Telemedicine: Solving the Brazilian PICU Shortage

This article discusses the implementation of a telemedicine model in Brazilian public PICUs to address specialist shortages. Observations from a three-year project suggest that synchronous telerounds and integrated education may support care standardisation and clinical improvements. This collaborative framework between public and private sectors offers a potential pathway to reduce regional healthcare disparities.

Introduction

The shortage of paediatric intensivists represents a critical challenge for the sustainability of healthcare systems, directly affecting the management of high-complexity, critically ill patients (Jacovas et al. 2021). According to World Health Organization (WHO) reports, an insufficient density of these specialists per hospital bed correlates with unfavourable clinical outcomes, a scenario significantly exacerbated by the care pressures arising from the COVID-19 pandemic (WHO 2020; WHO 2023). This scarcity of paediatric intensivists compromises care safety and exerts a negative impact on morbidity and mortality within Paediatric Intensive Care Units (PICUs).

In Brazil, this gap is deepened by an asymmetric geographical distribution of human resources. Data from the 2023 Medical Demography report indicate that approximately 70% of specialists operate in the South and Southeast regions, while the North and Northeast face substantial care gaps (Scheffer et al. 2023; 2025). The concentration of these professionals in large urban hubs, typically in municipalities with populations exceeding 500,000 inhabitants, establishes a barrier to access for populations residing in remote areas (AMB 2025). Furthermore, there is a concurrent lack of sufficient PICU beds to meet growing demand. Consequently, critically ill children frequently require long-distance inter-hospital transfers to reference centres, which increases the risk of clinical complications and burdens the public healthcare system (Marcin et al. 2004; Vinadé Chagas et al. 2021; Jacovas et al. 2021).

Within the context of the PICU, telemedicine emerges as a strategic tool to mitigate geographical barriers and facilitate access to specialised care (Marcin 2004; Nadar 2018; Dahmer et al. 2023; Pires 2024). In Brazil, studies on the impact of Telemedicine in the PICU (Tele-PICU) were previously non-existent. In this regard, the Brazilian Ministry of Health enabled a research project for assistance qualification in public hospital ICUs through Telemedicine, in partnership with Hospital Moinhos de Vento in Porto Alegre (Jacovas et al. 2021; Pires et al. 2025). The PROADI-SUS is a cooperation programme between the public sector, led by the Ministry of Health, and healthcare institutions of excellence, which reinvests resources into projects for promotion, research, management, and the incorporation of technologies aimed at qualifying the public network (HMV 2023; Brasil 2024). This article describes the implementation of the Tele-PICU model in Brazilian public units, focusing the analysis on the initial triennium of the project. The report prioritises care processes and clinical outcomes for patients undergoing mechanical ventilation, consolidating the primary evidence and operational lessons derived from this experience.

Methods

Study design and centre selection

This study was a prospective pre-post intervention cohort conducted between 2019 and 2021, totalling a 36-month monitoring period. The initial phase comprised 12 months of retrospective data collection (pre-intervention), followed by 24 months of prospective intervention involving synchronous telerounds (Jacovas et al. 2021; Pires et al. 2025).

The selection of participating centres followed a specific protocol structured into seven qualification stages, as recommended by the management model of the Programme to Support the Institutional Development of the Unified Health System (PROADI-SUS) and Hospital Moinhos de Vento. Inclusion criteria involved: (I) level II complexity units integrated into the public network (SUS); (II) an installed capacity of between 8 and 12 beds; (III) technical infrastructure viability for connectivity; and (IV) formal agreement from institutional management and local healthcare teams. The selected units were the Hospital Geral de Palmas (TO) and the Hospital Regional Norte in Sobral (CE), both located in regions with a shortage of paediatric intensivists (Jacovas et al. 2021).

Population and eligibility criteria

Patients aged 0 to 18 years admitted to the participating PICUs during the study period were included. For the analysis of specific mechanical ventilation (MV) outcomes, the sample consisted of children requiring invasive ventilatory support for more than 24 hours. Patients dependent on prolonged mechanical ventilation, those with chronic diseases, or those whose medical records presented inconsistencies that prevented the calculation of severity indices or primary outcomes were excluded (Pires et al. 2025).

Intervention: The teleround dynamics

The intervention was based on daily synchronous telerounds, conducted from Monday to Friday, with an average duration of 30 to 60 minutes per unit. The sessions were led by a paediatric intensivist from the reference centre (Hospital Moinhos de Vento), alongside the local multidisciplinary team (physicians, nurses, and physiotherapists). The discussion dynamics followed a systematised script:

• Clinical presentation and review of haemodynamic and ventilatory parameters, medications, and laboratory results.
• Joint real-time bedside analysis of each patient and collaborative decision-making between the control centre and remote teams.
• Discussion of therapeutic goals and adjustment of evidence-based protocols, with daily review and modification of plans during the round.

Alongside teleconsultations, the model integrated a continuing education component. This component involved discussing complex clinical cases, remote technical simulation sessions, and specific training for the nursing team, aiming at standardisation and improvement of care practices (Jacovas et al. 2021).

