The feasibility of nurse practitioner-performed, telementored lung telesonography with remote physician guidance - 'a remote virtual mentor'

New International Guidelines and Consensus on the Use of Lung Ultrasound

Following the innovations and new discoveries of the last 10 years in the field of lung ultrasound (LUS), a multidisciplinary panel of international LUS experts from six countries and from different fields (clinical and technical) reviewed and updated the original international consensus for point-of-care LUS, dated 2012. As a result, a total of 20 statements have been produced. Each statement is complemented by guidelines and future developments proposals. The statements are furthermore classified based on their nature as technical (5), clinical (11), educational (3), and safety (1) statements.

Point of care prehospital ultrasound in Basic Emergency Services in Portugal

Background and Aims

The Point of Care Ultrasound and Point‐of‐Care Ultrasound in Resource‐Limited Settings are differentiated diagnostic methods using ultrasound, essential in urgent patients screening, allowing better guidance in the diagnostic process and therapeutic approach. This study intends to observe the impact of these techniques in two Basic Emergency Services (SUB) in Portugal.

Methods

A longitudinal study was carried out in two remote locations in Portugal (SUB N and SUB S). Data were collected by trained radiographers in each location, and a total of 972 exams were considered. Imaging findings were documented by exam type, the exam normality and the resolution after exam. χ² and Cramer's V tests were performed to check significant correlations between the variables.

Results

Regarding the type of echographic findings, 289 (29.7%) were considered normal, 628 (64.6%) were classified as abnormal and 55 (5.7%) were considered inconclusive. As for the type of resolution, 58% had local resolution, 24% were referred to a hospital emergency service and 18% referred to ambulatory care. Regarding the Location versus Resolution after exam versus Findings variables, it was verified a stronger statistically significant association for the exams considered “Abnormal” (Cramer's V = 0.414; p < 0.001). In the variables Location versus Findings versus Resolution after exam, it was verified a stronger statistical significance for “Referral to Ambulatory” (Cramer V = 0.443; p < 0.001) although Referral for Hospital (Cramer V = 0.252; p = 0.003) or Local Resolution (Cramer V = 0.252; p < 0.001) also had a moderate association strength.

Conclusion

Ultrasonography is a useful diagnostic tool for patients screening, having an influence on patient management in remote settings. Given the limited literature in Portugal about this matter, further research and literature will be needed to support and complement the results of this study.

“A Head Start or a Pain in the Neck?”—Establishment and Evaluation of a Video-Based “Hands-On” Head and Neck Ultrasound Course

The COVID-19 pandemic has strongly highlighted the need for more digitalization in healthcare. Teaching ultrasound skills in online courses is a key challenge in this context. The aim of this study was to establish an online video-based head and neck ultrasound course with an evaluation of the quality, effectiveness, and feasibility of this teaching method compared to in-person teaching. Twenty-two medical students were taught head and neck ultrasound in two groups: one group in an in-person course and the other one in a video-based course. Learning success was analyzed using self-evaluation forms and external assessment by an experienced ultrasonographer. Comparing pre- and post-training self-evaluation, all participants showed statistically significant learning progress. In the external assessment, the overall scores in both groups did not differ significantly. The courses themselves were positively evaluated by all participants. Herein, we present the first feasibility study of a web-based head and neck-ultrasound course for medical students. The methodology provides the potential for future changes in telemedical education and sustainable improvements in telemedical teaching and global intra-clinical and interdisciplinary patient care.

Empowering the willing: the feasibility of tele-mentored self-performed pleural ultrasound assessment for the surveillance of lung health

Background

SARS-CoV-2 infection, manifesting as COVID-19 pneumonia, constitutes a global pandemic that is disrupting health-care systems. Most patients who are infected are asymptomatic/pauci-symptomatic can safely self-isolate at home. However, even previously healthy individuals can deteriorate rapidly with life-threatening respiratory failure characterized by disproportionate hypoxemic failure compared to symptoms. Ultrasound findings have been proposed as an early indicator of progression to severe disease. Furthermore, ultrasound is a safe imaging modality that can be performed by novice users remotely guided by experts. We thus examined the feasibility of utilizing common household informatic-technologies to facilitate self-performed lung ultrasound.

