From the Department of Anesthesia and Intensive Care Unit,
National Children's Hospital, Tokyo, Japan.
Caring for pediatric patients receiving long-term mechanical
ventilation at home is a preferred option for medical, social, and
economic reasons; however, its role is not sufficiently appreciated in
Japan.1,2 The availability and adequacy of home care
and the flexibility of reimbursement are common problems that arise when instituting home care in general.3,4 However, the lack of a designated system with specialists who are experienced in long-term respiratory care has been the major obstacle in promoting home ventilatory care in pediatric practice in Japan.1
The use of telecommunication tools in medicine (telemedicine) has been
in existence since the 1950s and is highly developed in the fields of
radiology and pathology.5,6 These systems, however, are too
complicated and expensive for home care use. We evaluated a
conventional analog videophone system (VisualPhone VP2000;
Nissei-Sangyo, Tokyo, Japan) for home health care in the past and
concluded that it had good potential. The resolution of the system
(256 × 240 resolutions) and the quality of the picture transmitted (color still images) were acceptable for certain medical uses, but the frame rate (1 frame per 18 seconds) was not fast enough
to observe the movement of ventilator functions.7
We developed a videophone system using a public digital telephone
network (Integrated Services Digital Network [ISDN] 64, with a
capacity of 64 bits per second) to use the limited number of
specialists in pediatric respiratory care better. This digital videophone system was implemented between our pediatric intensive care
unit (PICU), the patients' homes, and technical advisors. It has been
in use for the past 4 years in 14 pediatric patients receiving home
care. It is now being expanded to other children's facilities in both
the United States and Japan.
Pediatric Home Mechanical Ventilation in Japan
Pediatric home ventilatory care started in 1983 when we first
discharged a patient home with mechanical ventilation. However, home
mechanical ventilation is not used widely in Japan as an option for
pediatric patients with chronic respiratory failure, with only about 50 such patients in 1992.1 Reasons for keeping patients in
long-term hospital care rather than discharging home include the
limited number of specialists, inadequate reimbursement, and lack of a
support system for physicians.8 There are a limited number
of specialists in pediatric respiratory care and an embarrassingly insufficient number of pediatric critical care units. According to a
recent survey conducted by the Japanese Society of Intensive Care
Medicine (1993), there are only 158 pediatric critical care beds
(compared with 9214 ICU beds, 2000 coronary care unit beds, and 2741 neonatal intensive care unit beds).9 Many children who
require long-term mechanical ventilation are cared for in regular
pediatric wards. Patients needing special care converge in tertiary
centers, often far from home, to undergo long-term hospitalization for
chronic respiratory treatment.
The number of people who understand the need for home mechanical
ventilation and who could actually implement such a program is small.
This number is further limited by the licensing system in Japan,
because only physicians are allowed to operate ventilators in
hospitals. There is no system for respiratory therapists. Pediatric home respiratory care is organized and implemented directly by hospital-based pediatricians on an individual basis. The family expects
very little in terms of medical help, even in the form of visiting
nurses or other public services, once respiratory care such as
endotracheal suctioning or ventilator use is involved.
The current reimbursement plan by the national insurance system in
Japan is structured in such a way that home mechanical ventilation
costs significantly more (at least three times) to a patient's family
than in-hospital care. Pediatricians are often hesitant to select home
care, even when the family wants it. The mandatory monthly hospital
visits required by the health insurance plan are counterproductive to
the nature of home care.
A national survey we conducted in 1992 found that the biggest
frustration of pediatricians who have candidates for home respiratory care was the unavailability of a support system by respiratory care
specialists.1 The major concern of families who have
children who are receiving ventilation at home was a fear of complete
isolation from the hospital specialist. Most family physicians and
health care personnel nearby are not familiar with respiratory care, so
patients must depend on tertiary centers farther from home.
METHODS
Videophone System Modifications for Home Care Use
A stand-alone color videophone with a built-in fixed-focus
camera (Picsend R; NTT-Hitachi, Tokyo, Japan) was modified for home
respiratory care. This videophone is not based on personal computer
operation or Internet technology, thus no keyboard operation or
computer software knowledge is required. A simple remote camera operation control system (Aishin Cosmos Inc, Aichi, Japan) using telephone push buttons for panning and zooming a home video camera or
detachable handy charge-coupled device camera was set up in the
patient's home. This enabled us to control from the hospital the video
camera connected to the videophone at home (Figure).
