Background: The rapid expansion of telehealth, which was accelerated by the COVID-19 pandemic, has outpaced standardized approaches to data capture, resulting in fragmented documentation and limited research infrastructure. A centralized telehealth taxonomy would be useful for improving documentation, evaluating utilization, and informing decision-making. However, no comprehensive telehealth taxonomy has been developed to date. Methods: A scoping literature review was conducted to identify the characteristics needed to build a comprehensive telehealth taxonomy that informs a data repository. Then, a hybrid hierarchical mind map taxonomy was built using the frameworks and concepts from the reviewed articles, along with insight and feedback from eight telehealth domain experts. The taxonomy was revised using an iterative process, and the final version was approved by the domain experts. Results: Ten articles were ultimately included in this scoping review. Based on the findings of those articles, the final taxonomy includes 14 core variables that span the full telehealth appointment, including previsit preparation, during-visit interactions, and postvisit follow-up. The variables are arranged across both patient and provider perspectives. The taxonomy includes four dimensions: synchronous and asynchronous modalities, user perspectives, functionality, and payment considerations. Furthermore, the taxonomy aligns with electronic health record data fields, thus promoting interoperability and structured data capture. Discussion: The unified framework developed herein aims to bridge gaps in telehealth research by providing a scalable, interoperable foundation for data repositories. Ultimately, this taxonomy lays the groundwork for improved telehealth data infrastructure and can enhance research, clinical care, and data-informed policy development.

BACKGROUND:Children's Hospital of Philadelphia's Home Care respiratory therapy patient population becomes more acute and resource-intense each year. The organization's trach/vent patients have numerous clinical and equipment needs requiring complex home respiratory management. To conserve respiratory therapy resources, a remote patient management (RPM) program was integrated into the current respiratory services care model by introducing innovative technology to monitor patient data remotely. The authors expected this to reduce the number of home visits defined in the established program while maintaining safe, high-quality care. The goal was a reduction of 20%. METHODS:Biweekly, respiratory therapists (RTs) reviewed electronic health records and equipment downloads for specific patients and contacted them to assess their clinical status. RTs documented findings, planned interventions, communicated with interdisciplinary teams, and determined follow-up. Home and video contacts remained options for concerns. At minimum, RTs assessed patients in homes every three months. Chart reviews and safety rounds supported quality assessment. RESULTS:Results revealed a 38.7% reduction in home visits compared to the prior year and 59.6% reduction in home visits from pre-COVID-19 baseline data, with several instances of special cause variation observed on statistical process control analysis (p < 0.05). The authors found a 21.01% reduction in on-call volume for ventilator-related issues (p = 0.2) and a 5.8% increase in patient's status changing to lower acuity (p = 0.2); neither was statistically significant due to low sample size. Results showed time and mileage savings, improved communication with interdisciplinary teams and families, improved RT quality of life, active ventilator weaning for relevant patients, and potential prevention of hospital admissions. CONCLUSION:The program delivered innovation to an established care model, providing resource conservation, financial savings, and patient and staff satisfaction, and exceeded its goal.

BACKGROUND AND OBJECTIVES:Telehealth can improve pediatric access to care; however, substantial telehealth disparities continue to persist. Publications describing the implementation of innovative strategies to improve telehealth equity across pediatric health care organizations are limited. We aimed to describe the degree of implementation of telehealth equity interventions, identify facilitators and barriers to their implementation, and develop a quality improvement framework for future implementation efforts. METHODS:We conducted a national survey within the American Academy of Pediatrics' Supporting Pediatric Research on Outcomes and Utilization of Telehealth network from October to December 2023 to obtain an environmental scan of telehealth equity interventions adopted by pediatric health organizations since the onset of the COVID-19 pandemic. We used descriptive statistics to quantify intervention implementation and employed qualitative template analysis of open-ended responses to design a key driver diagram blueprint to advance pediatric telehealth equity. RESULTS:Of 134 organizations, members from 13 organizations completed the survey, mostly representing large, urban, academic children's hospitals. The most commonly implemented interventions included providing devices or internet access within health care facilities, offering on-demand help desk support, and integrating interpreter services within telehealth visit platforms. In contrast, less commonly implemented interventions included expanding broadband access in community settings, soliciting family visit preferences for telehealth versus in-person visits, and ensuring patient privacy during telehealth encounters. CONCLUSIONS:This study describes the degree of implementation of telehealth equity interventions among well-resourced pediatric health organizations. Our quality improvement framework provides a foundation for future multicenter, collaborative initiatives aimed at reducing telehealth disparities in pediatric populations.

