Telemedicine Use Among Burn Centers in the United States

The use of telemedicine for perioperative pain management during the COVID-19 pandemic

INTRODUCTION

Using a human factors engineering approach, the Johns Hopkins Personalized Pain Program adopted telemedicine for perioperative pain management in response to the COVID-19 pandemic. This study examines the impact of telemedicine adoption on the quality and outcomes of perioperative pain management.

METHODS

A mixed-methods study with a convergent parallel design was conducted. From June 2017 to December 2021, 902 patients participated in the Personalized Pain Program. Quantitative data on daily opioid consumption, pain severity and interference, physical and mental health status, and patient satisfaction and engagement were continuously collected with all patients using chart review and patient surveys. Beginning 23 March 2020, the Personalized Pain Program transitioned to telemedicine. A pre-post quasi-experimental design was used to examine the impact of telemedicine. In addition, qualitative interviews were conducted with 3 clinicians and 17 patients to explore their experience with telemedicine visits.

RESULTS

The monthly number of new patients seen in the Personalized Pain Program did not significantly change before and after telemedicine adoption. Compared to patients having in-person visits before the pandemic, patients having telemedicine visits during the pandemic achieved comparable improvements in daily opioid consumption, pain severity and interference, and physical health status. While telemedicine helped overcome many challenges faced by the patients, the limitations of telemedicine were also discussed.

CONCLUSION

The COVID-19 pandemic stimulated the use of telemedicine. To facilitate telemedicine adoption beyond the pandemic, future research is needed to examine best practices for telemedicine adoption and provide additional evidence on the effectiveness of telemedicine.

Virtual burn care - Friend or foe? A systematic review

INTRODUCTION

Evidence on the impact of virtual care for patients with burn injuries is variable. This review aims to evaluate its use in remote assessment, rounding, and follow-up through outcomes of efficacy, usability, costs, satisfaction, clinical outcomes, impacts on triage and other benefits/drawbacks.

METHODS

A PRISMA-compliant qualitative systematic review (PROSPERO CRD42021267787) was conducted in four databases and the grey literature for primary research published between 01/01/2010 and 12/31/2020. Study quality was appraised using three established tools. Evidence was graded by the Oxford classification.

RESULTS

The search provided 481 studies, of which 37 were included. Most studies (n = 30, 81%) were Oxford Level 4 (low-level descriptive/observational) designs and had low appraised risk-of-bias (n = 20, 54%). Most applications were for the acute phase (n = 26, 70%). High patient compliance, enhanced specialist access, and new educational/networking opportunities were beneficial. Concerns pertained to IT/connection, virtual communication barriers, privacy/data-security and logistical/language considerations. Low-to-moderate-level (Oxford Grade C) evidence supported virtual burn care's cost-effectiveness, ability to improve patient assessment and triage, and efficiency/effectiveness for remote routine follow-up.

CONCLUSION

We find growing evidence that virtual burn care has a place in acute-phase specialist assistance and routine outpatient follow-up. Low-to-moderate-level evidence supports its effectiveness, cost-effectiveness, usability, satisfactoriness, and capacity to improve triage.

Implementation evaluation of tiered tele-triage pathways for burn center consultations and transfers

BACKGROUND

Early transfer to specialized centers improves trauma and burn outcomes; however, overtriage can result in unnecessary burdens to patients, providers, and health systems. Our institution developed novel burn triage pathways in 2016 to improve resource allocation. We evaluated the implementation of these pathways, analyzing trends in adoption, resource optimization, and pathway reliability after implementation.

METHODS

Triage pathways consist of transfer nurses (RNs) triaging calls based on review of burn images and clinical history: green pathway for direct outpatient referral, blue pathway for discussion with the on-call provider, red pathway for confirmation of transfer as requested by referring provider, and black pathway for the rapid transfer of severe burns. We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate implementation. These pathways affected all acute burn referrals to our center from January 2017 to December 2019 (reach). Outcomes of interest were pathway assignment over time (adoption), changes to burn provider call volume (effectiveness), and the concordance of pathway assignment with final disposition (implementation reliability).

RESULTS

Transfer RNs triaged 5,272 burn referrals between 2017 and 2019. By January 2018, >98% of referrals were assigned a pathway. In 2018-2019, green pathway calls triaged by RNs reduced calls to burn providers by a mean of 40 (SD, 11) per month. Patients in green/blue pathways were less likely to be transferred, with >85% receiving only outpatient follow-up ( p < 0.001). Use of the lower acuity pathways increased over time, with a concordant decrease in use of the higher acuity pathways. Younger adults, patients referred from Level III to Level V trauma centers and nontrauma hospitals, and patients referred by APPs were less likely to be triaged to higher acuity pathways.