Fig. 1.
Videophone system used in this study. A camera for
remote operation (at the right side of the videophone) was used in
addition to the fixed-focus camera right above the liquid crystal
display screen. The same setup was used in the patient's home. A
separate monitor (on top of the personal computer) is used at the
hospital for additional viewers. The picture being transmitted is the
front panel of a home care ventilator (Puppy 2; Origin Medical Inc, Tokyo, Japan).
[View Larger Version of this Image (124K GIF file)]
This system can transmit near-television quality (320 × 200 resolution) pictures at 10 to 12 frames per second. Although motion is
still jagged, the oscillatory movement (up to 40 breaths per minute) of
an airway pressure manometer can be observed. The quality of sound
transmission is excellent, but there is a delay of approximately 0.5 seconds from the picture.
The videophone we used offered several additional features. The fine
still-picture mode can transmit high-resolution (704 × 480 resolution) pictures with a quality good enough to interpret routine
chest radiographs or to examine skin color and other patient conditions. Videotaped pictures such as an echocardiograph or the
operation manual of ventilators can also be transmitted. A specially
made microphone can be attached for stethoscopes. The conference
function enables discussion between up to four different locations.
These additional functions, however, were seldom used in home care.
Several clinical conferences with patients in the PICU who were
receiving respiratory care were held using this videophone system
before home care application to evaluate the clinical feasibility of
the quality and speed of images of this videophone. Videophones at our
PICU, our physician's office, children's hospitals in the United
States (Los Angeles, CA) and Osaka and Chiba, Japan, and the work
stations of technical service providers were connected. Six pediatric
intensive care specialists, three pediatric cardiologists, two
pediatric pulmonologists, and two medical engineers participated. The
general consensus was that this system was capable of transmitting clinically acceptable levels of chest wall movement, ventilator movement, chest radiographs, echocardiograpy, fiberbronchoscopy images,
and importantly, the emotional expressions of family members.
Study Protocol
The study was conducted between September 1994 and March 1996. The study protocol was approved by the Institutional Review Board, and
informed consent was obtained from individual participants.
A total of 10 families who were living in the ISDN 64 public telephone
network-accessible area and who were managed under the home respiratory
care program at the Department of Anesthesia and ICU, National
Children's Hospital (Tokyo, Japan) were enrolled. Group I consisted of
7 of our patients (ages 3 to 24 years) who were already receiving home
respiratory care (duration, 2 to 13 years) at the time of videophone
installation. Group II consisted of 3 patients (10, 14, and 20 months
of age) who were discharged and transferred to home care with this
system. The clinical characteristics of the patients are summarized in
Table 1. The distances between our hospital and the
homes of patients ranged from 10 to 500 km.
A total of 15 units of videophones were modified for home care use. One
unit each was installed at 10 individual patients' homes, 2 ventilator
technical service providers, 1 home oxygen supplier, 1 nurse station at
our PICU (24-hour answering capability), and 1 at the physician's
office at our department.
Videophones were treated exactly the same way as regular telephones.
The videophone installed in the PICU could be answered by any PICU
physician or nurse nearby. Patients or members of their families were
allowed to call the PICU anytime they wanted. Patients or members of
their families were allowed to call each other or technical service
providers when they thought it was necessary. Technical service
providers were allowed to call the patients' homes or the hospital. No
routine or special calling time arrangements were made among
participants. The videophone system and its installation fee were
provided to the family free during the study period, but the families
were asked to pay the monthly telephone charge.
All the unscheduled hospital visits, telephone calls, and videophone
calls made by patients to or from the hospital and/or technical service
providers were logged and analyzed. The parents, physicians, and
technical service providers involved were asked questions regarding the
degree of satisfaction with this system 6 months after the system was
introduced. Only phone calls initiated by the patient or care giver
were counted, and a series of videophone calls regarding one episode on
1 day was counted as one phone call. Patients receiving home care were
required to visit the hospital every month (routine visit) according to
the Japanese national uniform fee schedule, but those visits were not
counted in this study.
