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

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.

Integrating a community-based continuous mass dog vaccination delivery strategy into the veterinary system of Tanzania: A process evaluation using normalization process theory

Abstract

Sustained vaccination coverage of domestic dog populations can interrupt rabies transmission. However, challenges remain including low dog owner participation, high operational costs associated with current (centralized and annually delivered (pulse)) approaches and high dog population turnover. To address these challenges an alternative (community-based continuous mass dog vaccination (CBC-MDV)) approach was designed. We investigated the potential for successful normalization of CBC-MDV into routine practice within the context of local communities and the veterinary system of Tanzania.

Methods

In a process evaluation of a pilot implementation of CBC-MDV, we conducted in-depth interviews with implementers and community leaders (n = 24), focus group discussion with implementers and community members (n = 12), and non-participant observation (n = 157 h) of delivery of the intervention components. We analyzed these data thematically drawing on the normalization process theory, to assess factors affecting implementation and integration.

Main findings

Implementers and community members clearly understood the values and benefits of the CBC-MDV, regarding it as an improvement over the pulse strategy. They had a clear understanding of what was required to enact CBC-MDV and considered their own involvement to be legitimate. The approach fitted well into routine schedules of implementers and the context (infrastructure, skill sets and policy). Implementers and community members positively appraised CBC-MDV in terms of its perceived impact on rabies and recommended its use across the country. Implementers and community members further believed that vaccinating dogs free of charge was critical and made community mobilization easier. However, providing feedback to communities and involving them in evaluating outcomes of vaccination campaigns were reported to have not been done. Local politics was cited as a barrier to collaboration between implementers and community leaders.

Conclusion

This work suggests that CBC-MDV has the potential to be integrated and sustained in the context of Tanzania. Involving communities in design, delivery and monitoring of CBC-MDV activities could contribute to improving and sustaining its outcomes.

Elbow Evaluation Via Telephone and Video Visit

Background Elbow conditions and pathology are commonly seen in the outpatient clinic. Telephone and video visits can allow for expeditious assessment of elbow complaints, without the added challenges of commuting for a clinic-based evaluation. In the setting of a pandemic, the benefits of telemedicine are apparent, but the time and effort saved from being able to remotely evaluate musculoskeletal conditions are also useful in a non-pandemic situation. In this modern era of telemedicine, protocols need to be developed to provide guidance for a remote elbow evaluation. As with all musculoskeletal conditions, the history about the elbow complaint allows the clinician to develop a differential diagnosis, which is either supported or refuted based on physical examination and diagnostic studies. Appropriate questions asked over a telephone call can provide answers that lead the clinician to a specific diagnosis and treatment plan. Furthermore, responses to these same questions can be further supported by a video assessment of the affected elbow, which may provide additional evidence to support a diagnosis and plan of care. Aims To outline possible questions, responses, and video examination techniques to aid the clinician in elbow examinations conducted via telemedicine. Methods We have created a pathway for step-by-step evaluation to help physicians direct their patients through the typical elements of a thorough elbow examination via telehealth. Results We have created tables of questions, answers, and instructions to help guide the physician through different aspects of a telehealth elbow examination. We have also included a glossary of descriptive images that demonstrate each maneuver.  Conclusion This article provides a structured guide to efficiently extracting clinically relevant information during telemedicine examinations of the elbow.

Utility of Telehealth Platforms Applied to Burns Management: A Systematic Review

The financial burden of burn injuries has a considerable impact on patients and healthcare systems. Information and Communication Technologies (ICTs) have demonstrated their utility in the improvement of clinical practice and healthcare systems. Because referral centres for burn injuries cover large geographic areas, many specialists must find new strategies, including telehealth tools for patient evaluation, teleconsultation, and remote monitoring. This systematic review was performed according to PRISMA guidelines. PubMed, Cochrane, Medline, IBECS, and LILACS were the search engines used. Systematic reviews, meta-analyses, clinical trials, and observational studies were included in the study search. The protocol was registered in PROSPERO with the number CRD42022361137. In total, 37 of 185 studies queried for this study were eligible for the systematic review. Thirty studies were comparative observational studies, six were systematic reviews, and one was a randomised clinical trial. Studies suggest that telehealth allows better perception of triage, more accurate estimation of the TBSA, and resuscitation measures in the management of acute burns. In addition, some studies assess that TH tools are equivalent to face-to-face outpatient visits and cost-efficient because of transport savings and unnecessary referrals. However, more studies are required to provide significant evidence. However, the implementation of telehealth should be specifically adapted to each territory.