Caring for children in low- and middle-income countries (LMIC) can be challenging. This review article aims to explore role of telemedicine in supporting pediatric care in LMIC. A narrative review of existing English and Spanish literature was conducted to assess role of telemedicine to support pediatric care in LMIC. Beside medical education and direct pediatric care, telemedicine can provide sub-specialties consultations without extra burden on families. Additionally, telemedicine can help in lowering under-5 mortality by supporting neonatal care, infectious illnesses, and non-communicable diseases (NCDs). Telemedicine can be a gate for universal coverage for all children at a lower cost. For over a decade, it has been implemented successfully and sustained in a few LMIC. However, challenges in implementing telemedicine are enormous. Still, opportunities arise by using simpler technology, low-width band internet, smartphones, instant messaging applications and solar energy. COVID-19 pandemic facilitated acceptance and applicability of telemedicine worldwide including LMIC. Nevertheless, governments must regulate telemedicine by issuing policies and ensuring employment of local experts when possible to meet local resources and cultural competency. Telemedicine has proven successful in improving pediatrics care. Many LMIC should take advantage of this innovation to promote equity and access to high quality pediatric care.

Introduction: The surge in virtual care during the pandemic was accompanied by an increase in telehealth data of interest to policy stakeholders and other health care decision makers. However, these data often require substantial preprocessing and targeted analyses to be usable. By deliberately evaluating telehealth services with stakeholder perspectives in mind, telehealth researchers can more effectively inform clinical and policy decision making.Objective: To examine existing literature on telehealth measurement and evaluation and develop a new policy-oriented framework to guide telehealth researchers.Materials and Methods: A systematic rapid review of literature on telehealth measurement and evaluation was conducted by two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The findings were analyzed and applied to the Supporting Pediatric Research on Outcomes and Utilization of Telehealth Evaluation and Measurement (STEM) Framework through the lens of key health care delivery decision makers to create a STEM Policy FrameworkResults: An initial search yielded 2,324 peer-reviewed articles and gray literatyre from 2012 to 2022, of which 56 met inclusion criteria. These measured and evaluated telehealth access (41.5%), quality (32.1%), cost (15.1%), experience (5.7%), and utilization (5.7%), consistent with the STEM Framework domains, but there was no universal approach. The STEM Policy Framework focuses this literature by describing data measures for each domain from the perspectives of five stakeholders.Conclusions: Literature describing measurement and evaluation approaches for telehealth is limited and not standardized, with few considering policy stakeholder perspectives. With this proposed STEM Policy Framework, we aim to improve this body of literature and support researchers seeking to inform telehealth policy through their work.

BACKGROUND:Managing critically ill neonates has unique challenges, and the transport team plays an important role in stabilizing and facilitating the transfer of these neonates from lower-level nurseries to tertiary centers, and the use of telemedicine in transport (tele-transport) can potentially benefit patient care. We conducted a multicenter study to assess the readiness for utilizing telemedicine as an adjunct to guide the care of critically ill neonates among physicians and transport team members (TTMs). This is the first multicenter study that explored physicians' and TTMs' perceptions of telemedicine usage and its value in neonatal transport. METHODS:A confidential, voluntary survey on pre-implementation attitudes toward telemedicine usage during neonatal transport was conducted as part of a quality improvement initiative. This survey involved physicians and TTMs from four academic institutions whose responses were entered into an online survey using REDCap®. The survey inquired about satisfaction with the current practice of phone consultation and the perception of using telemedicine to optimize the management of neonates during transport. RESULTS:The overall response rate for the survey was 60.1%; 82 of 127 (64.6%) physicians and 64 of 116 (55.2%) TTMs responded to the surveys. Half of the physicians and less than one-fourth of the TTMs had prior experience with telemedicine other than that used on neonatal transport. TTMs expressed greater concern about the inconvenience of video (55% vs. physicians 35% agree or strongly agree) and its time consumption (84% vs. physicians 50%). More than 70% of physicians and less than half of TTMs endorsed the potential for added value and quality improvement with video capability. Almost half of TTMs reported concern about video calls reducing their autonomy in patient care. Physicians expressed confidence in management decisions they would make after video calls (72% confident or very confident) and less confidence (49%) about both the phone assessment by TTMs and their decisions based on phone assessment. In contrast, TTMs were confident or very confident (94%) in both sharing their assessment over the phone and executing patient management after a phone call, compared with 70% for decisions made after video calls. CONCLUSIONS:Physicians and TTMs had distinct opinions on the use of telemedicine during neonatal transport. Physicians were more likely than TTMs to agree with statements about the potential for improving quality of care, while TTMs were more likely than physicians to say video calls would be time-consuming and inconvenient. We speculate some differences may stem from the TTMs' concern about losing their autonomy. Therefore, during implementation, it is critical for physicians and TTMs to agree on a shared mental model of indications for telemedicine during transport and its value to the patient care.