The general feelings of the family toward this system, which were
voluntarily expressed during videophone communication, and both
positive and negative comments toward this system gathered at the time
of routine hospital visits were recorded and summarized. Feedback from
technical service providers was also recorded and summarized.
Statistical Analysis
A nonparametric Mann-Whitney U test was used for
statistical analysis because of the nonnormal distribution of data
(numbers of phone calls, unscheduled hospital visits, and hospital
admissions). P < .05 was considered statistically
significant.
RESULTS
Phone calls, unscheduled outpatient visits, and hospital
admissions before and after videophone installation are summarized in
Table 2.
|
Table 2.
Phone Calls, Unscheduled Outpatient Visits, and Hospital Admissions
Before and After Videophone Installation
[View Table]
|
Number of Videophone Calls, Hospital Visits, and Admissions
Group I (Patients Already Receiving Home Care at Videophone
Installation)
The number of phone calls (via regular telephone) was 11 before
the introduction of the videophone system, but there were 58 videophone
calls after installation of the videophones. A fivefold increase
(P < .004) in phone calls was observed in this
group. There were 24 unscheduled hospital visits before installation, but the number of unscheduled hospital visits decreased to 5 visits after the installation of the videophone system. The number of days the
patients were hospitalized was 22 days (4 admissions in three patients)
before the introduction of the videophone system. This decreased to 10 days (two admissions in two patients).
Two patients (both older than 15 years) who never had unscheduled
hospital visits in the previous 6 months had no unscheduled hospital
visits, but the number of phone calls increased from 1 to 28 times
after the installation of the videophone system. The majority of these
calls were friendly calls expressing the general feelings of patients
or family members to physicians.
The remaining five of seven patients already receiving home care
required a total of 24 unscheduled hospital visits and 4 hospital
admissions in 6 months before installation of the videophone. There
were 11 medical telephone calls, of which 9 ended in outpatient hospital visits. After the installation of the videophone system, there
were 30 videophone calls by these five families, of which 14 were about
medical concerns, 6 mechanical concerns, and 10 friendly calls. After
the installation of the videophone system, the number of unscheduled
hospital visits significantly decreased to 5, an 80% decrease
(P < .01). The number of admissions to the hospital was 4 (a total of 22 days) before and 2 (a total of 10 days)
after the videophone introduction, but the decrease was not
statistically significant.
Out of 30 videophone calls, 14 calls were for medical problems, all of
which had clinical significance. Three calls were related to a
recurrence of seizures that occurred in one patient. Two episodes were
treated at home under videophone supervision, but 1 call ended in
hospital admission. Seven calls were related to worrisome high fever,
all of which, except 1, were treated at home under videophone
supervision. Blood tint and tenacious suction materials were the
concerns for videophone calls on another 4 occasions. There were 6 calls related to mechanical concerns, of which 4 were related to the
malfunction of heated humidifiers and 2 to the overheating of an air
compressor. These were handled by videophone by a physician on call and
followed up by 2 nonurgent house visits by the technical service
provider. There were 12 semiurgent technical service visits during the
previous 6 months, but these decreased to 2.
Group II (Three Patients Sent Home With Videophone Systems)
Three patients were sent home with videophone systems from the
beginning. There were 45 videophone calls in the first 6 months, with
only one unscheduled hospital visit. No patient in this group was
hospitalized during the study period. Most (35 of 45) videophone calls
were made in the first 3 months. Of 45 videophone calls, 27 were
related to mechanical concerns, and 18 were related to medical
concerns.
All the mechanical troubles were directly handled by physicians by
videophones, and no urgent technical service was required. Of 27 calls
related to mechanical concerns, there were 7 actual mechanical
troubles: 2 related to the air compressor, 4 related to the breathing
circuit, and 1 related to the function of the ventilator itself. The
other 20 calls were general concerns about abnormal sounds or
vibrations or the operation of the ventilator. These diverse calls were
concentrated in the first 3 months.
There were 18 calls related to medical problems, of which 10 were of
clinical significance. Two calls were related to a recurrence of
seizures that occurred in one patient, and 3 calls were related to high
fevers, all of which were treated at home under videophone supervision.