Methods

A lung ultrasound expert remotely mentored and guided participants to image their own chests with a hand-held ultrasound transducer. The results were evaluated in real time by the mentor, and independently scored by three independent experts [planned a priori]. The primary outcomes were feasibility in obtaining good-quality interpretable images from each anatomic location recommended for COVID-19 diagnosis.

Results

Twenty-seven adults volunteered. All could be guided to obtain images of the pleura of the 8 anterior and lateral lung zones (216/216 attempts). These images were rated as interpretable by the 3 experts in 99.8% (647/648) of reviews. Fully imaging one’s posterior region was harder; only 108/162 (66%) of image acquisitions was possible. Of these, 99.3% of images were interpretable in blinded evaluations. However, 52/54 (96%) of participants could image their lower posterior lung bases, where COVID-19 is most common, with 99.3% rated as interpretable.

Conclusions

Ultrasound-novice adults at risk for COVID-19 deterioration can be successfully mentored using freely available software and low-cost ultrasound devices to provide meaningful lung ultrasound surveillance of themselves that could potentially stratify asymptomatic/paucisymptomatic patients with early risk factors for serious disease. Further studies examining practical logistics should be conducted.

Trial Registration: ID ISRCTN/77929274 on 07/03/2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00250-6.

Teleguided self-ultrasound scanning for longitudinal monitoring of muscle mass during spaceflight

Loss of muscle mass is a major concern for long duration spaceflight. However, due to the need for specialized equipment, muscle size has only been assessed before and after spaceflight where ~20% loss is observed. Here, we demonstrate the utility of teleguided self-ultrasound scanning (Tele-SUS) to accurately monitor leg muscle size in astronauts during spaceflight. Over an average of 168 ± 57 days of spaceflight, 74 Tele-SUS sessions were performed. There were no significant differences between panoramic ultrasound images obtained by astronauts seven days prior to landing and expert sonographer after flight or between change in muscle size assessed by ultrasound and magnetic resonance imaging. These findings extend the current capabilities of ultrasound imaging to allow self-monitoring of muscle size with remote guidance.

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We examined teleguided self-ultrasound to monitor leg muscle size on the ISS

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Muscle thickness ultrasound does not detect change in muscle size during spaceflight

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Panoramic ultrasound accurately monitors change in muscle size compared to MRI

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Teleguided self-ultrasound reveals upper and lower leg muscle loss during spaceflight

The Potential for Remotely Mentored Patient-Performed Home Self-Monitoring for New Onset Alveolar-Interstitial Lung Disease

Purpose: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is an acute respiratory illness. Although most infected persons are asymptomatic or have only mild symptoms, some patients progress to devastating disease; such progression is difficult to predict or identify in a timely manner. COVID-19 patients who do not require hospitalization can self-isolate at home. Calls from one disease epicenter identify the need for homebased isolation with telemedicine surveillance to monitor for impending deterioration. Methodology: Although the dominant approach for these asymptomatic/paucisymptomatic patients is to monitor oxygen saturation, we suggest additionally considering the potential merits and utility of home-based imaging. Chest computed tomography is clearly impractical, but ultrasound has shown comparable sensitivity for lung involvement, with major advantages of short and simple procedures, low cost, and excellent repeatability. Thoracic ultrasound may thus allow remotely identifying the development of pneumonitis at an early stage of illness and potentially averting the risk of insidious deterioration to severe pneumonia and critical illness while in home isolation. Conclusions: Lung sonography can be easily performed by motivated nonmedical caregivers when directed and supervised in real time by experts. Remote mentors could thus efficiently monitor, counsel, and triage multiple home-based patients from their "control center." Authors believe that this approach deserves further attention and study to reduce delays and failures in timely hospitalization of home-isolated patients.

Offshore telementored ultrasound: a quality assessment study

Background

Telementored ultrasound (US) connects experts to novices through various types of communication and network technologies with the overall aim to bridge the medical imaging gap between patients’ diagnostic needs and on-site user experience. The recurrent theme in previous research on remote telementored US is the limited access to US machines and experienced users. This study was conducted to determine whether telementored US was feasible in a remote offshore setting. The aim was to assess if an onshore US expert can guide an offshore nurse through focused US scanning protocols by connecting an US machine to existing videoconference units at the offshore hospitals and to evaluate the diagnostic quality of the images and cineloops procured.

