An initial experience with telemedicine in follow-up burn care

Are We Adequately Measuring Patient Satisfaction with Telemedicine? A Systematic Review with a Meta-Analysis

Introduction: Telemedicine has gained significant attention as an effective means of providing health care remotely, particularly during the COVID-19 pandemic. Patient satisfaction is a critical aspect of implementing telemedicine, but we have no comprehensive understanding of satisfaction levels and the associated factors. The aim of this systematic review and meta-analysis was to assess patient satisfaction related to telemedicine consultations and to identify key factors influencing satisfaction levels. Results: The search yielded a total of 147 cross-sectional studies, of which 107 met the criteria for inclusion in the meta-analysis. Overall, patient satisfaction with teleconsultations was found to be high, with satisfaction levels ranging from 38 to 100 on a scale of 0 to 100. Only a small percentage (2.72%) of the studies reported satisfaction levels below 75%. Surprisingly, most studies used nonvalidated satisfaction questionnaires, which highlight the need for the development of standardized measurement instruments. Conclusions: This systematic review and meta-analysis provide evidence that patients generally exhibit high levels of satisfaction with telemedicine consultations. The use of nonvalidated satisfaction questionnaires in many studies, however, suggests a need for more standardized assessment tools. Factors such as the time interval between the consultation and the assessment were found to influence satisfaction levels. Understanding these factors can help health care providers improve telemedicine services and patient-provider relationships and optimize health care delivery in the context of telemedicine. Further research is warranted to develop validated satisfaction measurement instruments and explore any additional factors that influence patient satisfaction with telemedicine.

Accuracy of remote burn scar evaluation via live video-conferencing technology

OBJECTIVE

Telemedicine in outpatient burn care, particularly in burn scar management, may provide cost-effective care and comes highly rated by patients. However, an effective scar scale using both video and photographic elements has not been validated. The purpose of this study is to test the reliability of the Patient and Observer Scar Assessment Scale (POSAS) using live video-conferencing.

METHODS

A prospective study was conducted with individuals with healed burn scars in Kathmandu, Nepal. Three independent observers assessed 85 burn scars from 17 subjects, using the Observer portion to evaluate vascularity, pigmentation, thickness, relief, pliability, surface area, and overall opinion. The on-site observer was physically present with the subjects and used a live videoconferencing application to show the scars to two remote observers in the United States. Subjects used the Patient portion to evaluate the scar that they believed appeared the worst appearance and had the greatest impact on function.

RESULTS

The single-rater reliability of the Observer scale was acceptable (ICC>0.70) in overall opinion, thickness, pliability, and surface area. The average-rater reliability for three observers was acceptable (ICC>0.70) for all parameters except for vascularity. When comparing Patients' and Observers' overall opinion scores, patients consistently reported worse opinion.

CONCLUSIONS

Evaluation of burn scars using the Patient and Observer Scar Assessment Scale can be accurately performed via live videoconferencing and presents an opportunity to expand access to burn care to rural communities, particularly in low- and middle-income countries, where patients face significant access barriers to appropriate follow-up care.

From 0-50 in Pandemic, and Then Back? A Case Study of Virtual Care in Ontario Pre-COVID-19, During, and Post-COVID-19

We review the evolution of virtual care (VC) in Ontario. Pre-COVID-19, the primary focus was on patients in remote and underserved areas who went to host sites for care. Ontario's vision pre-pandemic was for a gradual increase in VC by physicians registered with the Ontario Telemedicine Network (OTN), using OTN-approved video technologies; some accommodated patients and doctors wherever they were. Less than 1% of care was virtual pre-pandemic. We discuss how policies that altered access to in-person care (pandemic lockdowns and guidelines to seek and provide care virtually), compensation policy changes (allowing any Ontario physician to be compensated for VC), and policies allowing common technologies not previously allowed (including, importantly, the telephone), drove and enabled a rapid shift to >50% of care being virtual at the start of the pandemic, leveling off to ∼30% over time. We review policy changes in late 2022 and predict these will result in a drop in VC compared with the policies during the pandemic, particularly for walk-in clinic patients, in a province where 2.2-4.6 million people do not have a primary care doctor and presumably use walk-in clinics. This is because, going forward, physicians will be compensated less for telephone care than for in-person or video care for rostered patients, and because compensation will be less still for telephone or video care provided to walk-in patients. Through this case study we develop a visual model of how these key policy and technology factors influence the provision of VC.

