Telemedicine reduces discrepancies in rural trauma care

The impact of telehealth in sepsis care: A systematic review

OBJECTIVES

Sepsis is associated with significant mortality. Telehealth may improve the quality of early sepsis care, but the use and impact of telehealth applications for sepsis remain unclear. We aim to describe the telehealth interventions that have been used to facilitate sepsis care, and to summarize the reported effect of telehealth on sepsis outcomes.

DATA SOURCES

We identified articles reporting telehealth use for sepsis using an English-language search of PubMed, CINAHL Plus (EBSCO), Academic Search Ultimate (EBSCO), APA PsycINFO (EBSCO), Public Health (ProQuest), and Web of Science databases with no restrictions on publication date.

STUDY SELECTION

Included studies described the use of telehealth as an intervention for treating sepsis. Only comparative effectiveness analyses were included.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines, two investigators independently selected articles for inclusion and abstracted data. A random-effects subgroup analysis was conducted on patient survival treated with and without telehealth.

RESULTS

A total of 15 studies were included, involving 188,418 patients with sepsis. Thirteen studies used observational study designs, and the most common telehealth applications were provider-to-provider telehealth consultation and intensive care unit telehealth. Clinical and methodological heterogeneity was significantly high. Telehealth use was associated with higher survival, especially in settings with low control group survival. The effect of telehealth on other care processes and outcomes were more varied and likely dependent on hospital-level factors.

CONCLUSIONS

Telehealth has been used in diverse applications for sepsis care, and it may improve patient outcomes in certain contexts. Additional interventional trials and cost-based analyses would clarify the causal role of telehealth in improving sepsis outcomes.

Telemedicine in Acute Trauma Care: A Review of Quantitative Evaluations on the Impact of Remote Consultation

BACKGROUND

There is extensive literature describing the application of telemedicine techniques to trauma care. However, there is a paucity of articles showing quantitative assessment of its safety and efficacy. This structured review examines articles with quantitative assessment of telemedicine's impact in acute trauma care.

METHODS

Medline and CINAHL databases were searched for peer-reviewed articles that quantitatively assess the impact of telemedicine on diagnostic accuracy, clinical decision-making, emergency department length of stay, transfer rates, and mortality in initial trauma management.

RESULTS

Only 9 of the 408 screened articles met the criteria for quantitative assessment. Telemedicine appears to be preferentially used for more severely injured patients. Limited quality evidence supports procedural interventions at remote sites. Telemedicine may help abbreviate pre-transfer length of stay. However, its impact on diagnosis and mortality remains unclear.

CONCLUSIONS

Telemedicine's potential to enhance the quality and efficiency of trauma care, especially for resource-scarce areas, warrants continued quantitative research.

Multidisciplinary Perspectives on the Implementation of a Comprehensive Sexual Assault Telehealth Program in Rural Communities: A Qualitative Study

Access to quality sexual assault (SA) care in rural communities is limited by challenges surrounding building and sustaining a skilled SA nurse examiner workforce. Telehealth can facilitate access to expert care while cultivating a local sexual assault response. The Sexual Assault Forensic Examination Telehealth (SAFE-T) Center aims to decrease disparities in SA care by providing expert, live, interactive mentoring, quality assurance, and evidence-based training via telehealth. This study examines multidisciplinary perceptions of pre-implementation barriers and SAFE-T program impact using qualitative methods. Implications for the implementation of telehealth programs to support access to quality SA care are considered.

Patterns in the Use of Emergency Telemedicine Support in the Management of Traumatic Road Crashes

Objective: The introduction of emergency telemedicine care models is a common theme in health jurisdictions that include rural and remote populations. How the availability of these models influences the way clinicians manage traumatic road crashes is not yet fully understood. This study seeks to compare road crashes where telemedicine was and was not used and to identify any variables that may increase the likelihood of telemedicine usage by treating clinicians. Methods: Road crashes reported in the state Department of Transport and Main Roads (Queensland, Australia) crash database between January 1, 2019, and November 30, 2020 (n = 23,734) were compared to videoconferencing call logs to determine which crashes resulted in treatment that was supported by telemedicine (n = 204). Analysis was performed to examine differences in characteristics related to the crash depending on whether telemedicine support was requested. Results: Road crashes where telemedicine support was requested on average involved more casualties (1.6 vs. 1.41; t(11,287) = -3.26, p < 0.001, relative risk = 1.13). Crashes that occurred in rural settings accounted for most requests for telemedicine (65.68%; X2 = 159.2, p < 0.001) and a greater percentage of crashes in remote locations (3.36% vs. 2.35%; X2 = 256.97, p < 0.001, relative risk = 1.43). The use of telemedicine support for crashes was associated with a 13% increase in the mean number of casualties, compared to crashes where telemedicine support was not used. Conclusion: Telemedicine support is requested by clinicians providing emergency treatment in the management of road crashes that produce more severe injuries, involve multiple casualties, and take place in more rural settings or remote locations.

American Trauma Care: A System of Systems

OBJECTIVE

The benefits of organized trauma systems have been well-documented during 50 years of trauma system development in the United States. Unfortunately, despite this evidence, trauma system development has occurred only sporadically in the 50 states.

METHODS

The relevant literature related to trauma system design and development was reviewed based on relevance to the study. Information from these sources was summarized into a SWOT (strengths, weaknesses, opportunities, and threats) analysis.

RESULTS

Strengths discovered were leadership brought forth by the American College of Surgeons Committee on Trauma and meaningful change generated from The National Academy of Sciences, Engineering, and Medicine report addressing the fractionation of the nation's trauma systems, whereas weaknesses included patient outcome disparities due to the lack of a national governing authority, undertriage, underresourced rural trauma, and underfunded trauma research. Opportunities included the creation of level IV trauma centers; telemedicine; the development of rural trauma management courses; air medical transport to bring high-intensity care to the patient, particularly in rural areas; trauma research; and trauma prevention through outreach and educational programs. The following threats were determined: mass casualty incidents, motor vehicle collisions because of the high rate of motor vehicle collision deaths in the United States relative to other developed countries, and underfunded trauma systems.