Results

The diagnostic quality of cineloops was scored on a five-point scale. The percentage of cineloops suitable for interpretation (score 3 ≥) for the FATE and e-FAST protocols was 96.4 and 79.1. Lung sliding and seashore sign could be identified in all volunteers. The scan time for the FAST protocol (n = four scanning positions), FATE protocol (n = six scanning positions) and both lungs (n = two scanning positions) was 1 min 20 s, 4 min 15 s and 32 s, respectively.

Conclusion

A novice US user can be guided by a remote expert through focused US protocols within an acceptable time frame and with good diagnostic quality using existing communication and network systems found onboard offshore oil rigs.

Review of Health Economics of Point-of-Care Testing Worldwide and Its Efficacy of Implementation in the Primary Health Care Setting in Remote Australia

There are important differences concerning health outcomes between the Australian population living in rural/remote regions and the urban population. Health care provision in remote areas, particularly in regions with a low number of inhabitants, is not without challenges. Aboriginal, rural and remote communities are therefore affected, as they face various obstacles in accessing health services, owing to geographical settings, difficulties in transportation to nearby hospitals, limited or inexistent local qualified personnel. The implementation of point-of-care testing could be a plausible solution to these challenges, as various point-of-care services that have been successfully put into action worldwide indicate towards positive clinical outcomes. Point-of-care units have a real potential in reducing morbidity and mortality in all population groups. This article aims to review the published literature on point-of-care testing around the world, with a focus on health economics and the feasibility of its implementation in Australian rural and remote regions.

Point-of-care resuscitation research: From extreme to mainstream: Trauma Association of Canada Fraser Gurd Lecture 2019

The Gurd Family surgical legacy was deeply intertwined with National service in both World Wars. My own personal research mission has attempted to emulate such service, by enhancing the tools and techniques available to facilitate point-of-care diagnosis and resuscitation in extreme and adverse environments. Our efforts involving point-of-care diagnosis/resuscitation and the telementored guidance of those remotely responding to catastrophic injury have included collaborations with National Aeronautics and Space Administration (NASA) the Canadian Space Agency, the Canadian Forces, its democratic allies, and non-governmental surgical organizations. Research has been conducted in resuscitative suites and operating theaters, research laboratories, parabolic flight aircraft, on humanitarian surgical missions, and from ski-hills and firehalls. The initial phases of these efforts involved inaugural studies in resuscitative sonography including defining the Extended Focused Assessment with Sonography for Trauma (EFAST) examination. Although the original work was commissioned for Space Medicine, generalization to mainstream practice further justifies space medicine research. Iterative steps in advancing telementored resuscitation have subsequently involved the maturation of space-mandated telementored ultrasound support (TMUS), exploration of TMUS in terrestrial clinical practice, and the creation of increasingly mobile (hand-held) TMUS solutions. Subsequently it was recognized that teleultrasound is simply one informatic dimension of remote telemedicine, and current efforts are focused in a Program known as TeleMentored Ultrasound Supported Medical Interactions (TMUSMI) of remote responders required to intervene with catastrophic trauma. While this research program has yielded many techniques and findings that have benefited mainstream terrestrial practice, these investigations are currently ongoing, and we hope to demonstrate that TMUSMI may benefit all Canadians especially those in remote areas, as well as potentially every global inhabitant without immediate access to care. Further, we propose that to fully utilize these techniques, a new specialty, that of the remote medical mentor will be required, a new specialty that will require the creation and scientific validation of its principles and techniques.

Remote Mentoring of Point-of-Care Ultrasound Skills to Inexperienced Operators Using Multiple Telemedicine Platforms: Is a Cell Phone Good Enough?

OBJECTIVES

Telemedicine technology contributes to the teaching of point-of-care ultrasound (US); however, expensive equipment can limit its deployment in resource-challenged settings. We assessed 3 low-cost telemedicine solutions capable of supporting remote US training to determine feasibility, acceptability, and effectiveness. We also explored the value of instructional videos immediately before telementoring.

