Dartmouth Health Uses Telemedicine, Virtual Learning to Help With Difficult Births

The New Hampshire health system is using a virtual health program to train rural providers to handle difficult births, while also plugging in a robust telemedicine network to offer on-demand access to specialists.

Rural hospitals are closing their labor and delivery (L&D) units at alarming rates, forcing more expectant parents to give birth in an ill-prepared emergency room or other location, like the back of an ambulance.

At New Hampshire's Dartmouth Health, officials are combining virtual learning and a hub-and-spoke telemedicine platform to address difficult and emergency births. This includes STONE (Simulation Training for Obstetric and Neonatal Emergencies) training delivered on a virtual platform to rural healthcare providers such as emergency department personnel and paramedics, as well as an around-the-clock Tele-ED platform offering on-demand access to specialists to assist in emergency births.

"Sometimes babies come fast," Kevin Curtis, MD, MS, medical director of connected care and the Center of Telehealth at Dartmouth-Hitchcock Medical Center, said during a presentation at the Northeast Telehealth Resource Center's annual meeting this month in Nashua, New Hampshire.

In New Hampshire, 11 of 27 hospitals, or 40% of the state's hospitals, have shut down their L&D units since 2011. All but one are in areas designated by the U.S. Health Resources and Services Administration (HRSA) as rural service areas. Nationwide, 217 hospitals have closed their L&D departments, creating more maternity care deserts, where access to services is strained.

Many rural hospitals are closing L&D units because of the cost of staffing and keeping open a unit that doesn't see a lot of activity over the course of a year, but the consequences are dire, especially for expectant parents experiencing a difficult birth, requiring a C-section, or needing immediate care by neonatal intensivists. On top of that, most rural EMS units and emergency departments don't have quick access to those specialists. The result is an increase in difficult births and a resulting surge in babies and mothers experiencing health problems, including death.

That's true in New Hampshire, a decidedly rural state in northern New England with one teaching hospital (Dartmouth-Hitchcock Medical Center) and a network of smaller hospitals and clinics overseeing a population of roughly 1.4 million. Aside from lack of access, residents also must contend with rough terrain and snowy winters, making travel difficult.

The lack of resources for pregnant families "is projected to get worse, and it's happening all over the country," says Curtis. "We're seeing these [complicated births] more often, and even bedside teams are asking for our help."

Dartmouth Health's answer is two-fold. Using a one-year HRSA grant, the health system created a virtual STONE program, and has seen more than 120 rural providers and EMS personnel go through the program so far. The program gives providers the education they need to handle difficult births and uses simulation to guide those providers through various scenarios.

Beyond training rural providers to handle difficult births, Curtis and Patricia Lanter, MD, MS, associate professor of emergency medicine at Dartmouth-Hitchcock's Geisel School of Medicine and associate program director of the emergency medicine residency program, saw an opportunity to integrate the health system's robust telehealth network. Dartmouth Health Connected Care, which launched 11 years ago, now offers eight different telemedicine services across the state through its hub at Dartmouth-Hitchcock Medical Center in Lebanon, including TeleEmergency care at 13 hospital EDs and TeleICN (neonatal intensive care) services at 11 sites.

Through the Lebanon hospital, the health system's telehealth team can connect providers in distant and remote locations with ED doctors or OB-GYN or TeleICN specialists to handle difficult births and resulting in care for both the mother and baby.

Lanter says rural healthcare providers "are scared to death" of having to handle complicated births and are eager to have experts on a real-time audio-visual platform helping them. It's also important, she says, to have those specialists on hand to help providers when something goes wrong, such as the death of a baby or mother.

Curtis says the Tele-ED program has assisted in roughly five OB emergencies since the program was launched in May, while the TeleICN platform has been called in, on average, five times a month to help with infant care. And he expects those types of emergencies to become more frequent and complicated as rural healthcare sites struggle to stay open and difficult pregnancies and births increase.

But while the program is no doubt saving lives, it's also expensive. Curtis says the price tag to keep the hub manned 24 hours a day every day is prohibitive, particularly in a region where there aren't that many emergencies.

"TeleEmergency [care] still isn't pervasive at all in this country," he says.

Curtis and Lanter say they'll look for ways to make the STONE program sustainable. As for the Tele-ED platform, Curtis says that will remain open, as it's part of the health system's core mission. They charge a subscription rate to each hospital in the network, he says, but that doesn't cover the overall costs.

"It's very expensive," he says. "We couldn’t offer a break-even price because no one could afford it."