Telehealth presents both the potential to improve access to care and to widen the digital divide contributing to health care disparities and obliging health care systems to standardize approaches to measure and display telehealth disparities. Based on a literature review and the operational experience of clinicians, informaticists, and researchers in the Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT)–Clinical and Translational Science Awards (CTSA) Network, we outline a strategic framework for health systems to develop and optimally use a telehealth equity dashboard through a 3-phased approach of (1) defining data sources and key equity-related metrics of interest; (2) designing a dynamic and user-friendly dashboard; and (3) deploying the dashboard to maximize engagement among clinical staff, investigators, and administrators.

Children with pulmonary hypertension (PH) often demonstrate limited exercise capacity. Data support exercise as an effective nonpharmacologic intervention among adults with PH. However, data on exercise training in children and adolescents are limited, and characteristics of the optimal exercise program in pediatric PH have not been identified. Exercise programs may have multiple targets, including muscle deficits which are associated with exercise limitations in both adult and pediatric PH. Wearable accelerometer sensors measure physical activity volume and intensity in the naturalistic setting and can facilitate near continuous data transfer and bidirectional communication between patients and the study team when paired with informatics tools during exercise interventions. To address the knowledge gaps in exercise training in pediatric PH, we designed a prospective, single arm, nonrandomized pilot study to determine feasibility and preliminary estimates of efficacy of a 16-week home exercise intervention, targeting lower extremity muscle mass and enriched by wearable mobile health technology. The exercIse Training in pulmONary hypertEnsion (iTONE) trial includes (1) semistructured exercise prescriptions tailored to the participant's baseline level of activity and access to resources; (2) interval goal setting fostering self-efficacy; (3) real time monitoring of activity via wearable devices; (4) a digital platform enabling communication and feedback between participant and study team; (5) multiple avenues to assess participant safety. This pilot intervention will provide information on the digital infrastructure needed to conduct home-based exercise interventions in PH and will generate important preliminary data on the effect of exercise interventions in youth with chronic cardiorespiratory conditions to power larger studies in the future.

BACKGROUND:Unintended postoperative hypothermia in infants is associated with increased mortality and morbidity. We noted consistent hypothermia postoperatively in more than 60% of our neonatal intensive care (NICU) babies. Therefore, we set out to determine whether a targeted quality improvement (QI) project could decrease postoperative hypothermia rates in infants. OBJECTIVES:Our SMART aim was to reduce postoperative hypothermia (<36.5°C) in infants from 60% to 40% within 6 months. METHODS:This project was approved by IRB at Guangzhou Women and Children's Medical Center, China. The QI team included multidisciplinary healthcare providers in China and QI experts from Children's Hospital of Philadelphia, USA. The plan-do-study-act (PDSA) cycles included establishing a perioperative-thermoregulation protocol, optimizing the transfer process, and staff education. The primary outcome and balancing measures were, respectively, postoperative hypothermia and hyperthermia (axillary temperature < 36.5°C, >37.5°C). Data collected was analyzed using control charts. The factors associated with a reduction in hypothermia were explored using regression analysis. RESULTS:There were 295 infants in the project. The percentage of postoperative hypothermia decreased from 60% to 37% over 26 weeks, a special cause variation below the mean on the statistical process control chart. Reduction in hypothermia was associated with an odds of 0.17 (95% CI: 0.06-0.46; p <.001) for compliance with the transport incubator and 0.24 (95% CI: 0.1-0.58; p =.002) for prewarming the OR ambient temperature to 26°C. Two infants had hyperthermia. CONCLUSIONS:Our QI project reduced postoperative hypothermia without incurring hyperthermia through multidisciplinary team collaboration with the guidance of QI experts from the USA.