CONCLUSION

Much work remains to be done in the development of an American trauma system. Recommendations include implementation of trauma care governance at the federal level; national oversight and support of emergency medical services systems, particularly in rural areas with strict reporting processes for emergency medical services programs; national organization of our mass casualty response; increased federal and state funding allocated to trauma centers; a consistent model for trauma system development; and trauma research.

Interfacility transfer of pediatric trauma patients to higher levels of care: The effect of transfer time and level of receiving trauma center

BACKGROUND

Interfacility transfer of pediatric trauma patients to pediatric trauma centers (PTCs) after evaluation in nontertiary centers is associated with improved outcomes. We aimed to assess the outcomes of transferred pediatric patients based on their severity of the injury, transfer time, and level of receiving PTCs.

METHODS

This is a 3-year (2017-2019) analysis of the American College of Surgeons Trauma Quality Improvement Program database. All children (younger than 15 years) who were transferred from other facilities to Level I or II PTC were included and stratified by level of receiving PTCs and injury severity. Outcome measures were in-hospital mortality and major complications.

RESULTS

A total of 67,726 transferred pediatric trauma patients were identified, of which 52,755 were transferred to Level I and 14,971 to Level II. The mean ± SD age and median Injury Severity Score were 7 ± 4 years and 4 (1-6), respectively. Eighty-five percent were transported by ground ambulance. The median transfer time for Levels I and II was 93 (70-129) and 90 (66-128) minutes, respectively ( p < 0.001). On multivariable regression, interfacility transfers to Level I PTCs were associated with decreased risk-adjusted odds of in-hospital mortality among the mildly to moderately injured group (adjusted odds ratio, 0.59; p = 0.037) and severely injured group with a transfer time of less than 60 minutes (adjusted odds ratio, 0.27; p = 0.002).

CONCLUSION

Every minute increase in the interfacility transfer time is associated with a 2% increase in risk-adjusted odds of mortality among severely injured pediatric trauma patients. Factors other than the level of receiving PTCs, such as estimated transfer time and severity of injury, should be considered while deciding about transferring pediatric trauma patients to higher levels of care.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Patient-performed at-home surgical drain removal is safe and feasible following hernia repair and abdominal wall reconstruction

BACKGROUND

Traditionally, surgical drains are considered a relative contraindication to telemedicine-based postoperative care. We sought to assess the safety, feasibility, and outcomes of an at-home patient-performed surgical drain removal pilot program.

METHODS

A prospective cohort study among patients who were discharged with surgical drains was performed. Patients discharged with drains were given the option for in-clinic, provider-performed removal, or at-home, patient-performed drain removal. Patient demographics, health characteristics, perioperative metrics, and operative outcomes were compared and analyzed.

RESULTS

A total of 68 encounters with drain removal were included (at-home: 28%, n = 19; in-clinic: 72%, n = 49), with both groups having similar demographics, except for age (median age of telemedicine-based at-home: 50 vs in-clinic: 62 years, p = 0.03). Patients who opted into at-home, patient-performed drain removal were more likely to have drain removal occur earlier (9 vs 13 days for in-clinic, p < 0.001). In-clinic removal resulted in increased encounters with surgical nursing staff and increased travel time, with no significant difference in complication burden.

CONCLUSIONS

Patient-performed at-home drain removal is safe and allows for more timely drain removal.

National Estimates of Workplace Telehealth Use Among Emergency Nurses and All Registered Nurses in the United States

INTRODUCTION

The goal of this research was to quantify the baseline status of prepandemic workplace emergency nursing telehealth as a key consideration for ongoing telehealth growth and sustainable emergency nursing care model planning. The purpose of this research was to: (1) generate national estimates of prepandemic workplace telehealth use among emergency and other inpatient hospital nurses and (2) map the geographic distribution of prepandemic workplace emergency nurse telehealth use by state of nurse residence.

METHODS

We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses. Data were analyzed using jack-knife estimation procedures coherent with the complex sampling design selected as representative of the population and requiring analysis with survey weights.

RESULTS

Weighted estimates of the 161 865 emergency nurses, compared with 1 191 287 other inpatient nurses revealed more reported telehealth in the workplace setting (49% vs 34%) and individual clinical practice telehealth use (36% vs 15%) among emergency nurses. The geographic distribution of individual clinical practice emergency nurse telehealth use indicates greatest adoption per 10 000 state residents in Maine, Alaska, and Missouri with more states in the Midwest demonstrating emergency nurse adoption of telehealth into clinical practice per population than other regions in the United States.

DISCUSSION

By quantifying prepandemic national telehealth use, the results provide corroborating evidence to the potential long-term adoptability and sustainability of telenursing in the emergency nursing specialty. The results also implicate the need to proactively define emergency nursing telehealth care model standards of practice, nurse competencies, and reimbursement.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

A National Evaluation of Surgeon Experiences in Telemedicine for the Care of Hernia and Abdominal Core Health Patients

Background

Surgeons are increasingly utilizing telemedicine to provide perioperative services to patients. Safety, satisfaction, and feasibility of these programs in general populations have been established, but it is unclear how telemedicine can be integrated into subspecialty care. We report results of a national survey related to telehealth practices among members of the Abdominal Core Health Quality Collaborative (ACHQC).

Methods

Survey responses were analyzed to determine current strategies in telemedicine utilization. Surgeon preferences, perceptions of validity, and identified barriers to implementation of telemedicine were assessed.

Results

Forty surgeons within the ACHQC responded, with 90% of respondents reporting use of telemedicine to deliver perioperative care to patients with hernias and abdominal core health concerns. Surgeons appeared to be more comfortable managing preoperative patients with image-confirmed diagnoses of hernias. Surgeons were universally more comfortable delivering postoperative care via telemedicine. Connectivity, patient engagement, and reimbursement were identified as potential barriers to expansion of telemedicine. Seventy-eight percent of respondents reported that they would increase telemedicine utilization if current regulations were maintained in the future.