Burns Caused by Hand Sanitisers: The Trail of a Collateral Damage Left Behind by the Covid Pandemic

Background

The current COVID-19 pandemic has changed human lifestyle to follow COVID-19 Appropriate Behaviours (CAB) and that includes social distancing, and the use of masks and sanitiser for hand hygiene. With increased use of sanitiser; the incidence of burns due to sanitiser has been reportedly on the rise. The study analysed the reported burn incidences due to sanitiser, found the relation between sanitiser and the aetiology of burn and formulated guidelines for its safe use. The authors also suggested Do's and Don'ts to prevent and manage sanitiser burns.

Methodology

An online search was made to search the articles related to sanitiser burn targeting the words 'sanitiser', 'hand sanitiser', and 'burns and burns injury'. A general Google search was also made to look for any news reported in electronic media for sanitiser burns.

Result

A total number of 10 scholarly articles mentioning 95 cases were found satisfactory to fulfil the inclusion criteria. Most of the cases were flame burns due to the ignition of alcohol-based sanitiser (n=92, 98%) either by mistake or while lighting the flame for cooking or cigarette for smoking. In all cases, it was found that alcohol-based sanitiser was the agent causing burns which were more due to gel form. 61 patients were managed on an outpatient basis whereas 33 patients required admission.

Conclusion

Increasing use of sanitisers can be related to increased incidence of burns. Its safe use is warranted with proper guidelines.

Applications, opportunities, and challenges in using Telehealth for burn injury management: A systematic review

INTRODUCTION

Burns are global public health devastating and life-threatening injuries. Telehealth can be an appropriate answer for the effective utilization of health care resources, prevention referrals and reduce socio-economic burden of burns injuries. Thus, this study aimed to systematically evaluate the applications, opportunities, and challenges of using telehealth in burn injuries management.

METHODS

A structured search was conducted according to PRISMA statement guidelines in the Web of Science, PubMed, Scopus, and Science Direct as well as the Google Scholar for studies published until June 28, 2022. Of the total 2301 yielded studies, 36 articles were included in the final review. Quality appraisal was done according to the Mixed Methods Appraisal Tool (MMAT) version 2018. Thematic analysis was applied for data analysis.

RESULTS

Patient triage, transfer, and referral (38.9%) follow-up (22%), care (22%), consultation (9%), education (3%), and rehabilitation (3%) were the most prevalent application of telehealth, respectively. Our findings identified 72 unique concepts, eight initial themes, and two clinical and administrative final themes for opportunities of using telehealth in burn injury management. Furthermore, we identified 27 unique concepts, three initial themes, and two clinical and administrative final themes for remaining challenges.

CONCLUSIONS

Despite providing pivotal opportunities such as improving burn injury diagnosis and quality of care, increasing patient and provider satisfaction, and cost containment using telehealth in burn injuries management, the concept faces challenges such as the impossibility of the physical examination of patients and technological difficulties. Our findings provide valuable information for policymakers and decision-makers infield of burn injuries and effective planning for using telehealth technology.

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.

A six-week physical therapy exercise program delivered via home-based telerehabilitation is comparable to in-person programs for patients with burn injuries: A randomized, controlled, non-inferiority clinical pilot trial

BACKGROUND

Exercise programmes are essential for burn rehabilitation, however patients often have barriers accessing these services. Home-based telerehabilitation (HBT) may be an alternative. This study aimed to determine if exercise programs delivered via HBT were as effective as in-person (IP) programs with respect to clinical outcomes and participant and therapist satisfaction.

METHODS

A single center, randomized, controlled, non-inferiority pilot trial with blinded assessment was undertaken. Forty-five adults with ≤ 25% total body surface area (TBSA) burns were randomized to receive a 6-week exercise program delivered either by HBT or IP. The primary outcome was burn-specific quality of life (Burn Specific Health Scale - Brief). Secondary outcomes included health-related quality of life, burn scar-specific outcomes, exercise self-efficacy, pain severity, muscle strength and range of motion (ROM). Participant and therapist satisfaction, technical disruptions and adverse events were also recorded.

RESULTS

We found no significant within- or between-group differences for any outcome measures except ROM. Achievement of full ROM was significantly different between groups at Week 12 (IP=100% vs HBT=70%, p = 0.005). Non-inferiority was inconclusive. Participant satisfaction was high (median ≥ 9.8/10), with no significant between-group differences. Therapist satisfaction was high (median ≥ 8.9/10), major technical disruptions low (8%) and no adverse events reported.