CONCLUSION

Implementation of highly adopted, reliable triage pathways can optimize existing clinical resources by task-shifting triage of lower acuity burns to nursing teams.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Impact of Tele-Triage Pathways on Short-Stay Admission after Transfer to a Regional Burn Center for Acute Burn Injury

BACKGROUND

Regionalized care for burn-injured patients requires accurate triage. In 2016, we implemented a tele-triage system for acute burn consultations. We evaluated resource utilization following implementation, hypothesizing that this system would reduce short-stay admissions and prioritize inpatient care for those with higher burn severity.

STUDY DESIGN

We conducted a retrospective study of all transferred patients with acute burn injuries from January 1, 2010 to December 31, 2015, and January 1, 2017 to December 31, 2019. We evaluated the proportions of short-stay admissions (discharges less than 24 hours without operative intervention, ICU admission, or concern for nonaccidental trauma) among patients transferred before (2010 to 2015) and after (2017 to 2019) triage system implementation. Multivariable Poisson regression was used to evaluate factors associated with short-stay admissions. Interrupted time series analysis was used to evaluate the effect of the triage system.

RESULTS

There were 4,688 burn transfers (3,244 preimplementation and 1,444 postimplementation) in the study periods. Mean age was higher postimplementation (32 vs 29 years, p < 0.001). Median hospital length of stay (LOS) and ICU LOS were both 1 day higher, more patients underwent operative intervention (19% vs 16%), and median time to first operation was 1 day lower postimplementation. Short-stay admissions decreased from 50% (n = 1,624) to 39% (n = 561), and patients were 17% less likely to have a short-stay admission after implementation (adjusted relative risk [aRR], 0.83; 95% CI, 0.8 to 0.9). Pediatric patients younger than 15 years old composed 43% of all short-stay admissions and were much more likely than adult patients to have a short-stay admission independent of transfer timing (aRR, 2.36; 95% CI, 1.84 to 3.03).

CONCLUSIONS

Tele-triage burn transfer center protocols reduced short-stay admissions and prioritized inpatient care for patients with more severe injuries. Pediatric patients remain more likely to have short-stay admission after transfer.

Health systems research in burn care: an evidence gap map

BACKGROUND

Burn injury is associated with significant mortality and disability. Resilient and responsive health systems are needed for optimal response and care for people who sustain burn injuries. However, the extent of health systems research (HSR) in burn care is unknown. This review aimed to systematically map the global HSR related to burn care.

METHODS

An evidence gap map (EGM) was developed based on the World Health Organization health systems framework. All major medical, health and injury databases were searched. A standard method was used to develop the EGM.

RESULTS

A total of 6586 articles were screened, and the full text of 206 articles was reviewed, of which 106 met the inclusion criteria. Most included studies were cross-sectional (61%) and were conducted in hospitals (71%) with patients (48%) or healthcare providers (29%) as participants. Most studies were conducted in high-income countries, while only 13% were conducted in low-and middle-income countries, accounting for 60% of burns mortality burden globally. The most common health systems areas of focus were service delivery (53%), health workforce (33%) and technology (19%). Studies on health policy, governance and leadership were absent, and there were only 14 qualitative studies.

CONCLUSIONS

Major evidence gaps exist for an integrated health systems response to burns care. There is an inequity between the burden of burn injuries and HSR. Strengthening research capacity will facilitate evidence-informed health systems and policy reforms to sustainably improve access to affordable, equitable and optimal burn care and outcomes.

Optimizing an Outpatient mHealth Intervention for Children with Burns: A Convergent Mixed-Methods Study

Burn injury is one of the most common traumatic injuries in childhood. Fortunately, 90% of pediatric burns may be treated in the outpatient setting after appropriate burn triage. Patients with burns face significant geographic disparities in accessing expert burn care due to regionalized care. To aid patients and their families during acute outpatient burn recovery, we developed a smartphone app, Telemedicine Optimized Burn Intervention (TOBI). With this app, we aimed to increase access to care by allowing secure, streamlined communication between patients and burn providers, including messaging and wound image transfer. The purpose of this study was to systematically evaluate user feedback to optimize the patient and provider experience. TOBI was evaluated using a convergent mixed-methods approach consisting of qualitative semi-structured interviews and quantitative measurements of app usability via the mHealth App Usability Questionnaire. Participants included 15 caregivers of pediatric patients with burns who used TOBI during treatment and ten burn providers. Users found TOBI to be a highly usable application in terms of usefulness, ease of use, satisfaction, and functionality. Qualitative data provided insight into user experience, satisfaction and preferences, difficulty navigating, usability and acceptability, and potential improvements. Although most users were highly satisfied, improvements were needed to optimize the burn app. We systematically made these improvements before we released TOBI for routine patient use. This study uncovered helpful recommendations for app improvements that can be generalized to other mobile health apps to increase their appeal and adoption.