Conclusions

This study found that hernia specialists are utilizing telemedicine at a higher rate than before the COVID-19 pandemic, with surgeons reporting interest in continued use of this modality beyond the pandemic. These findings suggest that future work in telemedicine optimization may improve the quality of care that can be delivered to patients with abdominal core health concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06332-9.

Exploring user perspectives of factors associated with use of teletrauma in rural areas

BACKGROUND

Despite the existence of universal health care for Canadians, health inequalities persist and those residing in rural regions experience disparities when accessing appropriate services. To enhance access, a teletrauma program was implemented in a rural northern region in western Canada, connecting rural clinicians to urban emergency physicians and trauma specialists during emergency cases.

OBJECTIVE

To explore reasons why teletrauma is used in rural contexts from the perspectives of service users and stakeholders.

METHODS

14 semi-structured interviews were conducted with stakeholders, clinicians (physicians, specialists), management, and researchers. Interpretive description methodology guided the study and analysis, and findings were organized thematically.

RESULTS

Teletrauma was used to connect clinicians, manage complex cases when weather or distance delayed transfer, and to enable appropriate and timely treatment locally. Teletrauma was more likely to be activated when clinicians were uncomfortable with clinical management, when relationships were established, and when technology was familiar and easy to use.

CONCLUSIONS

Teletrauma is more than just the technology that is deployed. The establishment of relationships between teletrauma users was vital to the success of teletrauma. To design effective, integrated, and sustainable services, rural clinicians must remain at the center of teletrauma models.

Rural Telemedicine Use Before and During the COVID-19 Pandemic: Repeated Cross-sectional Study

Background

The COVID-19 pandemic has led to a notable increase in telemedicine adoption. However, the impact of the pandemic on telemedicine use at a population level in rural and remote settings remains unclear.

Objective

This study aimed to evaluate changes in the rate of telemedicine use among rural populations and identify patient characteristics associated with telemedicine use prior to and during the pandemic.

Methods

We conducted a repeated cross-sectional study on all monthly and quarterly rural telemedicine visits from January 2012 to June 2020, using administrative data from Ontario, Canada. We compared the changes in telemedicine use among residents of rural and urban regions of Ontario prior to and during the pandemic.

Results

Before the pandemic, telemedicine use was steadily low in 2012-2019 for both rural and urban populations but slightly higher overall for rural patients (11 visits per 1000 patients vs 7 visits per 1000 patients in December 2019, P<.001). The rate of telemedicine visits among rural patients significantly increased to 147 visits per 1000 patients in June 2020. A similar but steeper increase (P=.15) was observed among urban patients (220 visits per 1000 urban patients). Telemedicine use increased across all age groups, with the highest rates reported among older adults aged ≥65 years (77 visits per 100 patients in 2020). The proportions of patients with at least 1 telemedicine visit were similar across the adult age groups (n=82,246/290,401, 28.3% for patients aged 18-49 years, n=79,339/290,401, 27.3% for patients aged 50-64 years, and n=80,833/290,401, 27.8% for patients aged 65-79 years), but lower among younger patients <18 years (n=23,699/290,401, 8.2%) and older patients ≥80 years (n=24,284/290,401, 8.4%) in 2020 (P<.001). There were more female users than male users of telemedicine (n=158,643/290,401, 54.6% vs n=131,758/290,401, 45.4%, respectively, in 2020; P<.001). There was a significantly higher proportion of telemedicine users residing in relatively less rural than in more rural regions (n=261,814/290,401, 90.2% vs n=28,587/290,401, 9.8%, respectively, in 2020; P<.001).

Conclusions

Telemedicine adoption increased in rural and remote areas during the COVID-19 pandemic, but its use increased in urban and less rural populations. Future studies should investigate the potential barriers to telemedicine use among rural patients and the impact of rural telemedicine on patient health care utilization and outcomes.

Procedural Telementoring in Rural, Underdeveloped, and Austere Settings: Origins, Present Challenges, and Future Perspectives

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.

Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review

Introduction

Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients.

Materials and Methods

A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29^th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies.

Results

The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients.

Conclusions

The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.

Effectiveness and cost-effectiveness of telehealth in rural and remote emergency departments: a systematic review protocol

BACKGROUND

Emergency telehealth has been used to improve accessibility of rural and remote patients to specialist care. Evidence to date has demonstrated effectiveness and cost-effectiveness of telehealth in rural and remote emergency departments within a variety of contexts. However, systematic reviews to date have not focused on the rural and remote emergency departments. The purpose of this study is to review the outcome measures used in evaluations of emergency telehealth in rural and remote settings and assess evidence relating to their effectiveness and cost-effectiveness.

METHODS

Randomised controlled trials, non-randomised controlled trials, and full and partial economic evaluations (e.g. cost-effectiveness, cost-benefit, and cost-utility analyses) of telehealth in rural and remote emergency departments will be included. Comprehensive literature searches will be conducted in multiple electronic databases (from 1990 onwards): MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, EconLit, CRD databases (e.g. NHS Economic Evaluation database), and Tufts Cost-Effectiveness Registry. Two authors will independently screen all citations, full-text articles, and abstract data. The methodological quality (or risk of bias) of individual studies will be appraised using an appropriate tool. A systematic narrative synthesis will be provided with information presented in the text and tables to summarise and explain the characteristics and findings of the studies. If feasible, we will conduct random effects meta-analysis.

DISCUSSION

This review will identify gaps in the current body of evidence relating to the effectiveness and cost-effectiveness of rural and remote emergency telehealth services. By confining to articles written in the English language, this analysis may be subjected to publication bias and results need to be interpreted accordingly. We believe the results of this review could be valuable for the design of future economic evaluations of emergency telehealth services implemented in the rural and remote context.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019145903.