Teleconsultation at Sea and Acute Wound Management Onboard

Introduction: The French Tele-Medical Assistance Service (TMAS) provides medical teleconsultation for any ship at sea. At the end of the consultation, the doctor decides whether the problem can be taken care of onboard or not. In this study, we determined the factors associated with the decision for disembarkation or evacuation in case of wounds. Methods: We conducted a retrospective epidemiological study between 2011 and 2019 from consultations with the French TMAS. The inclusion criterion was the presence of an acute wound. Results: One thousand six patients (n = 1,006) were analyzed and 586 (58%) patients were disembarked or evacuated. Factors associated with disembarkation or evacuation are wound characteristics (severity and location), the onboard staff's medical training, the availability of photography, and the ship's location. Wound severity is a risk factor for disembarkation or evacuation. The availability of photography, staff with advanced training, and being at >1 day of navigation from a harbor are protective factors against being disembarked or evacuated. Conclusion: The added value of photography and an update of medium medical training could increase the number of wounds taken care of onboard.

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.

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.

Telemedicine for Sports-Related Injuries

BACKGROUND

Telemedicine use has expanded rapidly since the COVID-19 pandemic in order to adhere to social distancing protocols and has been met with much enthusiasm. However, less is known about the use of telemedicine in sports and exercise medicine (teleSEM) and its utility to treat emergent craniofacial injuries. Given how common facial trauma is among athletes and its possible complications, incorporation of telemedicine in sports-related injuries may prove to be quintessential for athletes and coaches.

METHODS

A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials was conducted for studies published through December 2020 with multiple search terms related to telemedicine in sports and trauma care.

RESULTS

Overall, teleSEM is appreciated by both patients and physicians alike. Studies show that the satisfaction rate among patients and physicians are high. Sports-related telemedicine visits can help improve resource utilization and total costs. Facial trauma studies also reveal that the level of concurrency of treatment options between telemedicine visits and in-person consultations is almost perfect. Further, there are many additional ways that teleSEM can be implemented in treating injured athletes, including possible collaboration between athletic coaches and physicians as well as mobile device applications. Telemedicine may be particularly useful in treating acute injuries in low-resourced areas with limited equipment and training.

CONCLUSION

Telemedicine has been widely employed for sports-related injuries and in traumatic care. Patients and providers alike have noted its utility over other methods of communication with physicians. Our findings suggest that telemedicine has a significant potential in treating sports-related injuries and improving the efficiency of diagnoses and treatments. It may enhance outcomes for participants in athletic events. This may become a key aspect of determining whether a player can return to immediate competition.

Design, Adoption, Implementation, Scalability, and Sustainability of Telehealth Programs

Telehealth and telemedicine services can be a solution for improving accessibility and reducing the cost of health care. Challenges remain in designing, implementing, and sustainably scaling telehealth solutions. Research is lacking on the health impacts and cost-effectiveness of telehealth; more data are needed in the evaluation of telehealth programs, adjusting for potential participant bias and extending the time frame of evaluating impact. In addition, rethinking and addressing the economic incentives and payment for telehealth services, as well as the medical-legal framework for provider competition across geographic regions (and jurisdictions), are needed for greater adoption of telehealth services.

Effects of increased distance to urgent and emergency care facilities resulting from health services reconfiguration: a systematic review

Background

Service reconfigurations sometimes increase travel time and/or distance for patients to reach their nearest hospital or other urgent and emergency care facility. Many communities value their local services and perceive that proposed changes could worsen outcomes for patients.

Objectives

To identify, appraise and synthesise existing research evidence regarding the outcomes and impacts of service reconfigurations that increase the time and/or distance for patients to reach an urgent and emergency care facility. We also aimed to examine the available evidence regarding associations between distance to a facility and outcomes for patients and health services, together with factors that may influence (moderate or mediate) these associations.