METHODS

Thirty-six participants were randomly assigned to receive US mentoring in 1 of 3 telemedicine conditions: multiple fixed cameras, a smartphone, and traditional audio with a live US stream. Participants were then asked to perform a standardized US examination of the right upper quadrant under remote guidance. We measured observer's global ratings of performance along with the mentor's and student's rating of effort and satisfaction to determine which of the 3 approaches was most feasible, acceptable, and effective. During the second phase, students were randomized to watch an instructional video or not before receiving remote coaching on how to complete a subxiphoid cardiac examination. Effort, satisfaction, and performance from the independent observer's and student's perspective were surveyed.

RESULTS

There was no significant difference between the different telemedicine setups from the observer's perspective; however, the mentor rated the smartphone significantly worse (P = .028-.04) than other technologies. Platforms were rated equivalent from the student's perspective. No benefit was detected for watching an instructional video before the mentored task.

CONCLUSIONS

Remote US skills can be taught equally effectively by using a variety of telemedicine technologies. Smartphones represent a viable option for US training in resource-challenged settings.

Which ultrasound transducer type is best for diagnosing pneumothorax?

Background

An accurate physical examination is essential in the care of critically ill and injured patients. However, to diagnose or exclude a pneumothorax, chest auscultation is unreliable compared to lung ultrasonography. In the dynamic prehospital environment, it is desirable to have the best possible ultrasound transducer readily available. The objective is to assess the difference between a linear-array, curved-array, and phased-array ultrasound transducer in the assessment for pneumothorax and to determine which is best.

Methods

In this double-blinded, cross-sectional, observational study, 15 observers, experienced in lung ultrasonography, each assessed 66 blinded ultrasound video clips of either normal ventilation or pneumothorax that were recorded with three types of ultrasound transducers. The clips were recorded in 11 adult patients that underwent thoracoscopic lung surgery immediately before and after the surgeon opened the thorax. The diagnostic accuracy of the three transducers, elapsed time until a diagnosis was made, and the perceived image quality was recorded.

Results

In total, 15 observers assessed 990 ultrasound video clips. The overall sensitivity and specificity were 98.2% and 97.2%, relatively. No significant difference was found in the diagnostic performance between transducers. A diagnosis was made slightly faster in the linear-array transducer clips, compared to the phased-array transducer (p = .031). For the linear-, curved-, and phased-array transducer, the image quality was rated at a median (interquartile range [IQR]) of 4 (IQR 3–4), 3 (IQR 2–4), and 2 (IQR 1–2), relatively. Between the transducers, the difference in image quality was significant (p < .0001).

Conclusions

There was no difference in diagnostic performance of the three transducers. Based on image quality, the linear-array transducer might be preferred for (prehospital) lung ultrasonography for the diagnosis of pneumothorax.

ABCDE of prehospital ultrasonography: a narrative review

Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.

Can an Offsite Expert Remotely Evaluate the Visual Estimation of Ejection Fraction via a Social Network Video Call?

We aimed to investigate whether an offsite expert could effectively evaluate visually estimated ejection fraction (EF) while watching and guiding the echocardiographic procedure of an onsite novice practitioner using a social network video call. Sixty patients presenting to the intensive care unit and requiring echocardiography between October and November 2016 were included. Sixty novice sonographers without any previous experience of echocardiography participated. Prior to the procedure, the onsite cardiologist completed the echocardiography and determined the EF using the modified Simpson's method (reference value). Then, the novice practitioner performed the echocardiography again with the offsite expert's guidance via a social network video call. The EF was visually estimated by the offsite expert while watching the ultrasound video on the smartphone display. Spearman's rank correlation and Bland-Altman plot analysis were conducted to assess the agreement between the two methods. There was excellent agreement between the two methods, with a correlation coefficient of 0.94 (p < 0.001). The Bland-Altman plot showed that the average bias was -3.05, and the limit of agreement (-10.3 to 4.2) was narrow. The offsite expert was able to perform an accurate visual estimation of ejection fraction remotely via a social network video call by mentoring the onsite novice sonographer. ClinicalTrials.gov Identifier: NCT02960685.

Telesonography in emergency medicine: A systematic review

Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.