Managing Emergencies in Rural North Queensland: The Feasibility of Teletraining

Introduction

Historically, the use of videoconference technologies in emergency medicine training has been limited. Whilst there are anecdotal reports of the use of teletraining for emergency medicine by rural doctors in Australia, minimal evidence exists in the literature. This paper aimed to explore the use of teletraining in the context of managing emergency presentations in rural hospitals.

Methods

Using a qualitative approach, a mixture of junior and senior doctors were invited to participate in semistructured interviews. Data were transcribed and analysed line by line. Applying the grounded theory principles of open and axial coding, themes and subthemes were generated.

Results

A total of 20 interviews were conducted with rural doctors, rural doctors who are medical educators, and emergency medicine specialists. Two major themes—(1) teletraining as education and (2) personal considerations—and ten subthemes were evident from the data. Most participants had some previous experience with teletraining. Access to peer teaching over videoconference was requested by rural generalist registrars. There was a preference for interactive training sessions, over didactic lectures with little mention of technical barriers to engagement. The ability of teletraining to reduce professional isolation was a major benefit for doctors practicing in remote locations.

Discussion

For these rural doctors, teletraining is a feasible method of education delivery. Wider application of teletraining such as its use in peer teaching needs to be explored. The benefits of teletraining suggest that teletraining models need to be core business for health services and training providers, including specialist colleges.

Use of telehealth in the management of non-critical emergencies in rural or remote emergency departments: A systematic review

BACKGROUND

Telehealth has been used extensively in emergency departments to improve healthcare provision. However, its impact on the management of non-critical emergency presentations within rural and remote emergency department settings has not been adequately explored. The objective of this systematic review is to identify how telehealth has been used to assist in the management of non-critical presentations in rural and remote emergency departments and the outcomes.

METHODS

Articles were identified through database searches of CINAHL, Cochrane, MEDLINE (OVID), Informit and SCOPUS, as well as the screening of relevant article reference and citation lists. To determine how telehealth can assist in the management of non-critical emergencies, information was extracted relating to telehealth programme model, the scope of service and participating health professionals. The outcomes of telehealth programmes were determined by analysing the uptake and usage of telehealth, the impact on altering a diagnosis or management plan as well as patient disposition including patient transfer, discharge, local hospital admission and rates of discharge against medical advice.

RESULTS

Of the 2532 identified records, 15 were found to match the eligibility criteria and were included in the review. Uptake and usage increased for telehealth programmes predominantly utilised by nursing staff with limited local medical support. Teleconsultation conservatively altered patient diagnosis or management in 18-66% of consultations. Although teleconsultation was associated with increased patient transfer rates, unnecessary transfers were reduced. Simultaneously, an increase in local hospital admission was noted and fewer patients were discharged home. Discharge against medical advice rates were low at 0.9-1.1%.

CONCLUSION

The most widely implemented hub-and-spoke telehealth model could be incorporated into existing referral frameworks. Telehealth programmes may assist in reducing unnecessary patient transfer and secondary overtriage, while increasing the capacity of emergency department staff to diagnose and manage patients locally, which may translate into increased local hospital admission and reduced discharge rates following teleconsultation.

Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients

BACKGROUND

Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes.

OBJECTIVES

This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota.

METHODS

Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality.

RESULTS

Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.

Usefulness of videoconferencing in psychiatric emergencies -- a qualitative study

High quality health services for psychiatric emergencies are difficult to maintain 24 h a day in sparsely populated areas, where the availability of specialists are limited. To overcome this challenge, the University Hospital of North Norway implemented an on-call system in psychiatric emergencies, by which psychiatrists are accessible 24/7 for telephone and videoconferencing consultations with patients and nurses at three regional psychiatric centers. The purpose of this study was to explore the usefulness of videoconferencing consultations in psychiatric emergencies. The on-call psychiatrists and nurses at the regional psychiatric centers who participated in at least one videoconferencing consultation were recruited for semi-structured interviews: 5 psychiatrists and 19 nurses for a total of 24 participants. The interviews were performed from July of 2012 to June of 2013. The interviews were transcribed and analyzed using a stepwise-deductive-inductive approach supported by the HyperRESEARCH analysis software. After the introduction of the videoconferencing system, telephone consultations were still used for straightforward situations when further treatment or admission decisions were obvious. Videoconferencing consultations, during which patients were present, were useful for challenging situations when there was 1) uncertainty regarding the degree of illness or the level of treatment, 2) a need to clarify the severity of the patient condition, 3) a need to build an alliance with the patient, and 4) disagreement either between health personnel or between the patient and health personnel. Videoconferencing is useful for challenging and complex psychiatric emergencies and is a suitable tool for building high quality, decentralized psychiatric services.

Emergency Department Telemedicine Is Used for More Severely Injured Rural Trauma Patients, but Does Not Decrease Transfer: A Cohort Study

OBJECTIVES

Traumatic injury is a leading cause of death in the United States, and rural populations are at increased risk of injury and death. Rural residents have limited access to trauma care, and telemedicine has been proposed as one strategy to improve the provision of trauma care locally. The objective of this study was to describe patient-level factors associated with telemedicine consultation in North Dakota critical-access hospital (CAH) emergency departments (EDs) and to measure the association between telemedicine consultation and interhospital transfer.

METHODS

Observational cohort study of all adult (age ≥ 18 years) trauma patients treated in North Dakota CAH EDs with an active telemedicine subscription between 2008 and 2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine-enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and interhospital transfer, adjusting for patient, injury, and hospital factors.

RESULTS

Of the 9,281 North Dakota trauma patients seen in CAHs, 2,837 were treated in an ED with an active telemedicine subscription. Telemedicine was consulted for 11% of all trauma patients in telemedicine-capable EDs. Factors associated with telemedicine consultation included higher Injury Severity Score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness, injury mechanism, and type of injury, telemedicine use was not associated with interhospital transfer (adjusted odds ratio = 1.28, 95% confidence interval = 0.94 to 1.75).