CONCLUSION

HBT is a safe, effective option to deliver exercise programs for patients with burn injuries ≤ 25% TBSA with comparable clinical outcomes to in-person programmes. Ongoing research is required to further analyze ROM and investigate the effectiveness of HBT for patients with larger burns.

Isolated facial fractures transferred for higher level of care

BACKGROUND

Isolated facial fractures (IFF) have been identified as overtriaged injuries in multiple single-center studies. We sought to describe IFF in a national database.

METHODS

The 2019 Trauma Quality Improvement Program database was queried for all patients with facial fractures and Abbreviated Injury Score<1 for other body regions. Descriptive statistics were performed.

RESULTS

Of 1,097,190 trauma patients, 36,077 (3.3%) had IFF. Median age was 39 [26-89], 92% had blunt mechanism, median Glasgow Coma Scale 15 [15-15], and vital signs were normal (ED systolic blood pressure 137 [125-153], ED pulse 86 [73-99]). 0.3% required unplanned intubation. 25.7% underwent operation after a median interval 26.4 [14.4-47.9] hours. IFF patients represented 4.4% of interfacility transfers and were more likely to have been transferred (34.4% vs 25%, p < 0.001). Hospital stay was 3 [2-4] days.

CONCLUSIONS

IFF are rarely surgical emergencies and frequently nonoperative, yet are disproportionately represented among transfers. IFFs may represent an opportunity for outpatient follow-up or telehealth consultation to decrease resource utilization.

Increasing Access to Care for Transgender/Gender Diverse Youth Using Telehealth: A Quality Improvement Project

Purpose:We sought to expand telehealth at an academic multidisciplinary pediatric gender center to increase access to gender-affirming care without compromising communication, privacy, or patient satisfaction.Materials and Methods:Patient needs assessments were performed from January 2019 to March 2020. The severe acute respiratory syndrome coronavirus 2 pandemic accelerated implementation of the quality improvement project, and clinically appropriate patients were scheduled for video visits starting March 16, 2020. From September 8, 2020 to October 2, 2020, caregivers of transgender and gender diverse (TGD) minors or TGD young adults pursuing gender-affirming medications completed 9-item surveys evaluating communication quality and privacy, access to care, and quality of services for video and clinic visits. Answers were rated via Likert scales (1 = strongly agree, 5 = strongly disagree; 1 = less travel time, 4 = more travel time).Results:Needs assessment (n = 69) showed that 63.8% felt that video visits would improve follow-up. Survey participants (n = 91) reported statistically significant differences (p < 0.05) in several areas. Compared with clinic visits, video visits were more convenient, 1.21 ± 0.435 versus 2.36 ± 1.207, took less time from other activities, 4.55 ± 0.522 versus 2.93 ± 1.281, required less travel time, 1.03 ± 0.180 versus 2.63 ± 0.901, and were more acceptable, 1.35 ± 0.545 versus 1.65 ± 0.736. Participants were more likely to choose video visits in the future, 1.32 ± 0.555 versus 1.57 ± 0.732. There were no statistically significant differences in communication quality, privacy, or overall satisfaction.Conclusion:An integrated clinic-video visit model increases access to gender-affirming care for TGD youth while maintaining excellent communication, privacy, and patient satisfaction.

systematized review of telemedicine applications in treating burn patients

Background: Telemedicine has been used in different fields of medicine in the past 20 years. The main advantages of this technology include saving costs, improving quality of care, and increasing access to specialists. This study aimed to review telemedicine applications in treating burn patients. Methods: In this systematized review study, related papers were searched using various databases, including PubMed, Scopus, and Science Direct. The time frame was between January 2000 and March 2016; finally, 32 papers were included in the study. Results: The findings revealed that telemedicine was used in burn care in three different ways: Remote patient follow-up, teleconsultation, and patient assessment. Conclusion: It seems that telemedicine can be easily applied in treating burn patients even when there is a limited financial resource. The use of this technology can help reduce possible errors in categorizing burn patients and decrease patients' transportation and treatment costs.