A Feasibility Study of Telementoring for Identifying the Appendix Using Smartphone-Based Telesonography

We investigated the feasibility of the clinical application of novice-practitioner-performed/offsite-mentor-guided ultrasonography for identifying the appendix. A randomized crossover study was conducted using a telesonography system that can transmit the ultrasound images displayed on the ultrasound monitor (ultrasound sequence video) and images showing the practitioner's operations (background video) to a smartphone without any interruption in motion over a Long-Term Evolution (LTE) network. Thirty novice practitioners were randomly assigned to two groups. The subjects in group A (n = 15) performed ultrasonography for the identification of the appendix under mentoring by an onsite expert, whereas those in group B (n = 15) performed the same procedure under mentoring by an offsite expert. Each subject performed the procedure on three simulated patients. After a 4-week interval, they performed the procedure again under the other type of mentoring. A total of 90 ultrasound examinations were performed in each scenario. The primary outcomes were the success rate for identifying the appendix and the time required to identify the appendix. The success rates for identifying the appendix were 91.1 % (82/90) in onsite-mentored ultrasonography and 87.8 % (79/90) in offsite-mentored ultrasonography; both rates were high, and there was no significant difference (p = 0.468) between them. The time required in the case of offsite mentoring (median, 242.9 s; interquartile range (IQR), 238.2) was longer than that for onsite mentoring (median, 291.4 s; IQR, 200.9); however, the difference was not significant (p = 0.051). It appears that offsite mentoring can allow novice onsite practitioners to perform ultrasonography as effectively as they can under onsite mentoring, even for examinations that require proficiency in rather complex practices, such as identifying the appendix.

A Feasibility Study of Smartphone-Based Telesonography for Evaluating Cardiac Dynamic Function and Diagnosing Acute Appendicitis with Control of the Image Quality of the Transmitted Videos

Our aim was to prove the feasibility of the remote interpretation of real-time transmitted ultrasound videos of dynamic and static organs using a smartphone with control of the image quality given a limited internet connection speed. For this study, 100 cases of echocardiography videos (dynamic organ)-50 with an ejection fraction (EF) of ≥50 s and 50 with EF <50 %-and 100 cases of suspected pediatric appendicitis (static organ)-50 with signs of acute appendicitis and 50 with no findings of appendicitis-were consecutively selected. Twelve reviewers reviewed the original videos using the liquid crystal display (LCD) monitor of an ultrasound machine and using a smartphone, to which the images were transmitted from the ultrasound machine. The resolution of the transmitted echocardiography videos was reduced by approximately 20 % to increase the frame rate of transmission given the limited internet speed. The differences in diagnostic performance between the two devices when evaluating left ventricular (LV) systolic function by measuring the EF and when evaluating the presence of acute appendicitis were investigated using a five-point Likert scale. The average areas under the receiver operating characteristic curves for each reviewer's interpretations using the LCD monitor and smartphone were respectively 0.968 (0.949-0.986) and 0.963 (0.945-0.982) (P = 0.548) for echocardiography and 0.972 (0.954-0.989) and 0.966 (0.947-0.984) (P = 0.175) for abdominal ultrasonography. We confirmed the feasibility of remotely interpreting ultrasound images using smartphones, specifically for evaluating LV function and diagnosing pediatric acute appendicitis; the images were transferred from the ultrasound machine using image quality-controlled telesonography.

The Damage Control Surgery in Austere Environments Research Group (DCSAERG): A dynamic program to facilitate real-time telementoring/telediagnosis to address exsanguination in extreme and austere environments

Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.

Remote tele-mentored ultrasound for non-physician learners using FaceTime: A feasibility study in a low-income country

PURPOSE

Ultrasound (US) is a burgeoning diagnostic tool and is often the only available imaging modality in low- and middle-income countries (LMICs). However, bedside providers often lack training to acquire or interpret US images. We conducted a study to determine if a remote tele-intensivist could mentor geographically removed LMIC providers to obtain quality and clinically useful US images.

MATERIALS AND METHODS

Nine Haitian non-physician health care workers received a 20-minute training on basic US techniques. A volunteer was connected to an intensivist located in the USA via FaceTime. The intensivist remotely instructed the non-physicians to ultrasound five anatomic sites. The tele-intensivist evaluated the image quality and clinical utility of performing tele-ultrasound in a LMIC.