Reliability, Validity, and Predictive Validity of Cutaneous Functional Units Predicted to Scar Following Palmar Burn Injury in Young Children

Identification of children at risk of palmar burn scar is important for early initiation of scar management. This study determined the interrater reliability of face-to-face and photographic assessments of 29 palmar cutaneous functional units (CFUs) predicted to scar following palmar burn. The validity of photographic compared to face-to-face assessment, and the predictive validity of both assessment types to identify scarring at 3 to 6 months following burn, was also established. Thirty-nine children (40 hands) post burn injury were assessed face-to-face in the clinical setting, following healing of their palmar burn, by three burn therapists. Photographs of the children's hands at initial assessment were assessed by the same therapists a minimum of 6 months later. To determine which CFUs scarred, children were reassessed face-to-face in the clinical setting 3 to 6 months following their burn. For analysis, 29 CFUs were merged into eight separate groups to determine the number of CFUs predicted to scar per CFU group for face-to-face and photographic assessments. The range of agreement for individual CFUs within CFU groups was also calculated for both assessment types. Excellent interrater reliability was established for face-to-face assessment in all eight CFU groups (ICC2,1 0.83-0.96). Photographic assessment demonstrated good to excellent interrater reliability in six CFU groups (ICC2,1 0.69-0.90) and validity in seven CFU groups (ICC2,1 0.66-0.87). Good to excellent predictive validity was established for both assessment types in seven CFU groups (face-to-face ICC2,1 0.60-0.95, photographic ICC2,1 0.69-0.89). Experienced therapists can reliably assess CFUs face-to-face or via photographs and predict future scar development.

Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study

BACKGROUND

The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response.

OBJECTIVE

To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response.

METHODS

We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability.

RESULTS

Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns.

CONCLUSIONS

Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.

Implementation of Tele-Intensive Care Unit Services During the COVID-19 Pandemic: A Systematic Literature Review and Updated Experience from Shandong Province

Background: While the use of telemedicine had been expanding before the initial outbreak of COVID-19, the pandemic has dramatically accelerated its implementation and expanded its usage in many hospitals. Tele-intensive care unit (ICU) is a specialized type of telemedicine that adapts available technologies to the unique needs of critically ill patients. We published an editorial in 2020 describing our initial experiences of Tele-ICU application in Shandong Province. Here, we update our insights gained over the past 2 years, and we provide a systematic review of the literature to compare our perspectives with those from other institutions. Methods: We performed a systematic literature review of publications describing the use of telemedicine in an ICU setting during COVID-19. The PubMed database was searched for studies published after January 1, 2020, which offered detailed descriptions of tele-ICU usage. Extracted data included details regarding tele-ICU technologies, descriptions of the institution, usage cases, assessments of tele-ICU effectiveness, and site-reported opinions (e.g., advantages, disadvantages). Results: We screened 162 studies resulting from the PubMed literature search, along with one expert recommendation. Of the 112 full-text articles retrieved, 11 were selected for inclusion in this qualitative summary. All were retrospective descriptions of tele-ICU experiences at a single site. Some pairs of included articles reported results from the same institution, with seven unique sites being described. Three sites employed centralized models of tele-ICU, while four allowed staff to participate from distant locations. Five sites collected user-reported feedback regarding tele-ICU. While the advantages and disadvantages described rarely overlapped directly between sites, many reported positive opinions of tele-ICU use overall. Conclusions: The potential applications of tele-ICU technologies vary widely, making them highly adaptable to the needs of individual institutions. Tele-ICU has proven invaluable to some hospitals during COVID-19 due to its effectiveness at aiding patient care while mitigating risk to health care workers.

Squamous Cell Carcinoma at Split Thickness Skin Graft Donor Site: A Case Report and Review of the Literature

Squamous cell carcinoma (SCC) or keratoacanthoma (KA) development at split thickness skin graft donor sites is a documented but very rare entity. We describe a case in which a patient develops a lesion at his graft site seven weeks postoperatively. Upon pathological review, it was found to be SCC and was excised expediently thereafter. Notably, in reviewing the literature, these lesions tend to develop soon after the trauma of skin graft harvest with over half diagnosed within 3 months and a vast majority within 1 year of the operation. This is in contrast to Marjolin ulcers which take years to develop after the initial burn insult. Given the diversity of autograft indications in the reviewed literature, it seems unlikely that the burns themselves contribute to the development of SCC at the donor site. Our case highlights the need for routine surveillance of graft donor sites postoperatively with an emphasis on catching malignant sequelae.

A multicenter evaluation on the impact of non-therapeutic transfer in rural trauma

INTRODUCTION

Trauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia.

METHODS

This retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use.

RESULTS

4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9-26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2-9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care.