CONCLUSION

Emergency department-based telemedicine consultation is requested for the most severely injured rural trauma patients, especially with those with penetrating trauma, burns, and abnormal presenting vital signs. Telemedicine consultation was not independently associated with increased probability of transfer. Future work should evaluate how telemedicine impacts the timeliness of care and specific care interventions.

A systematic review of the methodologies used to evaluate telemedicine service initiatives in hospital facilities

BACKGROUND

The adoption of telemedicine into mainstream health services has been slower than expected. Many telemedicine projects tend not to progress beyond the trial phase; there are a large number of pilot or project publications and fewer 'service' publications. This issue has been noted since 1999 and continues to be acknowledged in the literature. While overall telemedicine uptake has been slow, some services have been successful. The reporting and evaluation of these successful services may help to improve future uptake and sustainability. The aim of this literature review was to identify peer-reviewed publications of deployed telemedicine services in hospital facilities; and to report, and appraise, the methodology used to evaluate these services.

METHODS

Computerised literature searches of bibliographic databases were performed using the MeSH terms for "Telemedicine" and "Hospital Services" or "Hospital", for papers published up to May 2016.

RESULTS

A total of 164 papers were identified, representing 137 telemedicine services. The majority of reported telemedicine services were based in the United States of America (n=61, 44.5%). Almost two thirds of the services (n=86, 62.7%) were delivered by real time telemedicine. Of the reviewed studies, almost half (n=81, 49.3%) assessed their services from three different evaluation perspectives: clinical outcomes, economics and satisfaction. While the remaining half (n=83, 50.6%) described their service and its activities without reporting any evaluation measures. Only 30 (18.2%) studies indicated a two-step implementation and evaluation process. There was limited information in all reported studies regarding description of a structured planning strategy.

CONCLUSION

Our systematic review identified only 137 telemedicine services. This suggests either telemedicine service implementation is still not a part of mainstream clinical services, or it is not being reported in the peer-reviewed literature. The depth and the quality of information were variable across studies, reducing the generalisability. The reporting of service implementation and planning strategies should be encouraged. Given the fast paced technology driven environment of telemedicine, this may enable others to learn and understand how to implement sustainable services. The key component of planning was underreported in these studies. Studies applying and reporting more rigorous methodology would contribute greatly to the evidence for telemedicine.

Lessons from tele-emergency: improving care quality and health outcomes by expanding support for rural care systems

Tele-emergency services provide immediate and synchronous audio/video connections, most commonly between rural low-volume hospitals and an urban "hub" emergency department. We performed a systematic literature review to identify tele-emergency models and outcomes. We then studied a large tele-emergency service in the upper Midwest. We sent a user survey to all seventy-one hospitals that used the service and received 292 replies. We also conducted telephone interviews and site visits with ninety clinicians and administrators at twenty-nine of these hospitals. Participants reported that tele-emergency improves clinical quality, expands the care team, increases resources during critical events, shortens time to care, improves care coordination, promotes patient-centered care, improves the recruitment of family physicians, and stabilizes the rural hospital patient base. However, inconsistent reimbursement policy, cross-state licensing barriers, and other regulations hinder tele-emergency implementation. New value-based payment systems have the potential to reduce these barriers and accelerate tele-emergency expansion.

The 60 most highly cited articles published in the Journal of Telemedicine and Telecare and Telemedicine Journal and E-health

Summary

We analysed the most highly cited articles in two specialist telemedicine journals, the Journal of Telemedicine and Telecare (JTT) and Telemedicine Journal and E-health (TJEH). Articles were extracted from the Science Citation Index Expanded in September 2012. A total of 1810 articles were listed for the JTT and 1550 for TJEH. In the JTT, the mean number of citations was 43 (SD 13); in TJEH the mean number of citations was 30 (SD 11). The average number of citations for the JTT was significantly higher than for TJEH ( P < 0.001). In each journal, the 60 articles which had the most citations were identified as highly cited publications (HCPs). The 60 HCPs in the JTT originated from 16 countries; the 60 HCPs in TJEH originated from 10 countries. Considering both journals together, the majority of HCPs came from the US, UK, Australia and Canada. In the JTT, the mean number of authors for each HCP was 4.6 (SD = 3.1); in TJEH, the mean number of authors for each HCP was 4.5 (SD = 2.3). There was no difference between the two journals ( P = 0.84) and the characteristics of the HCPs published in the JTT and TJEH were broadly similar. Although HCPs are not a direct method of measuring quality, they are an indicator of the scientific impact of the articles.

Telehealth and Medicare: payment policy, current use, and prospects for growth

OBJECTIVE

Evaluate the growth in various types of Medicare-paid telehealth services.

BACKGROUND

There has been a long-standing hope that telehealth could be used to reduce rural patients' travel times to specialty physicians. Medicare covers telehealth services provided through live, interactive videoconferencing between a beneficiary located at a certified rural site and a distant practitioner.

METHODS

We analyzed 100% of telehealth Medicare claims for 2009 matched to individual patient ZIP codes and individual provider characteristics.

RESULTS

Despite increases in Medicare payment rates for telehealth services, expansions of covered services, reductions in provider requirements, and provisions of federal grants to encourage telehealth, growth in adoption of telehealth among providers has been modest. Medicare claims indicate that only 369 providers had 10 or more Medicare telehealth consultations in 2009. Roughly half of the 369 were mental health professionals, and about one-in-five of the 369 were non-physician professionals (e.g., physician assistants and nurse practitioners). On balance, the strong areas of telehealth are mental health and, surprisingly, nonphysician professionals. The comparative advantage of mental health could be the verbal (rather than physical contact) nature of mental health care, and the comparative advantage of non-physician professionals could be their lower labor costs.

State of Emergency Medicine in Switzerland: a national profile of emergency departments in 2006

Background

Emergency departments (EDs) are an essential component of any developed health care system. There is, however, no national description of EDs in Switzerland. Our objective was to establish the number and location of EDs, patient visits and flow, medical staff and organization, and capabilities in 2006, as a benchmark before emergency medicine became a subspecialty in Switzerland.