RESULTS

The intensivist agreed (defined as "agree" or "strongly agree" on a five-point Likert scale) that 90% (57/63) of the FaceTime images were high quality. The intensivist felt comfortable making clinical decisions using FaceTime images 89% (56/63) of the time.

CONCLUSIONS

Non-physicians can feasibly obtain high-quality and clinically relevant US images using video chat software in LMICs. Commercially available software can connect providers in institutions in LMICs to geographically removed intensivists at a relatively low cost and without the need for extensive training of local providers.

Barriers to point-of-care ultrasound use in rural emergency departments

Over the past few decades, point-of-care ultrasound (PoCUS) has come to play a major role in the practice of emergency medicine. Despite its numerous benefits, there has been a slow uptake of PoCUS use in rural emergency departments. Surveys conducted across Canada and the United States have identified a lack of equipment, training, funding, quality assurance, and an inability to maintain skills as major barriers to PoCUS use. Potential solutions include expanding residency training in ultrasound skills, extending funding for PoCUS training to rural physicians in practice, moving PoCUS training courses to rural sites, and creating telesonography training for rural physicians. With these barriers identified and solutions proposed, corrective measures must be taken so that the benefits of PoCUS are extended to patients in rural Canada where, arguably, it has the greatest potential for benefit when access to advanced imaging is not readily available.

Remote just-in-time telementored trauma ultrasound: a double-factorial randomized controlled trial examining fluid detection and remote knobology control through an ultrasound graphic user interface display

BACKGROUND

Remote-telementored ultrasound involves novice examiners being remotely guided by experts using informatic-technologies. However, requiring a novice to perform ultrasound is a cognitively demanding task exacerbated by unfamiliarity with ultrasound-machine controls. We incorporated a randomized evaluation of using remote control of the ultrasound functionality (knobology) within a study in which the images generated by distant naive examiners were viewed on an ultrasound graphic user interface (GUI) display viewed on laptop computers by mentors in different cities.

METHODS

Fire-fighters in Edmonton (101) were remotely mentored from Calgary (n = 65), Nanaimo (n = 19), and Memphis (n = 17) to examine an ultrasound phantom randomized to contain free fluid or not. Remote mentors (2 surgeons, 1 internist, and 1 ED physician) were randomly assigned to use GUI knobology control during mentoring (GUIK+/GUIK-).

RESULTS

Remote-telementored ultrasound was feasible in all cases. Overall accuracy for fluid detection was 97% (confidence interval = 91 to 99%) with 3 false negatives (FNs). Positive/negative likelihood ratios were infinity/0.0625. One FN occurred with the GUIK+ and 2 without (GUIK-). There were no statistical test performance differences in either group (GUIK+ and GUIK-).

CONCLUSIONS

Ultrasound-naive 1st responders can be remotely mentored with high accuracy, although providing basic remote control of the knobology did not affect outcomes.

Ultrasound images transmitted via FaceTime are non-inferior to images on the ultrasound machine

PURPOSE

Remote telementored ultrasound (RTMUS) systems can deliver ultrasound (US) expertise to regions lacking highly trained bedside ultrasonographers and US interpreters. To date, no studies have evaluated the quality and clinical utility of US images transmitted using commercially available RTMUS systems.

METHODS

This prospective pilot evaluated the quality of US images (right internal jugular vein, lung apices and bases, cardiac subxiphoid view, bladder) obtained using a commercially available iPad operating FaceTime software. A bedside non-physician obtained images and a tele-intensivist interpreted them. All US screen images were simultaneously saved on the US machine and captured via a FaceTime screen shot. The tele-intensivist and an independent US expert rated image quality and utility in guiding clinical decisions.

RESULTS

The tele-intensivist rated FaceTime images as high quality (90% [69/77]) and could comfortably make clinical decisions using these images (96% [74/77]). Image quality did not differ between FaceTime and US images (97% (75/77). Strong inter-rater reliability existed between tele-intensivist and US expert evaluations (Spearman's rho 0.43; P<.001).

CONCLUSION

An RTMUS system using commercially available two-way audiovisual technology can transmit US images without quality degradation. For most anatomic sites assessed, US images acquired using FaceTime are not inferior to those obtained directly with the US machine.

Clinical application of real-time tele-ultrasonography in diagnosing pediatric acute appendicitis in the ED

PURPOSE

We investigated the effectiveness of tele-mentored ultrasonography between emergency medicine (EM) residents and remote experts in diagnosing acute appendicitis.