Data sources

We searched seven bibliographic databases in February 2019. The search was supplemented by citation-tracking and reference list checking. A separate search was conducted to identify the current systematic reviews of telehealth to support urgent and emergency care.

Methods

Brief inclusion and exclusion criteria were as follows: (1) population – adults or children with conditions that required emergency treatment; (2) intervention/comparison – studies comparing outcomes before and after a service reconfiguration, which affects the time/distance to urgent and emergency care or comparing outcomes in groups of people travelling different distances to access urgent and emergency care; (3) outcomes – any patient or health system outcome; (4) setting – the UK and other developed countries with relevant health-care systems; and (5) study design – any. The search results were screened against the inclusion criteria by one reviewer, with a 10% sample screened by a second reviewer. A quality (risk-of-bias) assessment was undertaken using The Joanna Briggs Institute Checklist for Quasi-Experimental Studies. We performed a narrative synthesis of the included studies and assessed the overall strength of evidence using a previously published method.

Results

We included 44 studies in the review, of which eight originated from the UK. For studies of general urgent and emergency care populations, there was no evidence that reconfiguration that resulted in increased travel time/distance affected mortality rates. By contrast, evidence of increased risk was identified from studies restricted to patients with acute myocardial infarction. Increases in mortality risk were most obvious within the first 1–4 years after reconfiguration. Evidence for other conditions was inconsistent or very limited. In the absence of reconfiguration, evidence mainly from cohort studies indicated that increased travel time or distance is associated with increased mortality risk for the acute myocardial infarction and trauma populations, whereas for obstetric emergencies the evidence was inconsistent. We included 12 systematic reviews of telehealth. Meta-analyses suggested that telehealth technologies can reduce time to treatment for people with stroke and ST elevation myocardial infarction.

Limitations

Most studies came from non-UK settings and many were at high risk of bias because there was no true control group. Most review processes were carried out by a single reviewer within a constrained time frame.

Conclusions

We found no evidence that increased distance increases mortality risk for the general population of people requiring urgent and emergency care, although this may not be true for people with acute myocardial infarction or trauma. Increases in mortality risk were most likely in the first few years after reconfiguration.

Future work

Research is needed to better understand how health systems plan for and adapt to increases in travel time, to quantify impacts on health system outcomes, and to address the uncertainty about how risk increases with distance in circumstances relevant to UK settings.

Study registration

This study is registered as PROSPERO CRD42019123061.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 31. See the NIHR Journals Library website for further project information.

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.

Social, Organizational, and Technological Factors Impacting Clinicians' Adoption of Mobile Health Tools: Systematic Literature Review

Background

There is a growing body of evidence highlighting the potential of mobile health (mHealth) in reducing health care costs, enhancing access, and improving the quality of patient care. However, user acceptance and adoption are key prerequisites to harness this potential; hence, a deeper understanding of the factors impacting this adoption is crucial for its success.

Objective

The aim of this review was to systematically explore relevant published literature to synthesize the current understanding of the factors impacting clinicians’ adoption of mHealth tools, not only from a technological perspective but also from social and organizational perspectives.

Methods

A structured search was carried out of MEDLINE, PubMed, the Cochrane Library, and the SAGE database for studies published between January 2008 and July 2018 in the English language, yielding 4993 results, of which 171 met the inclusion criteria. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and the Cochrane handbook were followed to ensure a systematic process.

Results

The technological factors impacting clinicians’ adoption of mHealth tools were categorized into eight key themes: usefulness, ease of use, design, compatibility, technical issues, content, personalization, and convenience, which were in turn divided into 14 subthemes altogether. Social and organizational factors were much more prevalent and were categorized into eight key themes: workflow related, patient related, policy and regulations, culture or attitude or social influence, monetary factors, evidence base, awareness, and user engagement. These were divided into 41 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them.

Conclusions

The study results can help inform mHealth providers and policymakers regarding the key factors impacting mHealth adoption, guiding them into making educated decisions to foster this adoption and harness the potential benefits.