Blood tint and tenacious suction materials were the concerns for
videophone calls on another 5 occasions, and they were visually
ascertained to be nonsignificant. The other 8 phone calls were for
reassurance about the children's conditions.
Time Benefit Analysis
A potential time benefit analysis was performed based on the
figures reported in a time study of our hospital.10 It was estimated that a physician spends 1 hour for one outpatient visit, 2 hours for one hospital admission day, 4 hours for one house call, and
15 minutes for one videophone consultation. House calls for technical
support by the supplier were estimated to be 4 hours. A patient and
family were estimated to spend 5 hours for one outpatient hospital
visit, including preparation, commuting, and waiting time.
The total time physicians spent on 58 videophone consultations was
estimated at 14.5 hours. This was an 11.8-hour increase in the time
physicians spent on phone calls compared with the previous 6 months.
There were 11 phone calls, 25 unscheduled hospital visits, and 5 house
calls in the previous 6 months. There was a 100% decrease in house
calls (5 to 0), which took 20 hours less of the physicians' time, an
80% decrease in unscheduled hospital visits (24 to 5) for 19 hours
less, and a 50% decrease in hospital admissions (22 to 10 days), 24 hours less.
Thus, a total of 51.2 hours of the physician's time could be allocated
to other patient care during the 6-month period the videophone system
was in operation. The time saved by patients and their families by
avoiding unscheduled hospital visits was estimated at 95 hours. The
absence of urgent service calls by technical service providers (12 to
0) saved an estimated 48 working hours of technical support.
Hardware Costs
The hardware for this videophone system cost about $6000 to
purchase or $1000 initial installment plus $150 per month to lease at
the time of this study and was substantially more expensive to install
than a regular telephone. The cost of this system as of September 1996 had been substantially decreased to $2000 to purchase.
The running cost in terms of the telephone bill using one ISDN 64 line,
as in this study, is similar to that of using a regular telephone in
Japan.
Evaluation by the Families
Spontaneous and actively gathered comments from the families
indicated that none of the patients or family members involved in this
study wished to discontinue the use of the system during the study
period. Rather, they all wanted to extend it. They found the videophone
system easy to use and extremely helpful in easing the stress of the
care givers. The families reported a sense of immediate relief from
anxiety related to the technical aspects of home ventilation and the
decreased workload related to fewer hospital visits.
Communication between different families using home ventilation was
facilitated and was an unexpected benefit of this project.
The high initial installment cost ($1000) was the only major concern.
There were minor complaints regarding the hardware, especially
difficulties found in direct videotaping and occasional functional
instability experienced during the hot and humid summer season.
Concerns about invasion of privacy expressed before the introduction
soon dissipated as the families realized that they could use the system
exactly the same as a regular telephone.
Feedback From Technical Service Providers
The major concerns of the technical service providers for a system
of this type were the quality of the picture and the versatility of the
system. The system was able to allow them to service the respirators
without making house calls based on videophone images of the movement
of the manometer, readings of the operation panels, and mechanical
sound. It was thought that the current system with remote camera
control possesses the capability to eliminate most (up to 70%) urgent
home visits.10 They thought that the establishment of a
nationwide service network could be justified if the initial cost of
the hardware declined significantly.
DISCUSSION
A videophone system for home care using a public digital telephone
network, ISDN 64, was shown to have the ability to transmit clinically
useful data on both medical and emotional aspects of home care. The
amount of time saved with this system by health care professionals,
patients, and their families was significant. Specialist resources can
now be used more effectively to improve the quality of pediatric home
ventilatory care.
The system is not aimed at eliminating direct physical examination or
evaluation of patients. Instead, we used this system to facilitate the
involvement of pediatric respiratory care specialists to help decrease
the stress and anxiety of patients receiving home care and their
families. Some may argue the value of this system because of its lesser
quality and speed of picture transmission compared with a regular or
high-definition television system using a higher transmission network
(ISDN 1500) or personal computer-based technology. Although the use of
such technologies is preferable from a purely medical point of view, it
would add significantly to the cost and limit its availability to the
public. We thought that the quality and speed (320 × 200 resolutions, 10 to 12 frames per second) of this system were sufficient
to be used in patients receiving home care.