CONCLUSIONS

Non-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.

Telehealth and Burn Care: From Faxes to Augmented Reality

Despite advances in telemedicine, practices remain diverse, ranging from telephonic to still images and video-based conferencing. We review the various modes of telemedicine in burn care and summarize relevant studies, including their contributions and limitations. We also review the role of a more recent technology, augmented reality, and its role in the triage and management of burn patients. Telemedicine in burn care remains diverse, with varied outcomes in accuracy and efficiency. Newer technologies such as augmented reality have not been extensively studied or implemented but show promise in immersive, real-time triage.

Role, Development, and Value of Enzymatic Debridement as Integral Component in Initial Treatment of Burn Injuries Exemplified by NexoBrid®

Despite intensive research and increased knowledge over the past decades, the handling of severe burn injuries remains complex and is mainly based on clinical experience. High demands in terms of the diagnosis and choice of therapy often confront clinicians with challenging circumstances. Thus, the treatment of burn injuries has predominantly remained under the responsibility of specialised centres. As a new approach in addition to conventional surgery, enzymatically controlled debridement has come into focus for the treatment of burn injuries over the past years. The efficacy and safety of enzymatic debridement has already been implemented by numerous reputable studies. Promising results from the literature are enhanced by feedback from various conference contributions, intradisciplinary exchanges, and international collaborations. The implementation of enzymatic debridement in initial care management was found to be capable of reforming Standards of Care in numerous burn centres by facilitating treatment determinations and reducing the number of classical surgical interventions. Nevertheless, its use is also subject to certain restrictions as usage has shown limitations concerning efficacy when applied to scalds or pre-treated wounds. Enzymatic debridement shows high efficacy in terms of tissue debridement by combining this feature with the minimisation of collateral damage and a broad field of application in burn injuries. Due to their impressive performance in the treatment of burn injuries, enzyme-based techniques have also attracted attention for the treatment of other pathologies such as chronic wounds and are objects of ongoing research in this field. In this article, we illustrate the significance of enzyme-based treatment in initial burn care and shed some light on the potential value of enzymatic approaches in future burn surgery.

Virtual Visits for Outpatient Burn Care during the COVID-19 Pandemic

Burn-injured patients must frequently travel long distances to regional burn centers, creating a burden on families and impairing clinical outcomes. Recent federal policies in response to the coronavirus pandemic have relaxed major barriers to conducting synchronous videoconference visits in the home. However, the efficacy and benefits of virtual visits relative to in-person visits remained unclear for burn patients. Accordingly, a clinical quality assurance database maintained during the coronavirus pandemic (3/3/2020 to 9/8/2020) for virtual and/or in-person visits at a comprehensive adult and pediatric burn center was queried for demographics, burn severity, visit quality, and distance data. A total of 143 patients were included in this study with 317 total outpatient encounters (61 virtual and 256 in-person). The savings associated with the average virtual visit were 130 ± 125 miles (mean ± standard deviation), 164 ± 134 travel minutes, &104 ± 99 driving costs, and &81 ± 66 foregone wage earnings. Virtual visit technical issues were experienced by 23% of patients and were significantly lower in pediatric (5%) than in adult patients (44%; p=0.006). This study is the first to assess the efficacy of synchronous videoconference visits in the home setting for outpatient burn care. The findings demonstrate major financial and temporal benefits for burn patients and their families. Technical issues remain an important barrier, particularly for the adult population. A clear understanding of these and other barriers may inform future studies as healthcare systems and payors move toward improving access to burn care through remote healthcare delivery services.

Pictures Do Influence the Decision to Transfer: Outcomes of a Telemedicine Program Serving an Eight-State Rural Population

Triaging burn patients is a daunting task because burn injuries are rare; this inexperience leads to uncertainty in treatment and referral algorithms. Our regional burn center's catchment area includes eight states. Outlying facilities consult via telephone through the medical center's transfer center. Referring provider assessments of depth or size of injury infrequently correlates with burn provider's assessments. This causes over- and under-triage of patients managed outside of burn centers. A quality improvement telemedicine project was developed to allow burn providers to review photos with referring providers to determine best management, provide pertinent education, and initiate appropriate and timely resuscitation. Details tracked include date of service, consulting provider, follow-up education offered, and whether the image reviewed changed or confirmed the requested plan of care. Of the 155 cases between January 2017 and August 2018, 24.5% of patient images changed the initial transfer decision, and 75.5% confirmed the initial plan of care. Of the cases requiring change of plan, 60.5% were down-triaged to outpatient care and 39.5% were up-triaged to transfer. Implementation of this telemedicine program has increased efficiency of resource utilization, timely resuscitation, appropriate transfer of patients requiring admission, and real-time education. Findings suggest advanced practice providers' assessments are similar to those of referring physicians. These observations may have significant implications on Emergency Medical Treatment and Labor Act (EMTALA) guidelines defining physician to physician consultation and support efficient use of available resources. Telemedicine facilitates access to specialized care and improves fiscal responsibility.