Social, Organizational, and Technological Factors Impacting Clinicians' Adoption of Mobile Health Tools: Systematic Literature Review

BACKGROUND

There is a growing body of evidence highlighting the potential of mobile health (mHealth) in reducing health care costs, enhancing access, and improving the quality of patient care. However, user acceptance and adoption are key prerequisites to harness this potential; hence, a deeper understanding of the factors impacting this adoption is crucial for its success.

OBJECTIVE

The aim of this review was to systematically explore relevant published literature to synthesize the current understanding of the factors impacting clinicians' adoption of mHealth tools, not only from a technological perspective but also from social and organizational perspectives.

METHODS

A structured search was carried out of MEDLINE, PubMed, the Cochrane Library, and the SAGE database for studies published between January 2008 and July 2018 in the English language, yielding 4993 results, of which 171 met the inclusion criteria. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and the Cochrane handbook were followed to ensure a systematic process.

RESULTS

The technological factors impacting clinicians' adoption of mHealth tools were categorized into eight key themes: usefulness, ease of use, design, compatibility, technical issues, content, personalization, and convenience, which were in turn divided into 14 subthemes altogether. Social and organizational factors were much more prevalent and were categorized into eight key themes: workflow related, patient related, policy and regulations, culture or attitude or social influence, monetary factors, evidence base, awareness, and user engagement. These were divided into 41 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them.

CONCLUSIONS

The study results can help inform mHealth providers and policymakers regarding the key factors impacting mHealth adoption, guiding them into making educated decisions to foster this adoption and harness the potential benefits.

Health Care Professionals' Perspectives on Teleneonatology Through the Lens of Normalization Process Theory

BACKGROUND AND AIMS

Little research has been done on tele-intensive care unit (ICU) implementation across different types of ICUs, and there exist few studies that have used qualitative research methods to analyze the human and organizational factors influencing optimization of telemedicine for newborn resuscitation. The objective of this study was to understand health care professionals' acceptance, utilization, and integration of video telemedicine for newborn resuscitation (termed teleneonatology) in community hospital settings.

METHODS

Focus group and individual interviews were conducted with 49 health care professionals at six affiliated health system hospitals. Data were gathered from physicians (n = 18), nurses (n = 30), and a nurse practitioner. Data were inductively analyzed using a thematic approach, and then constructs from normalization process theory (NPT) were deductively applied. NPT rendered a general framework to describe and assess how care teams perceive the implementation of teleneonatology and how they interact with this telemedicine service in their local setting.

RESULTS

Local health care professionals accepted teleneonatology as an important, helpful service, yet its implementation was perceived as both valuable and a threat to professional traditions. Utilization may depend on perceived benefit, mutual understanding of the guidelines, and expectations of use, and other relational, human, contextual, and system factors. Participants in this study agreed on the need for collective work to successfully integrate teleneonatology into the local practice.

DISCUSSIONS

NPT uncovered that successful implementation of a teleneonatology program may be facilitated by strong interpersonal relationships among care teams, continuous programmatic training and education, and communicating the clinical value of teleneonatology, including its opportunities and benefits.

A smartphone-based consultation system for acute burns - methodological challenges related to follow-up of the system

BACKGROUND

A smartphone-based consultation system for acute burns is currently being implemented in the Western Cape, South Africa. Even though studies indicate that similar systems for burns tend to support valid diagnosis and influence patient management, the evidence is still sparse. There is a need for more in-depth evaluations, not least in resource-constrained settings where mHealth projects are increasing.

OBJECTIVE

This article describes the consultation system and assessments in relation to its implementation with a special focus on methodological challenges.

METHODS

A number of evaluations and assessments have been conducted, are ongoing or planned for in relation to the implementation of the teleconsultation system. Initial assessments showed that size and depth of burns could be assessed at least as well using photographs as at bedside and that the image quality of handheld devices can be used as well as computers. Studies on system usability are currently being done with a mixed-methods approach. A historical cohort design will be applied to assess the potential health impact of the system. Patients with burn injuries where the doctor at point of care has used the app to receive diagnostic support from a burns expert will be considered as exposed and patients with burn injuries where the app has not been used will be considered as non-exposed.