Methods

In 2007, we started to create an inventory of all hospital-based EDs with a preliminary list from the Swiss Society of Emergency and Rescue Medicine that was improved with input from ED physicians nationwide. EDs were eligible if they offered acute care 24 h per day, 7 days per week. Our goal was to have 2006 data from at least 80% of all EDs. The survey was initiated in 2007 and the 80% threshold reached in 2012.

Results

In 2006, Switzerland had a total of 138 hospital-based EDs. The number of ED visits was 1.475 million visits or 20 visits per 100 inhabitants. The median number of visits was 8,806 per year; 25% of EDs admitted 5,000 patients or less, 31% 5,001-10,000 patients, 26% 10,001-20,000 patients, and 17% >20,000 patients per year. Crowding was reported by 84% of EDs with >20,000 visits/year. Residents with limited experience provided care for 77% of visits. Imaging was not immediately available for all patients: standard X-ray within 15 min (70%), non-contrast head CT scan within 15 min (38%), and focused sonography for trauma (70%); 67% of EDs had an intensive care unit within the hospital, and 87% had an operating room always available.

Conclusions

Swiss EDs were significant providers of health care in 2006. Crowding, physicians with limited experience, and the heterogeneity of emergency care capabilities were likely threats to the ubiquitous and consistent delivery of quality emergency care, particularly for time-sensitive conditions. Our survey establishes a benchmark to better understand future improvements in Swiss emergency care.

Enhancing trauma education worldwide through telemedicine

Advances in information and communication technologies are changing the delivery of trauma care and education. Telemedicine is a tool that can be used to deliver expert trauma care and education anywhere in the world. Trauma is a rapidly-evolving field requiring access to readily available sources of information. Through videoconferencing, physicians can participate in continuing education activities such as Grand Rounds, seminars, conferences and journal clubs. Exemplary programs have shown promising outcomes of teleconferences such as enhanced learning, professional collaborations, and networking. This review introduces the concept of telemedicine for trauma education, and highlights efforts of programs that are utilizing telemedicine to unite institutions across the world.

Measuring tele-ICU impact: does it optimize quality outcomes for the critically ill patient?

AIMS

To determine the relationship between tele-ICU (intensive care unit) implementations and improvement in quality measures and patient outcomes.

BACKGROUND

Tele-ICUs were designed to leverage scarce critical-care experts and promised to improve patient quality.

EVALUATION

Abstracts and peer-reviewed articles were reviewed to identify the associations between tele-ICU programmes and clinical outcomes, cost savings, and customer satisfaction.

KEY ISSUES

Few peer-reviewed studies are available and many variables in each study limit the ability to associate study conclusions to the overall tele-ICU programme. Further research is required to explore the impact of the tele-ICU on patient/family satisfaction. Research findings are highly dependent upon the level of ICU acceptance.

CONCLUSIONS

The tele-ICU, in collaboration with the ICU team, can be a valuable tool for the enhancement of quality goals although the ability to demonstrate cost savings is extremely complex. Studies clearly indicate that tele-ICU nursing vigilance can enhance patient safety by preventing potential patient harm.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers and leaders play a vital part in optimizing the quality role of the tele-ICU through supportive modelling and the maximization of ICU integration.

Telemedicine in acute-phase injury management: a review of practice and advancements

OBJECTIVES

To offer a systematic review of the body of literature in the emerging field of telemedicine in the management of acute-phase injuries.

MATERIALS AND METHODS

We conducted a literature review.

RESULTS

Telemedicine has only recently been applied to the specialties of trauma, emergency care, and surgery. The potential benefits of telemedicine include a decrease in travel expenses, enhanced continuity of care, and increased access to specialized consultants in medically underserved and rural areas.

CONCLUSIONS

There still exist barriers to the use of teletechnologies in medicine that limit their wider adoption. Poor infrastructure, limited equipment availability, and insufficient access to training and education for medical personnel have prevented wider use.

Legal Bases for Medical Supervision via Mobile Telecommunications in Japan

This paper discusses the legal basis for mobile telecommunications-based medical supervision in Japan and bulletin from the Ministry of Health, Labour and Welfare. According to Article 44 of the Emergency Life-Saving Technician’s Act, an emergency technician shall not perform certain emergency medical procedures unless specifically authorized to do so by a medical practitioner. Actual conditions make these requirements unwieldy to put into practice. When requested to provide medical control in response to an ambulance call, a licensed physician has no choice but to allow the emergency technician to administer medical care. These circumstances expose medical practitioners to significant legal risks and societal ramifications. Is a mobile telecommunications environment characterized by insufficient information satisfactory for the medical care needed in ambulances? This paper discusses such medical care and its legal ramifications, including: how to implement such medical care under Article 21 of the Basic Act on Establishing a Networked Society Based on Advanced Information and Telecommunications. The Japanese government is obligated to provide citizens with broadband telecommunication lines in the near future to enable the smooth implementation of medical control over medical supervision provided in ambulances.

Telemedicine to a moving ambulance improves outcome after trauma in simulated patients

BACKGROUND

Rural trauma victims often require prolonged transport by s with limited scopes of practice. We evaluated the impact of telemedicine (TM) to a moving ambulance on outcomes in simulated trauma patients.

METHODS

This is an institutional review board approved, prospective double-blind study. Three trauma scenarios (blunt torso trauma, epigastric stab wound, and closed head injury) were created for a human patient simulator. Intermediate emergency medical technicians (EMTs; n = 20) managed the human patient simulator, in a moving ambulance. In the TM group, physicians (n = 12) provided consultation. In the non-TM group, EMTs communicated with medical control by radio, as necessary. We tabulated the fraction of 13 key signs, 5 pathologic processes, and 12 key interventions that were performed. Vital signs and Sao2 (%) were recorded. Data were compared using the Wilcoxon rank-sum test.

