Remote Collaboration and Evidence-Based Care
Evidence-based care can be a challenge in any medical situation, but particular challenges present themselves when care is being provided remotely. In order to provide quality care to patients who live in rural settings or have difficulty with transportation to a care site, health care professionals must sometimes collaborate with other professionals in different ZIP codes or even time zones.
In this activity, you will observe how health care professionals collaborate remotely and virtually to provide care for a patient in Valley City, North Dakota.
The Patient Presents
Dr. Erica Copeland and Virginia Anderson, a pediatric nurse, discuss Caitlynn, who came into the ER last night and has now been admitted to the pediatric unit.
Dr. Copeland starts the conversation.
Dr. Copeland: Nurse, can you give me an update on Caitlynn? I know she’s two years old and she’s been admitted for pneumonia. Does she have any history of breathing problems?
Virginia Anderson: Yes, this is her second admission for pneumonia in the last six months. She had a meconium ileus at birth.
Dr. Copeland: All right. Is she presenting with any other symptoms?
Virginia Anderson: She has decreased breath sounds at the right bases and rhonchi scattered in the upper lobes. Respirations are 32 and shallow with a temp of 101.
Dr. Copeland: What have we done for her so far?
Virginia Anderson: The respiratory therapist administered nebulized aerosol and chest physiotherapy. After the aerosol she had thick secretions.
Dr. Copeland: I see her weight is 20.7 pounds, and there’s been some decreased subcutaneous tissue observed in her extremities?
Virginia Anderson: Correct. I noticed this too, so she might have some malabsorption of nutrients.
Dr. Copeland: Have we done a sweat chloride test yet?
Virginia Anderson: Yes, and the results were 65 milliequivalents per liter. Also, the mother reports that when she kisses her, she tastes salty.
Dr. Copeland: All right. Well, I think it’s fair to say we might be dealing with cystic fibrosis here. Let’s get her started on an IV with piperacillin, and keep an eye on her temperature.
Later, the diagnosis is confirmed: Caitlynn has cystic fibrosis. Dr. Copeland, Virginia Anderson, and Rebecca Helgo, the hospital’s respiratory therapist have a short consult, where they realize that Caitlynn’s care will not be easy.
Dr. Copeland starts the conversation.
Dr. Copeland: Let’s talk about Caitlynn Bergan. Her mother, uh, [checks notes] Janice, has been informed of her diagnosis. I didn’t realize this when she first came in, but she doesn’t live in Valley City; she’s in McHenry.
Rebecca Helgo: That’s a tough drive during winter. They’re over an hour away, aren’t they?
Dr. Copeland: That’s right. It was a toss-up between coming here or going to Jamestown, but I guess the father — Doug — thought Valley City was the better choice. Anyway, I’ve put her on Pancrease enzymes and we’ll be recommending a high-protein, extra-calorie diet along with the fat-soluble vitamins — A, D, E, and K. I’ll update her pediatrician on her condition, and order dornase alfa. Let’s see how she does with the breathing treatments. How are those going?
Rebecca Helgo: Quite well, actually. She’s too young to get her to do the huff breaths, but we’re keeping the secretions thin and manageable with the aerosol treatments. I am concerned about her day-to-day treatment, though. She’ll be back here with pneumonia if the parents can’t stay on top of that. She’s at risk for impaired gas exchange and respiratory distress, which will cause her anxiety and more distress, and that’s not going to help her stay well.
Dr. Copeland: How well do you think the parents will be able to handle the treatment?
Virginia Anderson: That might get tricky. I gather that the mother and father are still married but separated. We’ll need to make sure that at least one of them gets the education they need. But they both work, and trips here aren’t the easiest choice. We should get a social services consult to coordinate services and identify some assistance for the family in McHenry.
Rebecca Helgo: I can do some education here, and then do a Skype consult with one or both of them once she’s been discharged and is back home.
Dr. Copeland: It sounded like both parents work long hours. Are you going to be able to schedule times that work?
Rebecca Helgo: I may have to do some after-hours appointments. We’ll have to sort that out.