Digital Otoscopy Videos Versus Composite Images: A Reader Study to Compare the Accuracy of ENT Physicians

OBJECTIVES/HYPOTHESIS

With the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video.

STUDY DESIGN

Diagnostic survey analysis.

METHODS

Five Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer-assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image.

RESULTS

There were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter-reader agreement was moderate.

CONCLUSIONS

Equal to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/family counseling, and clinical training.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1668-E1676, 2021.

Enzymatic debridement for burn wound care: Interrater-reliability and impact of experience in post-intervention therapy decision

INTRODUCTION

Enzymatic debridement (ED) has become a reliable tool for eschar removal. Although ED application is simple, wound bed evaluation and therapy decision post-intervention are prone to subjectivity and failure. Experience in ED might be the key, but this has not been proven yet. Aim of this study was to assess interrater reliability (IR) in post-intervention wound bed evaluation and therapy decision as well as the impact of experience. In addition, the authors introduce video assessment as a valuable tool for post-ED decision making and education.

MATERIAL AND METHODS

A video-based survey was conducted among physicians with various experience in ED. The survey involved multiple choice and 5-point Likert scale questions about professional status, experience in ED, confidence in post-ED wound bed evaluation and therapy decision. Subsequently, videos of 15 mixed pattern to full thickness burns immediately after removal of the enzyme complex were demonstrated. Participants were asked for evaluation of each burn wound, including bleeding pattern and consequent therapy decision. IR ≥80% was considered as a consensus. Responses were stratified according to participants' experience in applying ED (<10; 10-19; 20-49; ≥50 applications). IR was assessed by Chi^2-test (raw agreement (RA); ≥80% was considered as a consensus) and by Krippendorff's Alpha-test. In addition, expert consensus for therapy decision was compared to the actual clinical course of each shown patient. Last, participants were asked for their opinion on video as an assessment tool for post-ED wound bed evaluation, decision making and training.

RESULTS

31 physicians from 11 burn centers participated in the survey. Overall consensus (RA≥80%) in post-ED wound bed evaluation and therapy decision was achieved in 20 and 40%, respectively. Krippendorff's Alpha are given by 0.32 (95% CI: 0.15,0.49) and 0.31 (95% CI: 0.16,0.47), respectively. Subgroup analysis revealed that physicians with high experience in ED achieved significantly more consensus in post-intervention wound bed evaluation and therapy decision compared to physicians with moderate experience (60% vs. 13.3%; p=0.02 and 86.7 vs. 33.3%; p=0.04, respectively). Video analysis was considered a feasible (90.3%) and beneficial (93.5%) tool for post-intervention wound bed evaluation and therapy decision as well as useful for training purposes (100%).

CONCLUSION

Reliability of wound bed evaluation and therapy decision after ED depends on the experience of the rating physician. Video analysis is deemed to be a valuable tool for ED evaluation, decision making and user training.

A Review of the Use of Telemedicine in Dermatologic Surgery

BACKGROUND

Telemedicine is an emerging field with numerous applications within medicine. Previous review articles describe its use within plastic surgery and otolaryngology but none, to the authors' knowledge, within dermatologic surgery.

OBJECTIVE

To provide a review of the applications of telemedicine within dermatologic surgery.

MATERIALS AND METHODS

A PubMed search of articles published on teledermatology was conducted in July 2018. Articles were selected based on their relevance to dermatologic surgery and reviewed for their discussion of the applications of telemedicine in surgical and cosmetic dermatology.

RESULTS

The initial search resulted in 156 articles. Eleven ultimately met inclusion criteria: 2 in referral and consultation, 5 in telepathology, 2 in intraoperative uses, and 2 in postprocedural care.

CONCLUSION

For preoperative consultation, teledermatology enables the surgeon to plan ahead and increases access to care by reducing the number of clinic visits. Telepathology has the potential to allow intraoperative consultation with a dermatopathologist to achieve accurate tumor clearance without delay. Smartglasses represent a promising technology for greater care coordination and a teaching tool. Postprocedural monitoring via text messaging provides convenient access to expert advice and early detection of postoperative complications. With increasing technologic advancements, telemedicine holds great potential to augment the dermatologic surgeon's daily practice.

A Review of Telemedicine Applications in Otorhinolaryngology: Considerations During the Coronavirus Disease of 2019 Pandemic

OBJECTIVE/HYPOTHESIS

Review the published literature of telemedicine's use within otorhinolaryngology (ORL), highlight its successful implementation, and document areas with need of future research.

STUDY DESIGN

State of the Art Review.