The successes and challenges of providing a paediatric burns service by telehealth in Western Australia

The Princess Margaret Hospital Burns Telehealth Service provides a multidisciplinary service for paediatric burn outpatients living in rural and remote areas of Western Australia. In the two years since its establishment in August 2005, 164 patients have been referred to the service, with 297 clinical reviews undertaken via videoconference. An evaluation of the service was undertaken by surveying all families who had been reviewed by the service in a two-month period. Thirty survey forms were returned (a response rate of 51 %). The majority of respondents felt that the telehealth service saved them money (82%), time (86%) and stress (79%) compared with conventional face-to-face outpatient clinic attendance in Perth. Ninety-three percent of responders were satisfied with the service. The estimated cost-saving in avoided travel was Aus$994 per videoconference (Aus$1 is €0.64, US$0.88). The success of the Burns Telehealth Service is reflected in its place as an integrated part of service delivery for Western Australian paediatric burn patients.

Use of Telemedicine to Improve Adherence to American Diabetes Association Standards in Pediatric Type 1 Diabetes

BACKGROUND

The American Diabetes Association (ADA) recommends that children with type 1 diabetes (T1D) see a multidisciplinary team and have hemoglobin A1c (A1C) levels measured every 3 months. Patients in rural areas may not follow guidelines because of limited specialty care access. We hypothesized that videoconferencing would result in equivalent A1C compared with in-person visits and increased compliance with ADA recommendations.

MATERIALS AND METHODS

The Barbara Davis Center (BDC) (Aurora, CO) telemedicine program provides diabetes care to pediatric patients in Casper and Cheyenne, WY, via remote consultation with annual in-person visits. Over 27 months, 70 patients were consented, and 54 patients completed 1 year in the study.

RESULTS

Patients were 70% male, with a mean age of 12.1 ± 4.1 years and T1D duration of 5.4 ± 4.1 years. There was no significant change between baseline and 1-year A1C levels for patients with data at both time points. Patients saw diabetes specialists an average of 2.0 ± 1.3 times per year in the year prior to starting telemedicine and 2.9 ± 1.3 times (P < 0.0001) in the year after starting telemedicine. Patients and families missed significantly less school and work time to attend appointments.

CONCLUSIONS

Our study suggests telemedicine is equivalent to in-person visits to maintain A1C, whereas families increase the number of visits in line with ADA recommendations. Patients and families miss less school and work. Decreased financial burden and increased access may improve overall diabetes care and compliance for rural patients. Further study is needed to detect long-term differences in complications screenings and the financial impact of telemedicine on pediatric diabetes care.

The burden of attending a pediatric surgical clinic and family preferences toward telemedicine

BACKGROUND/PURPOSE

Indirect expenses for accessing health care may place significant fiscal strain on Canadian families. Telemedicine alternatives, using email, telephone, and video conferencing, can mitigate such financial burdens by reducing travel and related costs. Our objectives were to assess costs that families incur visiting an outpatient pediatric surgical clinic, and family attitudes toward telemedicine alternatives.

METHODS

A survey was offered pre-consult to all families who attended pediatric urology and general surgery outpatient clinics over a three-month period.

RESULTS

A total of 1032 of 1574 families screened participated (66.0%). Less than half (18.5%) of participants traveled over 200 km, and 32.9% spent over 4 hours in transit, round-trip. The proportion of participants who spent over $50 on travel and ancillary expenses was 33.0%. In 74.0% of families, 1 or more adults missed work. The proportion of families who perceived costs as somewhat high or high was 29.1%. Perceived cost was positively correlated to distance traveled, money spent, and missed work (p<0.01). Most were comfortable with medical communication using technology; and 34.3%-42.7% would avoid an in-person clinic visit utilizing email, telephone, and video conferencing. Higher perceived cost (p<0.001) and distance traveled (p<0.01) were only weakly associated with greater willingness to substitute a clinic visit with video conferencing.

CONCLUSIONS

Many families face high costs related to routine outpatient clinical visits, and there is a substantial willingness by them to access telemedicine alternatives, rather than the traditional face-to-face clinical visit.

