff to 90 per cent of the consultant neonatal surgeons being trained and doing ward rounds.

The neonatologist does a ward round carrying what looks like a very posh drip stand with a telly on it! The neonatal surgeon uses a high-definition camera which can zoom in really close to a baby (it is possible to zoom in close enough to see the weave in a baby’s bonnet) and allows them to remotely make clinical decisions – and that’s the clincher of the business case.

Conversations and advice can easily be done on Microsoft Teams or over the phone; but telehealth allows neonatal surgeons to actually make a clinical decision, where they would otherwise have to be physically present in the room.

These decisions are especially important, such as whether or not to transfer a sick baby for an operation, big things like that.

On the other side, the neonatal doctors at Liverpool Women’s were having to come over and see the babies when they were at Alder Hey. With COVID shielding and sickness the consultant team at Liverpool Women’s was reduced by 50 per cent, from 14 to seven. Covering all their commitments was impossible. 

However, consultant neonatologists who were well while shielding could deliver care remotely by doing daily ward rounds from home, at the Alder Hey Neonatal Surgical Unit.

This quickly evolved to them doing daily ward rounds in Liverpool Women’s low acuity unit as well. This sharing of the workload meant that the neonatal team did not need to have a single locum despite the significant challenge to their workforce.

Real-time online specialist investigations

I think the emerging need is going to be with cardiology and other tertiary level services. The Alder Hey specialities will want to work virtually at the Women’s because they will be able to see babies who require monitoring and/or urgent clinical opinions without the challenge of travelling distances and the delays that causes.

In the meantime, we have ordered four telehealth robots to be made for us which will arrive within a month, to be deployed at Alder Hey and Liverpool Women’s – and wherever else we have built the use case. These will have the ability to stream real-time investigations.

At the moment there is a PAC (picture archive communications) system which is brilliant, it allows us to share scans and X-rays from around the region – for instance I was looking at an X-ray today just five minutes after it was taken.

What we need to do with some scans, particularly echocardiograms, is orientate the scanner in a particular way to pick up the required information and this is a very specialist skill. We are exploring using the telehealth robots to stream these real time investigations; the specialist can direct the person scanning in real time, allowing decisions to be made remotely which would otherwise have required moving a poorly neonate across the region.

Emerging use cases

The success and ease of our rapid deployment of telehealth has encouraged other clinicians to come forward and explore how it could benefit their patients and families.

One example is Professor Zarko Alfirevic, the specialist fetal medicine consultant at the Women’s. He runs a multidisciplinary team meeting which can involve a paediatric neurosurgeon, a neonatal neurosurgeon and a cardiologist. Getting all these people in the same place at the same time is really difficult, so telehealth is ideal to bring them together and look at a real-time ultrasound scan of an expectant mum and make some decisions.    

It could potentially be a better experience for the mother as she does not have to face several senior consultants in a single consultation – which I expect can be a little intimidating! I look forward to exploring this further in the future.

We are also looking at other areas such as neurology, ambulances etc. The list is increasing every day!  Each speciality has its unique needs and making sure this is supported by the correct technology is exciting.

Teamwork made the dream work

Telehealth is something we have been desperate to do for years. Despite various efforts it has never got any traction and now, it’s almost as if every blocker evaporated overnight. We have been pushing forward and every time we find we can’t do something, all of a sudden it gets fixed or some critical assistance appears from elsewhere in the organisation!

One big asset in this has been the Innovation Team. They have supported and helped throughout this journey. Everything from hosting the initial symposium, providing project support, the list is endless! One major part has been the great teamwork between the Innovation and IT departments. This has been critical in getting this delivered at such speed.  We are incredibly lucky and just running with it.

I have been surprised at the speed of uptake of this new technology. The obvious people who are naturals with technology took to it easily, and even those colleagues who struggle with technology on a good day, are going out of their way to use it.

It has been fantastic to do all this; problems have melted away and nothing has been insurmountable, it has been an absolute blast.