METHODS

Three independent, comprehensive searches for articles published on the subject of telemedicine in ORL were conducted of literature available from January 2000 to April 2020. Search terms were designed to identify studies which examined telemedicine use within ORL. Consensus among authors was used to include all relevant articles.

RESULTS

While several, small reports document clinical outcomes, patient satisfaction, and the cost of telemedicine, much of the literature on telemedicine in ORL is comprised of preliminary, proof-of-concept reports. Further research will be necessary to establish its strengths and limitations.

CONCLUSIONS

Particularly during the coronavirus disease of 2019 pandemic, telemedicine can, and should, be used within ORL practice. This review can assist in guiding providers in implementing telemedicine that has been demonstrated to be successful, and direct future research. Laryngoscope, 131:744-759, 2021.

Triage and Transfer to a Regional Burn Center—Impact of a Mobile Phone App

Telemedicine technology can be used to facilitate consultations from nonburn-trained referring providers. However, there is a paucity of evidence indicating these technologies influence transfer decisions and follow-up care. In 2016, our regional burn center implemented a mobile phone app, which allows a referring provider to send photos of the wound along with basic demographic and clinical data to the burn specialist. A retrospective review was performed on consults to our regional burn center from a Level I trauma center approximately 70 miles away with a shared electronic medical record. Patients were considered to be “down-triaged” if they could be managed locally or if the transfer could occur via personal vehicle instead of ground or air ambulance transport. During the 2-year study period, 126 consultations were made for thermal injuries. Eighty-seven patients (69%) were referred using the Burn App. Overall, 49 patients (39%) were transferred. When the subset of intermediate size (1–10% TBSA) burns were considered (n = 48), the Burn App allowed for successful “down-triage” of 12 patients (33%) referred through the app. No patient referred without the app could be “down-triaged” (P = .02). Although 57 patients (44%) were recommended for outpatient follow-up, only 42% followed up. A mobile app can be used to successfully triage patients with intermediate size burn injuries to a lower acuity of follow-up and transfer mode. However, only a minority of patients triaged to outpatient management actually follow up with a regional burn center. Telemedicine efforts should focus on improving not only initial triage, but also aftercare.

Management of severe thermal burns in the acute phase in adults and children

OBJECTIVES

To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.

DESIGN

A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.

RESULTS

The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.

CONCLUSION

Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

Expert Outpatient Burn Care in the Home Through Mobile Health Technology

Access to care for pediatric burns remsains a major public health problem in the United States. Telemedicine has an opportunity to improve access to care, but current models are expensive and inefficient. They have developed and pilot-tested the TeleBurn App, a novel smartphone application, to treat partial thickness burns while outpatient. The app allows the provision of expert clinical burn care directly in the patient's home through text and image messaging, video conferencing, and instructional videos. They retrospectively reviewed clinical outcomes and usability in pediatric partial thickness burn patients treated using the TeleBurn App compared with standard therapy alone. Standard therapy is considered to be face-to-face delivery of care. Burn wound care was provided to 32 patients via the app and 35 patients with standard therapy. Most (74%) patients offered the app, used it as their primary source of follow-up care. This group had no wound infections or unexpected returns to clinic or hospital. Both TeleBurn App and standard therapy groups had similar burn severity, age, and burn mechanism. Mean healing time was shorter in the app group (mean ± standard deviation: 11.6 ± 4.7 days versus standard therapy: 14.3 ± 5.4 [P = .03]) with fewer clinical encounters (0.93 ± 0.6 vs standard therapy: 3.3 ± 1.0 [P = .001]). Adherence with completion of therapy in patients using the app was 80 vs 64 per cent with standard therapy. They describe a functional, scalable mobile health application in clinical use in a pediatric burn program. Further prospective, randomized studies may validate this mobile health platform, improving access to expert burn care for a vulnerable population.

[Telemedicine and initial medical regulation of severe burns]

The evaluation of the patient and his burned body surface is one of the fundamental prerequisites for his care on site as well as for the initiation of his care journey. New tools such as the E-burn application and telemedicine improve this assessment and remote medical assistance management by reducing the risk of under-sorting or over-sorting. Telemedicine limits inappropriate secondary inter-hospital transfers and the resulting increased mortality. It is carried out according to standards that ensure safety and confidentiality for the patient and caregivers.

Teleconsultation Using Mobile Phones for Diagnosis and Acute Care of Burn Injuries Among Emergency Physicians: Mixed-Methods Study

Background

The referral process in acute care remains challenging in many areas including burn care. Mobile phone apps designed explicitly for medical referrals and consultations could streamline the referral process by using structured templates and integrating features specific to different specialties. However, as these apps are competing with commercial chat services, usability becomes a crucial factor for successful uptake.

Objective

The aim of this study was to assess the usability of a mobile phone app for remote consultations and referrals of burn injuries.