CONCLUSIONS

Smartphone-based consultation systems have the potential to strengthen the assessment of burn injury in many settings. However, ethically and methodologically sound evaluations are needed to find the best systems and solutions. This article identifies challenges and suggests potential assessments in relation to the implementation of such a system.

Teleburn: Designing A Telemedicine Application to Improve Burn Treatment

Background

Due to the increasing rate of the burn injuries and a limited number of specialized treatment centers, providing medical advice and medical care at the point of need is necessary. The aim of the present study was to design and implement a teleburn system to enhance the quality of care for the burn patients.

Methods

This study was completed in 2016. In order to design the system, information needs assessment was conducted by using a questionnaire. The participants of this phase were five specialists, five general practitioners, and 12 nurses. The setting of the study was the burn department of a public hospital and a burn center. The prototype of the system was designed based on the findings derived from the first phase, and the usability of the system was evaluated later.

Results

The teleburn system was a web-based system with different sections for GPs/nurses and specialists. In total, 28 burn consultations were made successfully by using the system. The findings of the usability testing showed that most of the participants evaluated the system at a good level. The mean score for the specialists, general practitioners and nurses was 8.4±0.46, 7.7±0.39, and 7.5±0.51, respectively.

Conclusion

Although it was the first time in the country that the teleburn system was designed and introduced to the clinicians, they seemed to be satisfied with using the system. This system could help general practitioners and nurses to receive specialist's advice on a timely manner to improve the treatment of the burn patients. However, more research should be conducted to determine the effectiveness of using this technology in the real work environment.

Digital continuous healthcare and disruptive medical technologies: m-Health and telemedicine skills training for data-driven healthcare

INTRODUCTION

Disruptive medical technologies, wearable devices and new diagnostic solutions have been shaping the future of healthcare, and the health informatics skills gap has become a major problem for technology-centric healthcare applications. This study evaluated the relationships between a specific practical skills training method and students' confidence in using wireless monitoring devices along with the attitude towards technology adoption.

METHODS

Six practical exercises were developed to provide health informatics technical skills to transfer medical information and display multi-channel biological signals. Two hundred and six undergraduate nursing students received a telemedicine and homecare training course. Their familiarity with various data formats and likelihood to recommend telemedicine and remote monitoring applications were measured.

RESULTS

The skills training session changed students' attitudes towards remote patient monitoring, and the majority of students provided positive feedback about their confidence in using wireless monitoring devices after the training session. Students stated their plans to use the technology when they start practising and to educate their patients to promote the use of telemedicine.

CONCLUSION

We propose a skills training framework that covers (a) telemedicine, (b) m-Health and connected health, (c) health informatics application development, (d) health informatics device innovation, and (e) data science.

The value of WhatsApp communication in paediatric burn care

BACKGROUND

Telemedicine is increasingly applied in developed settings to facilitate transfer of information to and from burn surgeons across vast geographic areas. WhatsApp is a widely available and extremely user-friendly encrypted smartphone application that does not require the expensive physical and personnel infrastructure that characterizes many of these telemedicine systems. The aim of this study was to review the use of WhatsApp to facilitate paediatric burn injury consultations to a regional burn centre in a developing country, where burn care continues to be thwarted by administrative apathy, poor resource allocation and lack of attention to medical and nursing education at all levels.

METHODS

A retrospective review was undertaken of all consultations using WhatsApp over an 18-month period, received by the burn centre's two senior medical practitioners. The specific origin and nature of the telemedicine requests for advice, transfer or follow-up were collected, as were data relating to the demographics of the patients, the aetiology, mechanism and extent of the burn injury. The impact of the system of communication in terms of reductions in admissions and clinic visits was assessed, and a cost analysis was undertaken. Feedback was also obtained from those health practitioners regularly using the service.

RESULTS

838 communications occurred during the study period, which included 1562 distinct clinical queries. 486 interactions (58%) originated from within the hospital, the majority of which were initiated by surgeons in training or burn nurse practitioners. 352 (42%) consultations were from outside the hospital. Queries related to the full spectrum of burn care, including emergency management and stabilization, triage and transfer, the need for escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention, as well as follow-up and rehabilitation. While no significant changes in the number of surgical interventions or admissions were observed when compared to the five years prior to the intervention, outpatient visits reduced significantly during the study period. It was estimated that over 150 unnecessary admissions were also avoided as a result of the triage made possible by WhatsApp, which translated into considerable cost saving for the institution.