Background: The organizational culture (shared beliefs, perceptions, and values) of teams informs their behaviours and practices. Little is known about organizational culture for resuscitation teams. Our objective was to develop a reliable and valid resuscitation-specific organizational culture instrument (ROCI) with the goal of improving team performance. Methods: Using Neonatal Resuscitation Program principles, literature review, and discussion of existing culture measures with experts, we identified organizational culture components for resuscitation and adapted existing measures to resuscitation. We developed a ROCI with five subscales (role clarity, shared-mental models, closed- loop communication, team adaptability, and psychological safety) and administered it to neonatal resuscitation team members across a hospital network. Survey psychometric assessment included reliability analyses (Cronbach's alpha, Pearson correlation coefficients) and validity testing (confirmatory factor analysis [CFA] and regression models examining the association of culture with implementation outcomes: climate and perceived success). Results: Across 11 hospitals there were 318 complete responses (41 % response rate). Of the 22-items tested, 18 were retained after iterative psychometric assessment. The ROCI had excellent overall reliability (Cronbach's alpha = 0.994) and very good subscale reliability (Cronbach's alpha = 0.789-0.867). The CFA goodness-of-fit statistics confirmed five constructs (subscales). At the individual-level, the ROCI and all subscales were associated with both implementation outcomes. At the hospital-level, the ROCI overall and three subscales were associated with perceived success. Conclusion: The ROCI is a reliable and valid measure of the organizational culture of resuscitation teams. Future ROCI assessments may provide a foundation to inform culture change initiatives to improve resuscitation quality and outcomes across populations and contexts.

Purpose:Barriers to parents visiting the neonatal intensive care unit (NICU) in person for infant bonding include socioeconomic status, distance from NICU, and having children at home. Use of NICU bedside webcam can increase access to parent-infant interaction. This study aimed to describe the pattern of webcam logins by parents, relationship of logins to in-person visitation, and maternal factors affecting usage. Methods:In this retrospective cohort study, data pertaining to parental webcam logins and in-person visitation, maternal screening for depression, anxiety, and stress, and family sociodemographics were collected from medical records. Relationships between chart variables and webcam or in-person visitation were measured using Pearson's correlation coefficient and Mann-Whitney U test, as applicable. Login data were obtained from weeks 2 through 5 of NICU stay of the infant, while depression, anxiety, and stress scores were obtained in the second week as standard procedure by a dedicated NICU social worker. Results:A total of 59 mother-baby dyads were included. Percentage of days visited and webcam logins decreased from week 2 to week 5. A higher rate of webcam login was documented for all parents on days they did not visit in person. Parents who lived ≥15 miles away (P=0.004) and those with government insurance (P=0.01) visited in person significantly less, although webcam logins showed no difference between groups. One negative correlation was found between percentage of in-person visits and DASS-21 depression score (P=0.03), but no such correlation was seen with webcam logins. Conclusions:Parents utilized NICU webcams to connect with their infants when unable to be at the bedside. Webcam use reduced visitation disparities known to be exacerbated by insurance status, home-to-hospital distance, and psychological distress.

OBJECTIVES:This quality improvement initiative aimed to decrease unrelieved postoperative pain and improve family satisfaction with pain management.METHODS:NICUs within the Children's Hospitals Neonatal Consortium that care for infants with complex surgical problems participated in this collaborative. Each of these centers formed multidisciplinary teams to develop aims, interventions, and measurement strategies to test in multiple Plan-Do-Study-Act cycles. Centers were encouraged to adopt evidence-based interventions from the Clinical Practice Recommendations, which included pain assessment tools, pain score documentation, nonpharmacologic treatment measures, pain management guidelines, communication of a pain treatment plan, routine discussion of pain scores during team rounds, and parental involvement in pain management. Teams submitted data on a minimum of 10 surgeries per month, spanning from January to July 2019 (baseline), August 2019 to June 2021 (improvement work period), and July 2021 to December 2021 (sustain period).RESULTS:The percentage of patients with unrelieved pain in the 24-hour postoperative period decreased by 35% from 19.5% to 12.6%. Family satisfaction with pain management measured on a 3-point Likert scale with positive responses ≥2 increased from 93% to 96%. Compliance with appropriate pain assessment and numeric documentation of postoperative pain scores according to local NICU policy increased from 53% to 66%. The balancing measure of the percentage of patients with any consecutive sedation scores showed a decrease from 20.8% at baseline to 13.3%. All improvements were maintained during the sustain period.CONCLUSIONS:Standardization of pain management and workflow in the postoperative period across disciplines can improve pain control in infants.

As part of the Supporting Pediatric Research Outcomes Utilizing Telehealth (SPROUT) collaboration, three institutions (University of California, Davis, Children's Hospital Colorado, and Children's Hospital of Philadelphia) sought to improve communication with primary care providers (PCPs) using telehealth. This project connected families of neonatal intensive care unit (NICU) patients, their PCPs, and their NICU team through telehealth to provide an enhanced hospital handoff. This case series reports four cases that exemplify the benefits of these enhanced hospital handoffs: Case 1: assisting with changing care plans after NICU discharge, Case 2: demonstrating physical findings, Case 3: incorporation of additional subspecialties through telehealth, Case 4: arranging care for remote patients. Although these cases demonstrate some of the potential benefits of these handoffs, further study is needed to determine acceptability of these handoffs and to see whether they impact patient outcomes.