Virginia Anderson: She’s had one bowel obstruction already, so I think we need to help them monitor for DIOS too. Does the pediatrician’s office have a telemedicine relationship with us? That might be helpful in preventing unnecessary trips here.
Dr. Copeland: Let’s find out a bit more and see what our options are.
Consulting With the Pediatrician
Later that day, Dr. Copeland and Virginia Anderson talk to Dr. Benjamin, Caitlynn’s pediatrician, about how his office can coordinate with the hospital on Caitlynn’s care.
Dr. Copeland greets Dr. Benjamin.
Dr. Copeland: Hello, Dr. Benjamin. I’m sorry to be meeting under such circumstances, but I hope we can work with you to help the Bergans handle Caitlynn’s care. On the line with me is Virginia Anderson, the nurse assigned to Caitlynn while she’s here.
Dr. Benjamin: Hello to both of you. Yes, it’s unfortunate. This is the first case I’ve seen among my own patients.
Dr. Copeland: Are you familiar with the CF protocol?
Dr. Benjamin: I am, but I’d love to get any more details that relate to Caitlynn. She’s done with most of her immunizations, but she’s still needs her HAV and influenza, of course. I’m also not sure where to order some of the pancreatic enzymes and medications you listed.
Virginia Anderson: We can help with all that. Do you have telemedicine access to Valley City?
Dr. Benjamin: No, but we do have it with Cooperstown Medical Center. We kind of have to in a town of less than 100 people.
Dr. Copeland: We may be able to use Skype on a more informal basis for consults between us, but it might be good to get connected with Valley City on your telemedicine equipment. If the parents bring Caitlynn to you with symptoms, and you’re not sure whether the hour-long trip is necessary, we can do a telemedicine appointment and make sure.
Dr. Benjamin: All right. It sounds like we might see them often initially, and I understand that bowel obstructions and pneumonia are two possible complications. We can handle some of those issues here, but assuming they have trouble during working hours, I assume we can reach you by phone?
Dr. Copeland: You or your staff can send me a text. If we need to talk further we can set up a call, but if not, text is the quickest way to get my attention, and the easiest way for me to respond between things.
Virginia Anderson: And I’m available via text as well if you’re having trouble reaching Dr. Copeland or if it’s a question I can field.
The Care Plan Continues
To address some of the questions that came up during the consult, Virginia meets with Madeline Becker, the social worker at the clinic in McHenry.
Virginia starts the conversation.
Virginia Anderson: Hi, Madeline, this is Virginia Anderson at Valley City Regional Hospital. I’m on the line with Marta Simmons, our social worker here at the hospital.
Madeline Becker: Hi, both of you.
Marta Simmons: Madeline, we’re calling because Virginia is working on a care plan for a child from McHenry, a Caitlynn Bergan. She’s here after a bout of pneumonia and she’s been diagnosed with cystic fibrosis. We wanted to talk to you about resources there for some of the issues the Bergans are going to be dealing with.
Madeline Becker: Of course. I got the documentation you emailed earlier. Fortunately, the Bergans are both employed and have good insurance through Doug’s new job. But as you may have heard, he was unemployed for some time, so money is tighter than it might seem.
Virginia Anderson: We’ve talked to Janice and she isn’t sure what her insurance covers as related to the breathing and other treatments Caitlynn is likely to need.
Madeline Becker: I can do some initial work on that. I’ll need a release from Janice to get detailed information, but I should be able to get general coverage information. What other resources might they need? McHenry is pretty small, as I’m sure you’re aware.
Marta Simmons: The main issue is going to be the stress of caring for a child with a chronic illness. Even a group that helps members deal with grief would be helpful. Children with CF live much longer than they used to, but it’s still a difficult condition.
Madeline Becker: There isn’t a group like that here, but there is one in Sheyenne. I mean, it’s more for parents in grief already, parents who have lost a child, but it’s a sizable group, relatively speaking. I’m sure there will be some parents who understand what it’s like to have a child with a difficult condition.