METHODS

This prospective observational study was performed in an academic emergency department. Beginning in June 2014, the EM residents performed the initial ultrasonography for suspected pediatric acute appendicitis; then, the remote experts observed/mentored the residents' practice using the tele-ultrasonography system; and finally, an onsite expert verified the diagnosis. The diagnostic confidence of each examiner (resident, remote expert, and onsite expert) was rated on a 5-point Likert scale. The appendix identification rate and the diagnostic values; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each type of examination were calculated.

RESULTS

A total of 115 pediatric cases with suspected acute appendicitis, including 36 with pathology-confirmed acute appendicitis, between June 2014 and February 2015 were enrolled in this study. In 9 of the 115 (7.8%) cases, a non-appendicitis diagnosis was determined in the absence of the successful identification of a normal appendix upon resident examination. Of these, seven appendices were identified upon expert tele-ultrasonography. The diagnostic values for expert tele-ultrasonography were higher (sensitivity: 1.000, specificity: 0.975, PPV: 0.947, NPV: 1.000) than those for resident-performed ultrasonography (sensitivity: 0.917, specificity: 0.899, PPV: 0.805, NPV: 0.959) and similar to those for onsite expert-performed ultrasonography (sensitivity: 1.000, specificity: 0.987, PPV: 0.973, NPV: 1.000).

CONCLUSION

Tele-ultrasonography with tele-mentoring between EM residents and experienced mentors was effectively applied in diagnosing pediatric acute appendicitis in an emergency clinical setting.

Tele-intensivists can instruct non-physicians to acquire high-quality ultrasound images

PURPOSE

Intensive care unit telemedicine (tele-ICU) uses audiovisual systems to remotely monitor and manage patients. Intensive care unit ultrasound can augment an otherwise limited bedside evaluation. To date, no studies have utilized tele-ICU technology to assess the quality and clinical use of real-time ultrasound images. We assessed whether tele-intensivists can instruct nonphysicians to obtain high-quality, clinically useful ultrasound images.

METHODS

This prospective pilot evaluated the effectiveness of a brief educational session of nonphysician "ultrasonographers" on their ability to obtain ultrasound images (right internal jugular vein, bilateral lung apices and bases, cardiac subxiphoid view, bladder) with real-time tele-intensivist guidance. All ultrasound screen images were simultaneously photographed with a 2-way camera and saved on the ultrasound machine. The tele-intensivist assessed image quality, and an independent ultrasound expert rated their use in guiding clinical decisions.

RESULTS

The intensivist rated the tele-ICU camera images as high quality (70/77, 91%) and suitable for guiding clinical decisions (74/77, 96%). Only bilateral lung apices demonstrated differences in quality and clinical use. All other images were rated noninferior and clinically useful.

CONCLUSION

Tele-intensivists can guide minimally trained nonphysicians to obtain high-quality, clinically useful ultrasound images. For most anatomic sites, tele-ICU images are of similar quality to those acquired directly by ultrasound.

A comparison of telemedicine teaching to in-person teaching for the acquisition of an ultrasound skill - a pilot project

Telemedicine is widely used for medical education but few studies directly investigate how telemedicine teaching compares to conventional in-person teaching. Here we determine whether telemedicine teaching is as effective as in-person teaching for the acquisition of an ultrasound skill important in trauma care. Nurses with no prior ultrasound experience (n = 10) received study material and a teaching session on how to locate and image the hepatorenal space (Morison's pouch). One group of nurses was taught in-person (In-person Group) and the other group was taught via telemedicine (Telemedicine Group). Telemedicine allowed two-way audio and visual communication between the instructor and the nurses. A comparison of the teaching techniques showed that telemedicine teaching was equivalent to in-person teaching for the acquisition of practical and theoretical skills required to locate Morison's pouch. The average time required to locate Morison's pouch after teaching was similar between both groups. The results demonstrate that telemedicine teaching is as effective as in-person teaching for the acquisition of bedside ultrasound skills necessary to identify Morison's pouch. Remote teaching of these bedside ultrasound skills may help in the diagnosis of intra-abdominal bleeding in rural healthcare centers.