OBJECTIVES:Lack of discharge preparedness after NICU hospitalization is associated with risk of readmission and parental stress. Complex infants cared for at regional children's hospital NICUs would benefit from a systematic approach to transition home. Our objective was to identify potential best practices for NICU discharge and examine priorities for incorporating these best practices in regional children's hospital NICUs.METHODS:We used techniques from quality improvement, including fish bone and key driver diagrams, yielding 52 potential best practice statements for discharge preparation. Using the modified Delphi method, we surveyed stakeholders on their level of agreement for the statement to be included in the final guideline regarding discharge processes and parental education. Consensus was defined as 85% agreement among respondents. To identify implementation feasibility and understand unit-level priorities, a prioritization and feasibility assessment survey was used to rank the top best practices and performed gap analyses for the first prioritized intervention.RESULTS:Fifty of the 52 statements met the predefined criteria for consensus. The prioritization survey of potential best practice statements named assessment of families' social determinants of health with a standardized tool as the top priority among respondents. Conducting gap analyses enabled an understanding of current practice, barriers, and affordances, allowing for implementation planning.CONCLUSIONS:This multicenter and interdisciplinary expert panel reached a consensus on multiple potential best practices for complex discharge preparation from regional children's hospital NICUs. Better support for families navigating the complex NICU discharge process has the potential to improve infant health outcomes.

INTRODUCTION:Neonates have a high incidence of respiratory and cardiac perioperative events. Disease severity and indications for surgical intervention often dovetail with an overall complex clinical course and predispose these infants to adverse long-term neurodevelopmental outcomes and increased length of stay. Our aims were to describe severe and nonsevere early postoperative complications to establish a baseline of care outcomes and to identify subgroups of surgical neonates and procedures for future prospective studies.METHODS:Electronic health record data were examined retrospectively for a cohort of patients who had general anesthesia from January 26, 2015 to August 31, 2018. Inclusion criteria were full-term infants with postmenstrual age less than 44 weeks or premature infants less than 60 weeks postmenstrual age undergoing nonimaging, noncardiac surgery. Severe postoperative complications were defined as mortality, reintubation, positive blood culture, and surgical site infection. Nonsevere early postoperative outcomes were defined as hypoglycemia, hyperglycemia, hypothermia, hyperthermia, and readmission within 30 days.RESULTS:About 2569 procedures were performed in 1842 neonates of which 10.9% were emergency surgeries. There were 120 postoperative severe complications and 965 nonsevere postoperative outcomes. Overall, 30-day mortality was 1.8% for the first procedure performed, with higher mortality seen on subgroup analysis for patients who underwent exploratory laparotomy (10.3%) and congenital lung lesion resection (4.9%). Postoperative areas for improvement included hyperglycemia (13.9%) and hypothermia (7.9%).DISCUSSION:The mortality rate in our study was comparable to other studies of neonatal surgery despite a high rate of emergency surgery and a high prevalence of prematurity in our cohort. The early outcomes data identified areas for improvement, including prevention of postoperative glucose and temperature derangements.CONCLUSIONS:Neonates in this cohort were at risk for severe and nonsevere adverse postoperative outcomes. Future studies are suggested to improve mortality and adverse event rates.

Gender-affirming care (GAC) is critical to the well-being of transgender and gender diverse youth and was limited by COVID-19 stay-at-home orders. Telehealth created opportunities for youth to continue receiving lifesaving care. We examined the attitudes of patients (n=21) and caregivers (n=38) receiving telehealth-delivered GAC (TGAC) from May to July 2020. Participants completed surveys after telehealth visits. Descriptive statistics compared telehealth with in-person visits across key domains. Overall, 86.5% of patients and 95.4% of caregivers were satisfied with medical TGAC and 94.3% and 93.3% were satisfied with behavioral health TGAC. Future research should determine the effectiveness of TGAC and identify areas for improvement.

Abstract Fetal care centers, neonatal intensive care units, and neonatal follow-up settings provide a vast and unique frontier for important and novel research. Investigative efforts focusing on psychosocial issues and mental health across fetal and neonatal care settings have surged in recent decades, but additional research is necessary to further identify psychosocial needs of parents, refine and develop evidence-based care for families, better assist with staff education and support, create an evidence base to provide information critical to advocate for staffing and policy changes, and extend knowledge to propel the field forward. This chapter discusses two investigative disciplines—research and quality improvement—and presents their distinctions as well as their synergies and application within fetal and neonatal care settings. This is followed by presentation of key areas that warrant research exploration related to behavioral health issues and an overview of practical considerations for research application in these settings.