Methods

A total of 24 emergency doctors and 4 burns consultants were recruited for the study. A mixed-methods approach was used including a usability questionnaire and a think-aloud interview. Think-aloud sessions were video-recorded, and content analysis was undertaken with predefined codes relating to the following 3 themes: ease of use, usefulness of content, and technology-induced errors.

Results

The users perceived the app to be easy to use and useful, but some problems were identified. Issues relating to usability were associated with navigation, such as scrolling and zooming. Users also had problems in understanding the meaning of some icons and terminologies. Sometimes, some users felt limited by predefined options, and they wanted to be able to freely express their clinical findings.

Conclusions

We found that users faced problems mainly with navigation when the app did not work in the same way as the other apps that were frequently used. Our study also resonates with previous findings that when using standardized templates, the systems should also allow the user to express their clinical findings in their own words.

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.

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.

The role of preliminary hospitals in the management of a mass burn casualty disaster

PURPOSE

The Formosa Fun Coast explosion is an internationally-known event that occurred in Taiwan on June 27th, 2015. The blast involved 495 casualties in total, with 253 patients receiving 2nd degree or deeper burns on greater than 40% of the total body surface area (TBSA). Questions were raised regarding whether these victims were sent to the appropriate hospitals or not. Therefore, we analyzed the effect of the initial admission destination in this study.

MATERIAL AND METHODS

We retrospectively reviewed all of the victims from the explosion who were sent to the emergency department of Linkou and Keelung Chang Gung Memorial Hospitals. Patients were divided by direct admission and received via transfer. The basic demographics, the efficacy of the initial resuscitation and the clinical outcomes were analyzed.

RESULTS

In total, forty-six patients were included. Thirty-five of them were primarily admitted, and eleven of them were received via transfer. Between the two groups, there was no significant difference in the resuscitation outcome. The ratio of delaying intubation was similar (14.3% vs 27.3%, p=0.322). The rate of delayed-detected ischemic events was significantly increased in the referral group (0% vs 27.3%, p=0.001). However, there was no amputation event in either group. No difference in mortality was observed between groups (5.7% vs 9.1%, p=0.692).

CONCLUSION

Our preliminary findings suggest that local hospitals are capable of providing high-quality acute care to mass casualty burn victims. Our results suggest that patients with suspected limb ischemia should be rapidly transferred to a regional burn center to ensure optimal care. Systemic pre-planning such as employing telemedicine and personnel collaboration, should be considered by the administration to maximize the function of preliminary hospitals in burn care.

Interactive home telehealth and burns: A pilot study

OBJECTIVE

The objective of this study is to review our experience incorporating Interactive Home Telehealth (IHT) visits into follow-up burn care.

METHODS

A retrospective review of all burn patients participating in IHT encounters over the course of 15 months was performed. Connections were established through secure video conferencing and call-routing software. Patients connected with a personal computer or tablet and providers connected with a desktop computer with a high-definition web camera. In some cases, high-definition digital images were emailed to the provider prior to the virtual consultation. For each patient, the following was collected: (1) patient and injury demographics (diagnosis, prognosis, and clinical management), (2) total number of encounters, (3) service for each encounter (burn, psychiatry, and rehabilitation), (4) length of visit, including travel distance and time saved and, (5) complications, including re-admissions and connectivity issues.

RESULTS

52 virtual encounters were performed with 31 patients during the first year of the pilot project from March 2015 to June 2016. Mean age of the participant was 44 years (range 18-83 years). Mean total burn surface area of the participant was 12% (range 1-80%). Average roundtrip travel distance saved was 188 miles (range 4-822 miles). Average round trip travel time saved was 201min (range 20-564min). There were no unplanned re-admissions and no complications. Five connectivity issues were reported, none of which prevented completion of the visit.

CONCLUSIONS

Interactive Home Telehealth is a safe and feasible modality for delivering follow-up care to burn patients. Burn care providers benefit from the potential to improve outpatient clinic utilization. Patients benefit from improved access to multiple members of their specialized burn care team, as well as cost-reductions for patient travel expenses. Future studies are needed to ensure patient and provider satisfaction and to further validate the significance, cost-effectiveness and safety.