Use of telemedicine to improve burn care in Ukraine

Global burn injuries have been described as the "forgotten public health crises" by the World Health Organization. Nearly 11 million people a year suffer burns severe enough to require medical attention; more people are burned each year than are infected with human immunodeficiency virus/acquired immunodeficiency syndrome and tuberculosis combined. Telemedicine has the potential to link experts in specialized fields, such as burn care, to regions of the world that have limited or no access to such specialized care. A multilevel telemedicine program was developed between Massachusetts General Hospital/Shriners Hospital in Boston, Massachusetts, and City Hospital #8 in Lviv, Ukraine. The program should lead to a sustainable improvement in the care of burn victims in Ukraine. The authors helped establish a Learning Center at City Hospital #8 in Lviv, Ukraine, through which they were able to consult from Shriners Hospital in Boston, on a total of 14 acute burn patients in Ukraine. This article discusses two case reports with the use of telemedicine and how it has allowed the authors to provide not only acute care consultation on an international scale, but also to arrange for direct expert examination and international transport to their specialized burn center in the United States. The authors have established a program through doctors from Massachusetts General Hospital/Shriner's Hospital in Boston, which works with a hospital in Ukraine and has provided acute consultation, as well as patient transportation to the United States for treatment and direct assessment.

Photographic assessment of burn wounds: a simple strategy in a resource-poor setting

OBJECTIVE

To validate the use of photographic burn wound assessment in evaluation of burn size and wound characteristics.

METHODS

Feasibility study of agreement between methods of measurement of burn size and characteristics, in patients admitted to the burn unit at Kamuzu Central Hospital (KCH), Malawi, over two months in 2011. Burn wounds were photographed and assessed clinically, concurrently, by an experienced clinician. Photographs reviewed by two blinded burn clinicians after 4-6 weeks. Correlation between clinical assessment and photographic evaluation was calculated using kappa score and Pearson's correlation coefficient.

RESULTS

Thirty-nine patients were included in evaluation of TBSA, and fifty wounds assessed for their characteristics. Pearson's correlation coefficient for agreement of TBSA between clinical exam and photograph review by expert#1, and #2, was 0.96, 0.93 (p<0.001), respectively. Pearson's correlation coefficients comparing expert#1 and #2 to the gold standard were: proportion of full-thickness burn (0.88 and 0.81, p<0.001), and epithelialized superficial burn (0.89 and 0.55, p<0.001). Kappa scores were significant for wound evolution (expert#1 0.57, expert#2 0.64, p<0.001), and prognosis (expert#1 0.80, expert#2 0.80, p<0.001).

CONCLUSIONS

Burn assessment with digital photography is a valid and affordable alternative to direct clinical exam, alleviating access issues to burn care in developing countries.

Performance measures of the specialty referral process: a systematic review of the literature

BACKGROUND

Performance of specialty referrals is coming under scrutiny, but a lack of identifiable measures impedes measurement efforts. The objective of this study was to systematically review the literature to identify published measures that assess specialty referrals.

METHODS

We performed a systematic review of the literature for measures of specialty referral. Searches were made of MEDLINE and HealthSTAR databases, references of eligible papers, and citations provided by content experts. Measures were eligible if they were published from January 1973 to June 2009, reported on validity and/or reliability of the measure, and were applicable to Organization for Economic Cooperation and Development healthcare systems. We classified measures according to a conceptual framework, which underwent content validation with an expert panel.

RESULTS

We identified 2,964 potentially eligible papers. After abstract and full-text review, we selected 214 papers containing 244 measures. Most measures were applied in adults (57%), assessed structural elements of the referral process (60%), and collected data via survey (62%). Measures were classified into non-mutually exclusive domains: need for specialty care (N = 14), referral initiation (N = 73), entry into specialty care (N = 53), coordination (N = 60), referral type (N = 3), clinical tasks (N = 19), resource use (N = 13), quality (N = 57), and outcomes (N = 9).

CONCLUSIONS

Published measures are available to assess the specialty referral process, although some domains are limited. Because many of these measures have been not been extensively validated in general populations, assess limited aspects of the referral process, and require new data collection, their applicability and preference in assessment of the specialty referral process is needed.