Virginia Anderson: All right, that helps. Now, we’re going to provide as much education as we can before Janice takes Caitlynn home, but what kind of resources are there in McHenry? If she doesn’t have home Internet access, does the library offer it? Is there a library?
Madeline Becker: No, the closest library is in Cooperstown.
Marta Simmons: Well, we’ll talk to the Bergans’ pediatrician and see if they might be able to help if they need materials and can’t get them easily at home. This is progressive and lifelong, and they’re going to need some support as they learn to deal with it.
Respiratory Therapist Consult on Skype
A few days after Janice and Caitlynn go back to McHenry, Janice calls to talk to someone about whether she’s doing Caitlynn’s chest physiotherapy correctly. Virginia and Rebecca, the respiratory therapist, call her back on Skype to answer her questions.
Virginia Anderson starts the conversation.
Virginia Anderson: Hi, Janice, thanks for contacting us! We’re getting back to you about Caitlynn. With me on the line is Rebecca Helgo, the respiratory therapist who helped you out when you were here.
Rebecca Helgo: Hi, Janice.
Janice: [sounding stressed] Hi.
Virginia Anderson: Janice, how is it going with Caitlynn?
Janice: Well, that’s why I called, actually. Not so good. I mean, not bad, but I guess I’m not remembering everything you told me when we practiced the physiotherapy, the chest physiotherapy.
Virginia Anderson: That’s okay, Janice. I know this feels overwhelming. Caitlynn’s condition is an extensive one, and we’re here to help you manage it. We’ll continue to be here as you’re figuring this out, okay?
Rebecca Helgo: That’s right, Janice. I know you’ll get the hang of it, but in the meantime there’s a lot to learn. So you had some questions about the chest physiotherapy? What’s going on?
Janice: Okay, if you can see on the camera, Caitlynn has these red marks on her ribs here. Is that a symptom of something?
Rebecca Helgo: Can you get the camera just a bit closer?
Janice: How’s that?
Rebecca Helgo: Okay, very good. Yes, those look like marks from the percussion. Are those over her last two ribs?
Janice: I think so.
Rebecca Helgo: That’s one thing you’ll have to remember: You don’t want to do the percussion on her last two ribs on either side, her backbone, or her breastbone. And when you do it anywhere else, you don’t want to leave red marks. So if you see those, that’s a hint that you’re doing the percussion just a bit too hard.
Virginia Anderson: Don’t worry, you haven’t hurt her that I can see. Plus, you’re obviously really staying on top of things and you’re following the recommended treatment procedures for Caitlynn, and I really want to praise you for that. So, is she acting like that area is hurting her? Or can you tell?
Janice: No, it doesn’t seem like it’s hurting her at all.
Rebecca Helgo: She should be fine, then.
Virginia Anderson: And remember, Janice, if you continue to have trouble with this, we’ve got other options. There’s a vest that vibrates the child if percussion isn’t getting the job done. And you won’t have to do exactly this forever. As she gets older and can learn how to do huff coughs, you’ll be doing less work and she’ll be doing more.
Janice: Okay. Thank you, that makes me feel better. I couldn’t get hold of my pediatrician and I was just getting worried.
Rebecca Helgo: Good, that’s what we’re here for.
Virginia Anderson: Janice, should we review the signs and symptoms of respiratory distress? We’re happy to go over anything you need to feel more confident about monitoring Caitlynn.
Janice: I think I remember those. I feel like I check for them every hour.
Rebecca Helgo: [chuckles] That’s understandable. Well, remember to check with Dr. Benjamin or me or Virginia if you need to.
As you saw in this activity, coordinating care can be a challenge when the patient lives far from her provider or when multiple providers are distant from each other. Many technologies may be necessary in order to provide quality evidence-based care to patients when care teams and patients are not in the same location. Nurses and other health care professionals must find creative solutions when problems arise, so that care planning for remote patients is just as comprehensive and outcome-based as that for patients nearby or on site.
As you work on your assignment, consider these questions:
How was remote collaboration used to improve the quality and safety of the care being provided in the scenario?
In what ways was evidence-based practice being effectively applied to help the patient in the scenario? Were there opportunities for improvement? If so, what were they?