Technological infrastructure

To enable telerounds, specific mobile telemedicine carts were used, equipped with high-definition cameras with Pan-Tilt-Zoom (PTZ) functionality, allowing the remote specialist a detailed view of the patient and bedside monitors. Communication was established via a secure data transmission network, ensuring the confidentiality and integrity of information in compliance with current regulations. Clinical data integration was performed through the review and recording in electronic medical records specially developed for the project (Nadar et al. 2018; Jacovas et al. 2021).

Outcomes and statistical analysis

Considering only the most critical patients who progressed to mechanical ventilation, the primary outcomes were the overall crude mortality rate, the duration of mechanical ventilation (MV), and the Ventilator-Free Days (VFD) index. The VFD was calculated based on 28 days after the initiation of ventilatory assistance, subtracting the number of days on invasive support from the total period; patients who died within the 28-day interval received a score of zero, as per literature standards to avoid survival bias (Verghis et al. 2023; Pires et al. 2025).

The statistical analysis compared the pre- and post-intervention periods. Categorical variables were expressed as frequencies and compared using the chi-squared test or Fisher’s exact test. Continuous variables were tested for normality and compared using Student’s t-test or the Mann-Whitney test. Values of p<0.05p < 0.05p<0.05were considered statistically significant. Analyses were performed for the global sample and stratified by participating centre to identify local variations in response to the intervention.

Results

The sample comprised 790 paediatric patients requiring ventilatory support, distributed between the pre-intervention period (n=261) and the post-intervention phase (n=529). Comparison between cohorts revealed no statistically significant variations regarding age, sex distribution, or severity scores upon admission, ensuring group homogeneity for outcome analysis (Pires et al. 2025).

MV outcomes and mortality

Primary outcome analysis revealed a statistically significant reduction in overall mortality, which declined from 20.7% in the pre-intervention period to 10.4% in the post-intervention phase (p<0.001). Regarding Ventilator-Free Days (VFD), there was an increase from 3 to 4 days (p<0.001).

As for total MV duration, the aggregate analysis showed no significant variations between periods. However, an isolated increase in this variable was observed in Centre A (p=0.025), a finding that may be associated with the increased survival of high-severity patients following the implementation of telemedicine.

Best practices and lessons learned

The favourable clinical outcomes of this project point towards a promising future for Tele-PICU, which is not limited merely to the use of a technological tool. The reduction in mortality and the optimisation of ventilatory support reflect a restructuring of processes. The experience accumulated throughout the implementation of this model allowed for the consolidation of replicable operational models that enabled the intervention's efficacy, as highlighted below.

Operational model viability and care standardisation

The implementation of Tele-PICU demonstrated the technical viability of this replicable care model (Nadar et al. 2018; Jacovas et al. 2021). The use of a synchronous teleround model through a specific platform with security and high-definition requirements allowed for remote clinical guidance and assistance support. The systematic application of this methodology resulted in the standardisation of therapeutic conduct and the implementation of care protocols within the units, which correlated with improvements in clinical parameters, such as mortality reduction and the optimisation of mechanical ventilation strategies (Jacovas et al. 2021; Pires et al. 2025).

Integration of continuous education and multidisciplinary training

The educational component was structured to be integrated into daily care activities, encompassing local training, discussions of high-complexity cases, and remote multidisciplinary sessions. This strategy aligns with guidelines for the qualification of critical centres located in hard-to-reach areas (Marcin et al. 2004). Knowledge sharing between centres contributed to the global improvement of care parameters and a growing learning curve in remote centres, fostering progressive autonomy for each centre to develop its own improvement strategies (Jacovas et al. 2021; Pires et al. 2025).

Mitigation of geographical and logistical barriers

The Tele-PICU model established a technical support network connecting centres in the North and Northeast regions to Hospital Moinhos de Vento (HMV) in Southern Brazil. In a continental-scale scenario, technology acted as the vector for decentralising expertise in paediatric intensive care. This workflow allowed for the application of standardised processes, resulting in greater efficiency in resource management within the public health system and a reduction in regional care gaps (Jacovas et al. 2021; Pires et al. 2025).

Effectiveness of the governance model in public-private partnerships

The structuring of the project under PROADI-SUS governance enabled a technical linkage between the Ministry of Health and philanthropic centres of excellence. The PROADI-SUS model, established in 2009, utilises tax exemption mechanisms to finance training, research, and specialised management activities (Ministry of Health 2025). Implementation analysis demonstrates that this partnership modality optimises the allocation of financial and technical resources, contributing to the reduction of care disparities within the Unified Health System (SUS) (Eisenstein et al. 2020; Pires 2024).

Conclusion

Tele-PICU represents a care model with the technical capacity to mitigate the shortage of specialised intensive care physicians. The Brazilian experience demonstrated that the model produces favourable outcomes, promoting the qualification of care and distance education, while reducing geographical disparities in access. The coordination between the public sector and centres of excellence via PROADI-SUS was the central element for the project’s operational viability. Although clinical indicators demonstrate efficacy during the study period, controlled studies with larger samples are necessary to consolidate the impact of telemedicine within the paediatric intensive care network.

Acknowledgements and Declarations

To the Ministry of Health via PROADI-SUS, Hospital Moinhos de Vento Association, and the participating remote ICU centres. AI tools (ChatGPT-5.0) and Grammarly assisted in the linguistic structuring and review. The final content was fully reviewed, edited, and validated by the authors, who assume technical responsibility.

Conflict of Interest

None.