RESULTS

Lowest Sao2 (84 ± 0.7 vs. 78 ± 0), lowest systolic blood pressure (70 ± 1 vs. 53 ± 1), and highest heart rate (144 ± 0.9 vs. 159 ± 0.5) were significantly improved in the TM group (p < 0.001). Recognition rates for key signs (0.96 ± 0.01 vs. 0.79 ± 0.05), processes (0.98 ± 0.02 vs. 0.75 ± 0.05), and critical interventions (0.92 ± 0.02 vs. 0.49 ± 0.03) were higher in the TM group (p < 0.003). EMTs were successfully guided through needle decompression procedures in 22 of 24 cases (zero in the non-TM group).

CONCLUSION

TM to a moving ambulance improved the care of simulated trauma patients. Furthermore, procedurally naïve EMTs were able to perform needle thoracostomy and pericardiocentesis with TM guidance.

"Initiate-build-operate-transfer"--a strategy for establishing sustainable telemedicine programs in developing countries: initial lessons from the balkans

Establishing sustainable telemedicine has become a goal of many developing countries around the world. Yet, despite initiatives from a select few individuals and on occasion from various governments, often these initiatives never mature to become sustainable programs. The introduction of telemedicine and e-learning in Kosova has been a pivotal step in advancing the quality and availability of medical services in a region whose infrastructure and resources have been decimated by wars, neglect, lack of funding, and poor management. The concept and establishment of the International Virtual e-Hospital (IVeH) has significantly impacted telemedicine and e-health services in the Balkans. The success of the IVeH in Kosova has led to the development of similar programs in other Balkan countries and other developing countries in the hope of modernizing and improving their healthcare infrastructure. A comprehensive, four-pronged strategy, "Initiate-Build-Operate-Transfer" (IBOT), may be a useful approach in establishing telemedicine and e-health educational services in developing countries. The development strategy, IBOT, used by the IVeH to establish and develop telemedicine programs, was discussed. IBOT includes assessment of healthcare needs of each country, the development of a curriculum and education program, the establishment of a nationwide telemedicine network, and the integration of the telemedicine program into the healthcare infrastructure. The endpoint is the transfer of a sustainable telehealth program to the nation involved. By applying IBOT, a sustainable telemedicine program of Kosova has been established as an effective prototype for telemedicine in the Balkans. Once fully matured, the program will be transitioned to the national Ministry of Health, which ensures the sustainability and ownership of the program. Similar programs are being established in Albania, Macedonia, and other countries around the world. The IBOT model has been effective in creating sustainable telemedicine and e-health integrated programs in the Balkans and may be a good model for establishing such programs in developing countries.

Video conferencing versus telephone calls for team work across hospitals: a qualitative study on simulated emergencies

Background

Teamwork is important for patient care and outcome in emergencies. In rural areas, efficient communication between rural hospitals and regional trauma centers optimise decisions and treatment of trauma patients. Little is known on potentials and effects of virtual team to team cooperation between rural and regional trauma teams.

Methods

We adapted a video conferencing (VC) system to the work process between multidisciplinary teams responsible for trauma as well as medical emergencies between one rural and one regional (university) hospital. We studied how the teams cooperated during simulated critical scenarios, and compared VC with standard telephone communication. We used qualitative observations and interviews to evaluate results.

Results

The team members found VC to be a useful tool during emergencies and for building "virtual emergency teams" across distant hospitals. Visual communication combined with visual patient information is superior to information gained during ordinary telephone calls, but VC may also cause interruptions in the local teamwork.

Conclusion

VC can improve clinical cooperation and decision processes in virtual teams during critical patient care. Such team interaction requires thoughtful organisation, training, and new rules for communication.

Comparison of critically ill and injured children transferred from referring hospitals versus in-house admissions

OBJECTIVE

The purpose of this work was to compare the outcomes, severity of illness, and resource use of patients transferred to PICUs from outside hospitals to patients admitted from within the same hospital.

METHODS

We conducted a secondary analysis of patients from the 20 US PICUs in the most recent Pediatric Intensive Care Unit Evaluations Software Recalibration Database on a total of 13,017 emergent PICU admissions between January 2001 and January 2006. Dependent variables were PICU resource use and risk-adjusted mortality. The main independent variable was the PICU admission source: patients transferred from referring emergency departments and inpatient wards versus in-house admissions from the same hospitals' emergency departments and inpatient ward.

RESULTS

Patients admitted from referring emergency departments had higher use of vasoactive infusions (7.31% vs 5.23%) and mechanical ventilation (33.45% vs 23.6%) than same-hospital emergency department admissions. Compared with in-house ward admissions, patients transferred from referring inpatient wards had higher mechanical ventilation rates (45.05% vs 28.56%) and PICU lengths of stay (8.0 vs 6.7 days).

CONCLUSIONS

On average, children admitted to a cohort of US PICUs from referring hospitals were more ill and required more intensive care resources than patients admitted to the same PICUs from within the institution. Hospital-level differences in PICU efficiency and severity of illness were highly variable. These data highlight the need for standardized PICU admission criteria to maximize hospital efficiency and suggest opportunities for earlier intervention and consultation by hospitals with PICU-level services to improve quality of care for critically ill children.

Telemedicine and telepresence for trauma and emergency care management

The use of telemedicine is long-standing, but only in recent years has it been applied to the specialities of trauma, emergency care, and surgery. Despite being relatively new, the concept of teletrauma, telepresence, and telesurgery is evolving and is being integrated into modern care of trauma and surgical patients. This paper will address the current applications of telemedicine and telepresence to trauma and emergency care as the new frontiers of telemedicine application. The University Medical Center and the Arizona Telemedicine Program (ATP) in Tucson, Arizona have two functional teletrauma and emergency telemedicine programs and one ad-hoc program, the mobile telemedicine program. The Southern Arizona Telemedicine and Telepresence (SATT) program is an inter-hospital telemedicine program, while the Tucson ER-link is a link between prehospital and emergency room system, and both are built upon a successful existing award winning ATP and the technical infrastructure of the city of Tucson. These two programs represent examples of integrated and collaborative community approaches to solving the lack of trauma and emergency care issue in the region. These networks will not only be used by trauma, but also by all other medical disciplines, and as such have become an example of innovation and dedication to trauma care. The first case of trauma managed over the telemedicine trauma program or "teletrauma" was that of an 18-month-old girl who was the only survival of a car crash with three fatalities. The success of this case and the pilot project of SATT that ensued led to the development of a regional teletrauma program serving close to 1.5 million people. The telepresence of the trauma surgeon, through teletrauma, has infused confidence among local doctors and communities and is being used to identify knowledge gaps of rural health care providers and the needs for instituting new outreach educational programs.