Urban Telemedicine: The Applicability of Teleburns in the Rehabilitative Phase

Telemedicine has been successfully used in many areas of medicine, including triage and evaluation of the acute burn patient. The utility of telemedicine during the rehabilitative phase of burn care has yet to be evaluated; therefore, we expanded our telemedicine program to link our burn center with a rehabilitation facility. The goal of this project was to demonstrate cost-effective improvements in the transition and quality of care. A retrospective review was performed on all patients enrolled in our telemedicine/rehabilitation program between March 2013 and March 2014. Data collected included total number of encounters, visits, type of visit, physician time, and readmissions. Transportation costs were based on local ambulance rates between the two facilities. The impact of telemedicine was evaluated with respect to the time saved for the physician, burn center, and burn clinic, as well as rehabilitative days saved. A patient satisfaction survey was also administered. A total of 29 patients participated in 73 virtual visits through the telemedicine project. Virtual visits included new consults, preoperative evaluations, and postoperative follow-ups. A total of 146 ambulance transports were averted during the study period, totaling $101,110. Virtual visits saved 6.8 outpatient burn clinic days, or 73 clinic appointments of 30-min duration. The ability to perform more outpatient surgery resulted in 80 inpatient bed days saved at the burn hospital. The rehabilitation hospital saved an average of 2 to 3 patient days secondary to unnecessary travel. Satisfaction surveys demonstrated patient satisfaction with the encounters, primarily related to time saved. The decrease in travel time for the patient from the rehabilitation hospital to outpatient burn clinic improved adherence to the rehabilitation care plan and resulted in increased throughput at the rehabilitation facility. Videoconferencing between a burn center and rehabilitation hospital streamlined patient care and reduced health care costs, while maintaining quality of care and patient satisfaction. This program has improved inpatient burn rehabilitation by maximizing time spent in therapy and avoiding unnecessary patient travel to offsite appointments.

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.

Unnecessary Transfers for Acute Surgical Care: Who and Why?

Interhospital transfers for acute surgical care occur commonly, but without clear guidelines or protocols. Transfers may subject patients and delivery systems to significant burdens without clear clinical benefit. The incidence and factors associated with unnecessary transfers are not well described. We conducted a retrospective cohort study of patient transfers within a regional referral network to a tertiary center for nontrauma acute surgical care from 2009 to 2013. Clinically unnecessary transfers were defined as transfers that resulted in no intervention (operation, endoscopy, or interventional radiology procedure) and discharge to home within 72 hours. We performed bivariate and multivariate logistic regression analyses. The study population included 2177 patient transfers, 19 per cent of which were determined to be clinically unnecessary. After adjustment, clinically unnecessary transfers were more commonly performed for patient request (odds ratio = 2.52, 95% confidence interval = 1.60–3.99), continuity of care (1.87, 1.44–2.42), and care by urologic (1.50, 1.06–2.13) and vascular services (1.44, 1.03–2.01). Patients with higher comorbidity and severity of illness scores were less likely to have unnecessary transfers. The burden of unnecessary transfers could be mitigated by identifying appropriate transfer candidates through mutually developed guidelines, interfacility collaboration, and increased use of remote care to provide surgical subspecialty consultation and maintain continuity.

Recent Directions in Telemedicine: Review of Trends in Research and Practice

Objectives

Healthcare is now routinely delivered by telecommunications-based services in all developed countries and an increasing number of developing countries. Telemedicine is used in many clinical specialities and across numerous healthcare settings, which range from mobile patient-centric applications to complex interactions amongst clinicians in tertiary referral hospital settings. This paper discusses some recent areas of significant development and progress in the field with the purpose of identifying strong trends in both research and practice activities.

Methods

To establish the breadth of new ideas and directions in the field, a review of literature was made by searching PubMed for recent publications including terms (telemedicine OR telehealth) AND (challenge OR direction OR innovation OR new OR novel OR trend), for all searchable categories. 3,433 publications were identified that have appeared since January 1, 2005 (2,172 of these since January 1, 2010), based on a search conducted on June 1, 2015.

Results

The current interest areas in these papers span both synchronous telemedicine, including intensive care, emergency medicine, and mental health, and asynchronous telemedicine, including wound and burns care, dermatology and ophthalmology.

Conclusions

It is concluded that two major drivers of contemporary tele medicine development are a high volume demand for a particular clinical service, and/or a high criticality of need for clinical exper tise to deliver the service. These areas offer promise for further study and enhancement of applicable telemedicine methods and have the potential for large-scale deployments internationally, which would contribute significantly to the advancement of healthcare.

The evaluation and management of thermal injuries: 2014 update

Burns are among the most common injuries presenting to the emergency department. While burns, especially large ones, may be associated with significant morbidity and mortality, most are minor and can be managed by emergency practitioners and discharged home with close follow-up. In contrast, patients with large burns require aggressive management of their airway, breathing and circulation in order to reduce mortality and morbidity. While early endotracheal intubation of patients with actual or impending airway compromise and aggressive fluid resuscitation have been emphasized, it appears that the pendulum may have swung a bit too far towards the extreme. The current review will briefly cover the epidemiology, pathogenesis and diagnosis of burn injuries with greater emphasis on airway and fluid management. We will also discuss the local management of the burn wound, which is all that is required for most burn patients in the emergency department.

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.