Improvement in the physician-patient relationship and the facilitation
of communication between patients receiving home care were observed.
The strength of the physician-patient relationship existing in our home
care setting may well have been both a cause and an effect of the
success of the system. Patients felt close enough to make numerous
calls to the physician, even calls about mechanical problems, which
usually would have been made to the technical service providers. This,
as a result, reduced the number of urgent technical visits. The
videophone calls made patients feel closer to each other, and several
patients and their parents started talking to each other for mutual
support and reassurance about their own conditions.
The limited trials with other institutions, including one in the United
States, showed the favorable potential of this system in eliminating
national borders and time zones. Specialist consultation about a rare
condition in Japan (eg, cystic fibrosis) could be obtained without
imposing the patient stress of traveling or the risk of getting
infections.11
A telephone with moving pictures is far more effective in conveying
information than a regular telephone. It is, however, not easy to
compare the actual effectiveness of videophones with regular telephones
in a home care setting. Not only the devices, but the way they are
used, significantly affects their effectiveness.
Patients receiving home care and their families are very familiar with
their conditions, and it is usually their last resort to call the
physician. All the phone calls in five patients from group I ended in
unscheduled hospital visits or admissions before the introduction of
videophones. Twenty of 30 videophone calls from the same patients were
of clinical significance after the installation of videophones, of
which only 7 ended in unscheduled visits or admissions. It is thus
conceivable that a videophone can be considered capable of decreasing
by 77% the number of unscheduled hospital visits or admissions. This
was not possible with regular telephone calls.
There are several limitations of this study. One is the
before-and-after comparison nature of this study. Exactly the same patients and families were involved in this with- and
without-videophone comparison (group I). This cannot be considered a
controlled study. The duration of each study period did not extend for
a full four seasons. The switchovers to the videophones did take place
during the summer months (July, August, and September), and both
periods included a few winter months. A decrease in unscheduled
hospital visits after the videophone system implementation could still be argued as coincidental or seasonal. We did not think this was the
case, judging from feedback from families and the magnitude of the
decrease. Although unscheduled hospital visits dramatically decreased,
the substantial reduction in hospitalization from 22 to 10 days was
statistically not significant. Similar to the reluctance families have
to call physicians, the families of patients receiving home care have a
strong determination to avoid hospital admissions. This and the
relatively short study duration may account for the weak effect
videophones had on decreasing hospitalization. The potential capability
of videophones in handling seizures and worrisome fevers may produce a
future reduction in days of hospitalization.
Another limitation is that we could only study the initial 6-month
period of videophone introduction, when situations were changing and
learning effects were taking place. In fact, the decline observed in
the number of phone calls after 3 months in group II indicated this
effect. It, however, does not affect the meaning of this study,
indicating the potentially beneficial effects, especially during the
introduction of home care.
Last, this study took place in Japan in a very small and specific
environment, pediatric home respiratory care. Although cost configurations may differ in different health care
systems,12,13 the effective use of specialists and
improvement in quality of life for patients should be universal
concerns.11,14 The ISDN 64 designated videophone we used
was basically developed for home use, unlike other more sophisticated
systems being used in telemedicine aiming at higher-quality data
transmission.6,15 The cost of the hardware should fall
rapidly, once its usefulness is recognized by the medical community.
The number of cases involved in this study was small, but we thought
that it was important to encourage the establishment of a designated
home care system.
In summary, the videophone system using ISDN 64 can now be considered a
practical and effective tool to use specialist resources more
effectively in home care, extending national borders and time zones and
improving the quality of pediatric home ventilatory care. The
establishment of a designated home care support system using this
system is warranted.
Received for publication Jul 23, 1996; accepted Sep 6, 1996.
Reprint requests to (K.M.) Department of Anesthesia and
Intensive Care Unit, National Children's Hospital, 3-35-31 Taishido,
Setagaya, Tokyo 154, Japan.
We thank Dr Thomas G. Keens of the Children's Hospital of Los
Angeles for cooperation and encouragement in the international videophone project and Hideo Nakazawa for technical cooperation.
ISDN, Integrated Services Digital Network.
PICU, pediatric intensive care unit.