Success factors for telehealth—A case study

PURPOSE

To present the lessons learned from an evaluation of a comprehensive telehealth project regarding success factors and evaluation methodology for such projects.

METHODS

A recent experience with the evaluation of new telehealth services in BC, Canada, is summarized. Two domains of clinical applications, as well as educational and administrative uses, and the project environment were evaluated. In order to contribute to the success of the project, the evaluation included formative and summative approaches employing qualitative and quantitative methods with data collection from telehealth events, participants and existing databases. The evaluation had to be carried out under severe budgetary and time constraints. We therefore deliberately chose a broad ranging exploratory approach within a framework provided, and generated questions to be answered on the basis of initial observations and participant driven interviews with progressively more focused and detailed data gathering, including perusal of a variety of existing data sources. A unique feature was an economic evaluation using static simulation models.

RESULTS

The evaluation yielded rich and detailed data, which were able to explain a number of unanticipated findings. One clinical application domain was cancelled after 6 months, the other continues. The factors contributing to success include: Focus on chronic conditions which require visual information for proper management. Involvement of established teams in regular scheduled visits or in sessions scheduled well in advance. Problems arose with: Ad hoc applications, in particular under emergency conditions. Applications that disregard established referral patterns. Applications that support only part of a unit's services. The latter leads to the service mismatch dilemma (SMMD) with the end result that even those e-health services provided are not used. The problems encountered were compounded by issues arising from the manner in which the telehealth services had been introduced, in particular the lack of time for preparation and establishment of routine use. Educational applications had significant clinical benefits. Administrative applications generated savings which exceeded the substantial capital investment and made educational and clinical applications available at variable cost.

CONCLUSION

Evaluation under severe constraints can yield rich information. The identified success factors, including provision of an overarching architecture and infrastructure, strong program management, thorough needs analysis and detailing applications to match the identified needs should improve the sustainability of e-health projects. Insights gained: Existing assumptions before the study was conducted: Evaluation has to proceed from identified questions according to a rigorous experimental design. Emergency and trauma services in remote regions can and should be supported via telehealth based on video-conferencing. Educational applications of telehealth directed at providers are beneficial for recruitment and retention of providers in remote areas. Insights gained by the study: An exploratory approach to evaluation using a multiplicity of methods can yield rich and detailed information even under severe constraints. Ad hoc and emergency clinical applications of telehealth can present problems unless they are based on thorough, detailed analyses of environment and need, conform to established practice patterns and rely on established trusting collaborative relationships. Less difficult applications should be introduced before attempting to support use under emergency conditions. Educational applications are of interest beyond the provider community to patients, family and community members, and have clinical value. In large, sparsely populated areas with difficult travel conditions administrative applications by themselves generate savings that compensate for the substantial capital investment for telehealth required for clinical applications.

The impact of information technology on haemophilia care

The past decade has seen an explosion in the use of computers, data programs, hand-held electronic devices and the Internet. How these advances impact on haemophilia management both now and in the future are discussed from the perspective of haemophilia registries, Internet-based electronic haemophilia treatment records, and the potential for haemophilia telehealth.

The use of multi-media messaging in the referral of musculoskeletal limb injuries to a tertiary trauma unit using: a 1-month evaluation

OBJECTIVES

New developments in telecommunications will have a profound effect on the delivery of medical care throughout the world. In Northern Ireland three trauma centres provide fracture care for their own and surrounding Emergency Departments. All trauma referrals are currently taken by telephone. It is our experience that the verbal description of the radiographs of a musculoskeletal limb injury can be inaccurate, necessitating us to view the plain films of the patient. By utilising a recent advance in telecommunications technology, the launch of mobile handsets with multi-media messaging (MMS) service capability, it is now possible to digitally capture and instantly send an image of a plain film.

PURPOSE

To evaluate the use of multi-media messaging as a supplement to the telephone referral of musculoskeletal limb injures.

METHOD

: Following a referral using, the emergency physician and the trauma surgeon evaluated the multi-media consult through a survey questionnaire.

RESULTS

Between the 1st December 2003 and the 1st January 2004, 46 multi-media consultations were performed. Picture quality was acceptable in all but one of the referrals. In 35 of the 46 referrals the multi-media image of the plain films was felt to improve the management of the patient. In 8 of the 46 referrals the multi-media image of the plain films was felt to change the management of the patient.

CONCLUSION

A multi-media messaging store- and forward telemedicine system has potential to facilitate the rapid, cost-effective management of musculoskeletal limb injuries thereby enhancing clinical care.

A mobile teletrauma system using 3G networks

This paper introduces a cost-effective portable teletrauma system that assists health-care centers in providing prehospital trauma care. Simultaneous transmission of a patient's video, medical images, and electrocardiogram signals, which is required throughout the prehospital procedure, is demonstrated over commercially available 3G wireless cellular data service. Moreover, the physician can remotely control the information sent from the patient side. Such a technology will allow a trauma specialist to be virtually present at the remote location and participate in prehospital care, which improves the quality of trauma care and can potentially reduce mortality and morbidity. To alleviate the limited and fluctuant bandwidth barriers of the wireless cellular link, the system adapts to network conditions through media transformations, data prioritization, and application-level congestion control methods. Experimental evaluation of the system prototype over real network conditions, transmitting different media types between the trauma patient and hospital unit, is encouraging. The teletrauma system reported in this paper is the first of its kind and it provides a basis for future enhancements.