Design and implementation of a telecare information platform

For the aging population and for people with dominant chronic diseases, countries all over the world are promoting an "Aging in Place" program with its primary focus on the implementation of telecare. In 2009, Taiwan held a "Health Care Value-Added Platinum Program" with the goal of promoting the development of "Telecare" services by integrating medical treatment, healthcare, information communication, medical equipment and materials and by linking related cross-discipline professions to enable people to familiarize themselves with preventive healthcare services offered in their household and community environments. In addition, this program can be utilized to effectively provide diversified healthcare service benefitting society as a whole. This study aims to promote a diversified telecare service network in Taiwan's household and community environments, establish telecare information platforms, build an internal network of various healthcare service modes, standardize externally interfacing telecare information networks, effectively utilize related healthcare service resources, and complete reasonable service resource links forming an up-to-date health information exchange network. To this end, the telecare information platform based on service oriented architecture (SOA) is designed to promote an open telecare information interface and sharing environment to assist in such tasks as developing healthcare information exchange services, integrating service resources among various different healthcare service modes, accessing externally complex community affairs information, supporting remote physiological information transmissions, and providing diversified remote innovative services. Information system architecture and system monitoring indices of various types of healthcare service modes are used for system integrations for future development and/or expansions.

Telemedicine Follow-up of Burns: Lessons Learned from the First Thousand Visits

Telemedicine is an evolving technology that is used for health education, health care administration, and health care distribution. The potential benefits of telemedicine include a decrease in travel expenses, improved continuity of care, and increased access to specialized consultants, thus meeting the needs of patients, practitioners, and communities. Telemedicine has many evolving applications, including improved access to health care in medically underserved and rural areas. Regions Burn Center assessed the efficacy and efficiency of burn visits via telemedicine and identified the barriers and benefits specific to burn care. Information regarding travel costs and financial data were evaluated from a total of 1000 burn follow-up visits with 294 patients via telemedicine during a 5-year interval. Our results indicate that telemedicine burn visits are a cost-effective clinical alternative for the patient. However, telemedicine can be a financial burden to health care systems and inefficient for health care providers.

A review of three years experience using email and videoconferencing for the delivery of post-acute burns care to children in Queensland

A virtual outpatient service has been established in Queensland for the delivery of post-acute burns care to children living in rural and remote areas of the state. The integration of telepaediatrics as a routine service has reduced the need for patient travel to the specialist burns unit situated in Brisbane. We have conducted 293 patient consultations over a period of 3 years. A retrospective review of our experience has shown that post-acute burns care can be delivered using videoconferencing, email and the telephone. Telepaediatric burns services have been valuable in two key areas. The first area involves a programme of routine specialist clinics via videoconference. The second area relates to ad-hoc patient consultations for collaborative management during acute presentations and at times of urgent clinical need. The families of patients have expressed a high degree of satisfaction with the service. Telepaediatric services have helped improve access to specialist services for people living in rural and remote communities throughout Queensland.

Regional Air Transport of Burn Patients: A Case for Telemedicine?

BACKGROUND

Air transport of burn patients is plagued by frequent "overtriage." We examined the use of air transport and the feasibility of using alternative methods such as telemedicine to assist in evaluation and treatment of burn patients within our region.

METHODS

We reviewed all burn patients transported by air during 2000 to 2001. Each patient was classified as being most appropriate for air, ground, or family transport. In addition, a decision was made regarding whether telemedicine evaluation of the patient before transport could have significantly altered initial treatment decisions.

RESULTS

Two hundred twenty-five acutely burned patients were transferred from referring hospitals in nine states, at a mean distance of 246 air miles. Mean burn size calculated by burn center physicians was 19.7% total body surface area, whereas referring physicians' mean estimate was 29% total body surface area. In 92 cases, over- or underestimation of burn size by referring physicians of as much as 560% or decisions regarding performance of endotracheal intubation suggested that telemedicine evaluation before transport might have significantly altered transport decisions or care. Air transport charges exceeded hospital charges in 21 cases.

CONCLUSION

Frequent discrepancies in burn assessment contribute to overuse of air transport. The ability to evaluate burn patients by telemedicine may have the potential to assist decisions regarding transfer, avoid errors in initial care, and reduce costs. We are currently attempting to develop and test such a system.

The reliability of digital images when used to assess burn wounds

Sixty burn wounds were assessed in person. The same observer later assessed them using digital images of different sizes. The file sizes tested were 2.25, 5.5 and 9 MByte per image. There was good agreement between the diagnoses of burn depth made using the digital images and those made in person, with kappa scores of 0.53-0.60. There were no major differences between the three file sizes. The assessments made of the partial-thickness burns showed a lower rate of agreement between the in-person and the digital image assessments and for these burns the 2.25 MByte images were apparently as good or better than the larger images. There was little difference between the three file sizes in terms of observer confidence, usefulness of the location shot, or perceived image quality. There was no significant advantage in using larger file sizes to assess burn wounds.