DISCUSSION

Incorporating WhatsApp technology into the daily processes of burn care has significantly improved the quality of paediatric burn care referrals to specialist burn services. Specifically, WhatsApp has contributed to reductions in unnecessary referrals and outpatient visits, facilitated opportunities for continuing medical education, improved the care of major burn injuries through more effective prehospital communication, and enabled greater allocation of scarce specialist resources at the burn centre. This study motivates for the wider application of WhatsApp for burn care referrals, especially in developing countries.

Telemedicine for neonatal resuscitation

Maintaining high levels of readiness for neonatal resuscitation in low-risk maternity settings is challenging. The neonatal resuscitation program (NRP) algorithm is a community standard in the United States; yet training is biannual, and exposure to enough critical events to be proficient at timely implementation of the algorithm and the advanced procedures is rare. Evidence supports hands-free leadership to help prevent task saturation and communication to promote patient safety. Telemedicine for neonatal resuscitation involves the addition of remote, expert NRP leadership (a NICU-based neonatal nurse practitioner) via camera link to augment effectiveness of the low-risk birth center team. Unanticipated outcomes to report include faster times to transfer initiation and neuroprotective cooling. The positive impact of remote NRP leadership could lead to use of telemedicine to support teams at birthing centers throughout the United States as well as around the world.

Emerging technology in surgical education: combining real-time augmented reality and wearable computing devices

The authors describe the first surgical case adopting the combination of real-time augmented reality and wearable computing devices such as Google Glass (Google Inc, Mountain View, California). A 66-year-old man presented to their institution for a total shoulder replacement after 5 years of progressive right shoulder pain and decreased range of motion. Throughout the surgical procedure, Google Glass was integrated with the Virtual Interactive Presence and Augmented Reality system (University of Alabama at Birmingham, Birmingham, Alabama), enabling the local surgeon to interact with the remote surgeon within the local surgical field. Surgery was well tolerated by the patient and early surgical results were encouraging, with an improvement of shoulder pain and greater range of motion. The combination of real-time augmented reality and wearable computing devices such as Google Glass holds much promise in the field of surgery.

Image-based medical expert teleconsultation in acute care of injuries. A systematic review of effects on information accuracy, diagnostic validity, clinical outcome, and user satisfaction

Objective

To systematically review the literature on image-based telemedicine for medical expert consultation in acute care of injuries, considering system, user, and clinical aspects.

Design

Systematic review of peer-reviewed journal articles.

Data sources

Searches of five databases and in eligible articles, relevant reviews, and specialized peer-reviewed journals.

Eligibility criteria

Studies were included that covered teleconsultation systems based on image capture and transfer with the objective of seeking medical expertise for the diagnostic and treatment of acute injury care and that presented the evaluation of one or several aspects of the system based on empirical data. Studies of systems not under routine practice or including real-time interactive video conferencing were excluded.

Method

The procedures used in this review followed the PRISMA Statement. Predefined criteria were used for the assessment of the risk of bias. The DeLone and McLean Information System Success Model was used as a framework to synthesise the results according to system quality, user satisfaction, information quality and net benefits. All data extractions were done by at least two reviewers independently.

Results

Out of 331 articles, 24 were found eligible. Diagnostic validity and management outcomes were often studied; fewer studies focused on system quality and user satisfaction. Most systems were evaluated at a feasibility stage or during small-scale pilot testing. Although the results of the evaluations were generally positive, biases in the methodology of evaluation were concerning selection, performance and exclusion. Gold standards and statistical tests were not always used when assessing diagnostic validity and patient management.

Conclusions

Image-based telemedicine systems for injury emergency care tend to support valid diagnosis and influence patient management. The evidence relates to a few clinical fields, and has substantial methodological shortcomings. As in the case of telemedicine in general, user and system quality aspects are poorly documented, both of which affect scale up of such programs.